Ntev Ex-vivo Normothermic raum Perfusion: Qhov cuam tshuam ntawm Perfusate Composition
Feb 26, 2022
Abstract
Normothermic tshuab perfusion (NMP) ntawm tus publub raum muab lub cib fim rau kev txhim kho graft preservation thiab lub hom phiaj pre-transplant ex-vivo organ soj ntsuam. Tam sim no, muaj ntau ntau cov kev daws teeb meem rau lub raum NMP. Txoj kev tshawb no tsom los ntsuas plaub qhov sib txawv perfusion daws ib sab thiab txiav txim siab qhov cuam tshuam ntawm cov perfusate sib txawv ntawm kev ntsuaslub raumperfusion parameters. Porcinelub raumthiab ntshav tau los ntawm lub tsev tua tsiaj.Lub raumunderwent NMP ntawm 37˚C rau 7 teev, nrog 4 qhov sib txawv perfusion daws (n=5 ib pab pawg). Pawg 1 muaj cov qe ntshav liab (RBCs) thiab cov tshuaj perfusion raws li Williams 'Medium E. Pawg 2 muaj RBCs, albumin thiab cov khoom sib npaug ntawm cov electrolyte. Pawg 3 muaj RBCs thiab nruab nrab raws li kev kho mob British NMP kev daws teeb meem. Pawg 4 muaj RBCs thiab qhov nruab nrab siv hauv 24-teev perfusion thwmsim. NMP cov qauv ntws rau cov kev daws teeb meem 1 thiab 2 tau zoo sib xws, cov kev daws teeb meem 3 thiab 4 tau pom qis dua tab sis cov nqi ntws ruaj khov dua. Thiobarbituric acid reactive tshuaj tau ntau dua hauv cov tshuaj 1 thiab 4 piv rau lwm pawg. Qib ntawm cov cim raug mob N- acetyl- -D glucosaminidase tau qis dua hauv cov tshuaj 2 hauv kev sib piv nrog cov tshuaj 3 thiab 4. Txoj kev tshawb no qhia pom tias cov perfusate muaj pes tsawg leeg thaum NMP cuam tshuam rau qhov ntsuas perfusion thiab raug mob thiab yog li cuam tshuam rau kev txhais lus. ntawm tej zaum viability markers. Kev tshawb fawb ntxiv yog xav tau los tshawb xyuas tus kheej cov kev cuam tshuam ntawm cov ntsiab lus tseem ceeb perfusate los txiav txim siab cov xwm txheej zoo tshaj plaws thaum NMP thiab thaum kawg tsim cov qauv ntsuas thoob ntiaj teb.
Ntsiab lus:lub raum ua haujlwm; raum; mob raum; lub raum perfused; cev tubular
CISTANCHE yuav txhim kho lub raum / raum FUCTION
Taw qhia
Thoob ntiaj teb, tus qauv pub dawbraumTxoj kev khaws cia yog static txias cia (SCS). Txawm li cas los xij, hauv Netherlands hypothermic tshuab perfusion (HMP) yog siv kho mob los khaws txhua tus neeg pub dawb uas tuag lawm.lub raum.HMP tau pom qhov txo qis hauv kev ncua sij hawm graft thiab kev txhim kho 1- thiab 3- xyoolub raumgraft ciaj sia nyob rau hauv kev sib piv nrog SCS preservation [1,2]. Txhawm rau txo qhov sib txawv ntawm qhov sib txawv ntawm cov khoom siv thiab kev thov rau cov neeg pub dawblub raum,suboptimal tuag-dawblub raumtau siv ntau ntxiv. Vim muaj kev siv ntau dua ntawm cov no tsawg dua qhov pom zoo pub dawblub raum,Nws yog ib qho tseem ceeb tshaj plaws los tsim kom muaj cov tswv yim zoo ntxiv rau kev ua kom muaj zog thiab lub hom phiaj kev ntsuam xyuas ua ntej hloov pauv nrog rau kev khaws cia. Kev siv normothermic tshuab perfusion (NMP) rau cov neeg tuag-dawblub raumtab tom txiav txim siab zuj zus. Cov kev tshawb fawb ua ntej tau pom tias NMP tuaj yeem ua rau muaj txiaj ntsig zoo dua qub piv rau SCS ib leeg [3]. Raws li kev pub dawb tom qab lub plawv tuag thiab txuas ntxiv cov txheej txheem pub dawblub raumtsawg dua kev cia siab ntawm hypothermic cia piv rau cov khoom nruab nrog cev tau los ntawm cov txheej txheem pub dawb cov txheej txheem, marginal-zoo pub khoom nruab nrog cev tuaj yeem tau txais txiaj ntsig los ntawm NMP khaws cia [4,5]. Tam sim no, tsuas yog ib qho chaw kho mob xwblub raumNMP kev sim tau ua nyob rau hauv UK, nrog lub sijhawm luv luv ua ntej hloov pauv ntawm 1 teev [6]. Txawm li cas los xij, rau kev ntsuam xyuas lub cev txaus thiab kev ua kom rov zoo, txawm li cas los xij, ntev NMP lub sij hawm yog qhov tsim nyog [7]. Txoj kev no muab lub sijhawm rau kev kuaj mob ua ntej hloov pauv hauv nruab nrog cev, txhim kho kev khaws cia, thiab kev cuam tshuam ntawm ex-vivo ua ntej kev hloov pauv los txhim kho tom qab hloov pauv.lub raum ua haujlwm. Niaj hnub no, ntau lub chaw hloov pauv tau pib nqis peev hauv qhov kev cog lus no zoo li qub ex-vivo perfusion zoo. Ntawm cov chaw no, muaj ntau yam NMP perfusion daws teeb meem. Qhov loj heterogeneity nyob rau hauv muaj pes tsawg leeg tuaj yeem cuam tshuam lub hom phiaj kawg los txhais cov qauv kev ntsuam xyuas zoo thiab muaj zog NMP. Qhov no heterogeneity yog ib feem tsav los ntawm tam sim no tsuas yog kev nkag siab ntawm qhov tseeb formulation ntawm NMP kev daws yuav tsum yog. Feem ntau yuav, ib qho kev daws teeb meem tsis zoo yuav tsum muaj cov pa oxygen carrier, colloid, thiab sib npaug electrolyte muaj pes tsawg leeg [8]. Cov muaj pes tsawg leeg kuj tseem nyob ntawm lub sijhawm ntawm NMP, vim tias lub sijhawm ntev ntawm perfusion yuav xav tau cov tshuaj perfusate zoo kom muaj kev ruaj ntseg nyob ze-physiological thoob plaws tag nrho perfusion. Txoj kev tshawb no tau soj ntsuam plaub qhov sib txawv ntawm cov kev daws teeb meem sib txawv, peb feem ntau siv cov kev daws teeb meem uas twb muaj lawm uas tsis muaj kev hloov pauv thiab ib qho kev daws teeb meem tshiab. Peb tau ua ntev (7h) NMP hauv ib lub porcineraumpub dawb qauv. Peb lub hom phiaj yog los txheeb xyuas qhov sib txawv perfusate compositions raws li tag nrho cov cuam tshuam electrolyte tshuav,lub raum ua haujlwm, thiab cov cim kev raug mob ntsuas thaum lub sij hawm NMP.
Cov ntaub ntawv thiab cov txheej txheem
Lub raum thiab ntshav retrievalMuaj peev xwm porcinelub raumlos ntawm domestic landrace npua (sow; hom Topigs 20) thiab cov ntshav tau los ntawm ib lub zos slaughterhouse (Kroon Vlees, Groningen, lub Netherlands). Npua tau stunned nrog ib tug bi-temporal hluav taws xob shock thiab tom qab exsanguinated raws li ib txwm slaughterhouse txheej txheem. Cov ntshav autologous tau sau thiab heparin (5000 thoob ntiaj teb units ib ml (IU), LEO1 pharma, Ballerup, Denmark) tau ntxiv los tiv thaiv cov ntshav los ntawm txhaws.Lub raumtau rov qab tau sai sai tom qab cov ntshav tuag ntawm tus npua, uas ua rau kwv yees li 20 feeb ntawm sov ischemia (WI) ua ntej kev khaws cia txias. Tom qab lub sijhawm WI,lub raumtau ntxuav thiab txias nrog 180 ml sodium chloride (NaCl) (0.9 feem pua) (Baxter BV, Utrecht, Netherlands) ntawm 4˚C, uas cim qhov pib mob khaub thuas ischaemia (CI).Lub raumtau muab tshem tawm tsis pub dhau cov ntaub so ntswg rog thiab cov hlab ntsha raug nthuav tawm. Tom ntej no,lub raumtau txuas nrog aLub raumAssist Transport HMP device (Organ Assist, Groningen, the Nether-lands). Lub tshuab HMP no khaws cialub raumnrog txias (0–4˚C) UW tshuab perfusion tov (Belzer UW-MP tov, Choj rau lub neej Ltd, Columbia, SC) rau 2-4 teev siv oxygenated pulsatile HMP ntawm qhov nruab nrab arterial siab ntawm 25 mmHg . Heparinised autologous ntshav yog leukocyte depleted siv lub lim leukocyte (BioR 02 ntxiv rau BS PF, Fresenius Kabi, Zeist, Netherlands), centrifuged thiab tom qab ntawd, supernatant plasma raug tshem tawm.
Perfusion dawsPlaub pawg sim tau raug txiav txim siab (n=5 ib pawg), nrog rau kev daws teeb meem NMP sib txawv hauv txhua pab pawg. Ua ntejraumretrieval, cov tshuaj perfusion uas yuav siv thaum lub sij hawm sim tau txiav txim siab. Tag nrho plaub qhov kev daws teeb meem muaj autologous porcine qe ntshav liab (RBCs), tab sis qhov sib xyaw ntawm txhua NMP nruab nrab yog txawv (Table 1). Nyob rau hauv peb lub chaw soj nstuam, muaj kev paub txaus tau txais nrog perfusion ntawm porcinelub raumthiab nas lub siab siv Williams 'Medium E (WME) (Life Technologies Ltd, Bleiswijk, Neth- erlands) [9–11]. Qhov no perfusate tsis muaj vasodilator thiab peb txiav txim siab tsis ua
kev hloov pauv rau qhov kev daws teeb meem pib. Cov tshuaj perfusion ntawm pab pawg 2 yog tsim los ntawm peb pab pawg kom muaj cov electrolytes nyob rau hauv physiological concentrations thiab exert ib physiological colloid osmotic siab ntawm glomerular membrane. Cov pab pawg 3 perfusate yog ib qho tshuaj tsis muaj colloid siv cov tshuaj British NMP, uas yog tam sim no siv nyob rau hauv ib tug randomized tswj mus sib piv 1h NMP nrog SCS ntawm tib neeg tuag pub.lub raumnyob rau hauv lub tebchaws United Kingdom [12] Raws li rau pawg 4, qhov kev daws teeb meem no tau ua tiav hauv kev kawm porcine autotransplantation hauv Aarhus, Denmark [13]. Nws yog raws li perfusate tsim los ntawm Weissenbacher li al., leej twg per-fused pov tseg tib neeglub raumhauv 24 teev [7]. Ntxiv nrog rau cov ntsiab lus saum toj no, perfusate hauv pawg 1 tau ntxiv nrog cov piam thaj thaum cov concentration poob qis dua 4 mmol / l. Tsim cov zis yog
ib teev hloov nrog WME. Nyob rau hauv pab pawg 2 ib tug syringe infusion twj tso kua mis infused tag nrho parenteral khoom noj khoom haus (SmofKabiven) (Fresenius Kabi Nederland BV, Zeist, Netherlands) ntawm tus nqi ntawm 0.5 ml / tes insulin (10{{1{ {12}}}}0 IU, kuj Novo Nordisk A/S) ntawm tus nqi ntawm 0.005 ml/h. Tom qab txhua teev, cov zis tso zis tau rov ua dua hauv pawg 2 kom tswj tau qhov sib npaug ntawm electrolyte ruaj khov. Hauv pab pawg thib peb, 170 ml ntshiab RBCs tau muab sib xyaw nrog 120 ml saline, adenine, qabzib thiab mannitol (SAG-M), ua rau hematocrit ntawm 0.5-0.65 l / l, kom ua raws li cov ntsiab lus ntawm kev siv tshuaj kho mob. RBCs (uas yog siv hauv British chaw kho mob NMP perfusate). Thaum cov kev sim no, peb lub syringe infusion twj tau siv los ua kom Flolan (GlaxoSmithKline BV, Zeist, Netherlands) ntawm tus nqi ntawm 5 ml / h, qabzib 5 feem pua (Baxter BV, Utrecht, Neth-erlands) ntawm tus nqi ntawm 4 ml / h thiab sib tov ntawm 150 ml ntawm Synthamin-17 10 feem pua (Baxter Healthcare Ltd., Norfolk, United Kingdom), 6 ml sodium bicarbonate (NaHCO 3) 8.4 feem pua (B. Braun Melsun-gen AG, Melsungen, Germany) , 30 IU insulin (1000 IU, Novo Nordisk A / S, Bagsværd, Den-mark) thiab Cernevit (Baxter BV, Utrecht, Netherlands) ntawm tus nqi ntawm 20 ml / h, raws li txoj cai ntawm kev tshawb fawb UK tam sim no. Cov zis zis tau hloov ib teev los ntawm Ringers lactate (tseem Baxter BV). Thaum lub sij hawm NMP ntawm pawg plaub, ib tug syringe infusion twj tso kua mis infused verapamil (2.5 mg / ml, thiab Sandoz BV) yaj nyob rau hauv saline ntawm tus nqi ntawm 0.3 ml / h. Cov zis ntau lawm kuj tau rov ua dua tshiab hauv pab pawg no tom qab txhua teev kom muaj qhov sib npaug ntawm electrolyte ruaj khov. Cov qauv ntim hauv txhua pab pawg tau raug kho nrog cov khoom sib txawv. Qhov ntim hauv pawg 1 tau hloov nrog WME, hauv pawg 2 nrog perfusion nruab nrab, hauv pawg 3 nrog Ringers lactate thiab hauv pawg 4 nrog Sterofundin1 (tseem B. Braun).
NMP kev teeb tsaKev teeb tsa perfusion yog zoo ib yam li qhov tau piav qhia yav dhau los los ntawm peb pawg [14]. Covlub raumtau perfused nyob rau hauv asinusoid pulsatile zam, nrog ib tug zaus ntawm 60pulses ib feeb, ata teeb, tsis-feedback tswj, siab ntawm 110/70 mmHg thiab oxygenated nrog 95 feem pua oxygen / 5 feem pua carbon dioxide (carbogen) thaum lub sij hawm tag nrho cov kev sim. Qhov no supraphysiological oxygen theem yog txheej txheem txheej txheem nyob rau hauv tag nrho plaub txoj cai uas twb muaj lawm. Perfusion yog tswj los ntawm kev cai tsim hluav taws xob interface thiab tswj software (LabView Software, National Instruments Netherlands BV, Woerden, Netherlands). Ib daim duab schematic ntawm thenormothermic perfusion circuit yog qhia hauv daim duab 1.
Tso zis thiab perfusate tsom xamIb teev twg, arterial perfusate thiab cov zis kuaj tau raug coj mus kuaj. Hauv pab pawg 2 thiab 4, uas tso zis tau rov ua dua, cov qauv perfusate tau coj ua ntej tso zis rov ua haujlwm. Arterial blood gas samples ntawm perfusate tau soj ntsuam tom qab 0, 240 thiab 420 feeb ntawm NMP. Perfusion parameters tau sau tseg txhua ib nrab teev. Kev sib xyaw ntawm lactate dehydrogenase (LDH) thiab aspartate aminotransferase (ASAT), sodium, potassium, qabzib thiab creatinine tau ntsuas nrog cov qauv tshuaj ntsuam xyuas hauv perfusate. Creatinine clearance, fractional excretion ntawm creatinine ib 100g (FE creatinine / 100g), thiab fractional sodium excretion (FENa plus) raug xam los txiav txim.lub raum ua haujlwm. Cov kev sib npaug tuaj yeem pom nyob rau hauv S1 Appendix. Ob leeg N-acetyl- -D glucosaminidase (NAG) (tseem Sigma-Aldrich), ua tus cim ntawmlub raumTubular tsis ua haujlwm / raug mob, thiab thiobarbituric acid reactive tshuaj (TBARS) (Lipid Peroxidation-malondialdehyde (MDA)) Assay Kit, Sigma-Aldrich BV, Zwijndrecht, Netherlands), kom muaj nuj nqis oxidative kev nyuaj siab, raug ntsuas hauv perfusate.
HistologyAneedle biopsy ntawm sab sauvlub raum cortextau coj ua ntej pib ntawm NMP. Thaum kawg ntawm txhua qhov kev sim, cov ntaub so ntswg phais tau sau los ntawm lub cortex sab sauv. Cov biopsies no tau
Kev txheeb caisKev txheeb xyuas cov ntaub ntawv tau ua tiav siv GraphPad Prism Version 8.3.1 (GraphPad software Inc., La Jolla, CA, USA). Rau tag nrho cov kev ntsuas ncua ntev ntev, xws li ASAT thiab LDH, thaj tsam hauv qab qhov nkhaus (AUC) raug xam. Ib txoj kev ANOVA nrog ntau qhov sib piv tau siv los sib piv AUC qhov tseem ceeb ntawm cov pab pawg yog tias cov ntaub ntawv tau muab faib ua ib txwm (Shapiro Wilk test) thiab muaj qhov sib txawv ntawm qhov sib txawv (kuaj los ntawm kev xeem Bartlett). Yog tias cov ntaub ntawv ua tsis tiav cov kev xav no, Kruskal-Wallis test nrog Dunn tau siv ntau qhov kev sib piv. Ob sab p-tus nqi ntawm 0.05 lossis tsawg dua raug suav hais tias yog qhov tseem ceeb ntawm kev txheeb cais.
Cov txiaj ntsig
Perfusion parametersHauv Table 2, cov ntaub ntawv (txhais tau tias, yam tsawg kawg nkaus thiab siab tshaj) ntawm qhov sov thiab txias ischemia, HMP lub sijhawm thiab qhov hnyav ua ntej pib thiab tom qab NMP nrog rau qhov hnyav ntawm qhov hnyav (qhov sib txawv ntawm qhov hnyav ntawm t=420 piv rau t {{2. }}) tau nthuav tawm. Delta qhov hnyav hnyav dua hauv pawg 1 hauv kev sib piv nrog pawg 2 (p=0.041). Tsis muaj lwm qhov sib txawv tseem ceeb ntawm cov txiaj ntsig ntawm txhua pawg kev sim. Thaum NMPlub raumarterial flow nce nyob rau hauv thawj 60 feeb ntawm reperfusion nyob rau hauv pab pawg neeg 1 thiab 2. Tom qab 60 feeb cov flow rate feem ntau pib txo. Perfusions hauv pab pawg 3 thiab 4 tau pib nrog cov txiaj ntsig qis dua tab sis pom tias muaj kev ntws mus tas li thoob plaws NMP. Cov txiaj ntsig kawg tom qab 7 teev ntawm NMP yog kwv yees li 75 ml / min / 100g hauv txhua pab pawg (Fig 2).
Tso zis thiab perfusate tsom xamCov ntaub ntawv tus kheej ntawm kev ua haujlwm thiab kev raug mob tsis zoo thoob plaws hauv perfusion tuaj yeem pom hauv Table 3.Lub raum ua haujlwm.Pawg 3 tau pom qhov tso zis ntau tshaj plaws (Fig 3). Cov tshuaj diuresis hauv pawg 3 tau nce siab dua hauv kev sib piv nrog pawg 1 (p=0). Qee qhovlub raumhauv pawg 2 tsis tsim cov zis ntawm t=180 thiab t=300, ua rau qis qis nruab nrab ntawm cov zis ntau lawm ntawm t=360 thiab t=420. Sodium thiab potassium qib sib txawv ntawm cov pab pawg (Fig 4). Cov theem ntawm t=0 qhia qhov pib pib qhov tseem ceeb ntawm perfusion. Tshwj xeeb yog pab pawg 3 tau pom zoo heev
Thaum lub sij hawm perfusion, pH hauv pab pawg 3 poob qis tsis muaj kev ruaj ntseg thaum lwm pab pawg tau mus txog qhov sib npaug ntawm kwv yees li 7.4 tom qab 7 teev ntawm NMP (Fig 5). Creatinine tshem tawm tau qis hauv txhua pab pawg (Daim duab 6A thiab 6B). Txawm li cas los xij, nws tau siab dua hauv pawg 3 piv rau pawg 2 (p=0.039). Fractional excretion ntawm creatinine ib 100g (Daim duab 6C thiab 6D) tau ntau dua hauv pawg 3 piv rau pawg 1 (p=0.026), pawg 2 (p=0.017), thiab pawg 4 ( p=0.045). FENa ntxiv yog siab nyob rau hauv tag nrho cov pab pawg, qhia tias tubular muaj nuj nqi yog heev tsis zoo (Daim duab 6E thiab 6F) nyob rau hauv cov ischaemically puas.lub raum. FENa ntxiv rau hauv pab pawg 3 tau ntau dua piv rau pawg 2 (p=0.037) thiab pawg 4 (p=0.019). Tag nrho lwm pab pawg tsis txawv heev.Lub raum raug mob.ASAT theem thaum NMP tau txheeb xyuas (Daim duab 7A thiab 7B) ua tus cim rau kev raug mob ntawm tes. Qhov nruab nrab AUC tau txiav txim siab rau txhua pab pawg. Qib hauv pawg 4 tau siab dua piv rau pawg 1 (p=0.022) thiab pawg 2 (p=0.011). Cov qib LDH kuj tau ntsuas hauv qhov perfusate raws li kev raug mob dav dav (Daim duab 7C thiab 7D). Ib qho AUC tau suav nrog uas pom tias qis tshaj ntawm LDH hauv pawg 1 thiab 2. Pawg 2 tau qis dua piv rau pawg 4 (p=0.020). Pab pawg 1 tau pom cov qib qis dua piv rau pawg 4 (p=0.022). NAG qib tau siab dua hauv pawg 3 hauv kev sib piv nrog pawg 1 (p=0.043) thiab pawg 2 (p=0.006) (Fig 8A thiab 8B). TBARS, qhov concentration ntawm malondialdehyde (MDA), tau ntsuas nyob rau hauv tag nrho plaub pawg ua tus cim rau lipid peroxidation (Fig 8C thiab 8D). MDA qib tau siab dua hauv pawg 1 thaum piv rau pawg 2 (p=0.003) thiab pawg 3 (p <0.001). pab="" pawg="" 2="" pom="" tau="" tias="" mda="" qis="" dua="" piv="" rau="" pawg="" 4="" (p="0.006)." pawg="" 3="" pom="" tau="" tias="" qis="" dua="" piv="" rau="" pawg="" 4=""><>
Histology
Cov dot plots hauv daim duab 9 qhialub raumtubular puas/ATN, tubular dilatation, thiab glomerular dilatation cov qhab nia ua ntej pib ntawm NMP (t {0}}) thiab tom qab 7 teev ntawm NMP (t=420). Thawj qhov tseem ceeb ntawm histological necrosis thiab tubular dilatation tau sib piv ntawm cov pab pawg, tsuas yog qhov sib txawv ntawm qhov kawg ntawm cov qhab nia. Glomerular dilatation ntawm t=420 tau qis dua hauv pawg 2 piv nrog rau lwm pawg 3. Cov duab histological ib pawg tuaj yeem pom nyob rau hauv S1 Fig. Bax thiab Bcl -2 fold induction, qhov taw qhia rau pro- thiab anti-apoptotic gene qhia, ntsig txog, ob qho tib si pom qhov hloov pauv hauv qhov kawg-point NMP qib piv rau qib ntawm t=0 (Fig 10). Delta Bax gene qhia (qhov txawv ntawm t=0 thiab t=420) raug xam nyob rau hauv tag nrho cov pab pawg thiab tau ntau dua nyob rau hauv pawg 1 piv rau pawg 2 (p=0.046), pawg 3 (p <0.001) thiab="" pawg="" 4="" (p="0.003)." bcl-2="" kev="" qhia="" tau="" txo="" qis="" hauv="" txhua="" pab="" pawg="" tom="" qab="" 7="" teev="" ntawm="" perfusion="" uas="" tsis="" muaj="" qhov="" sib="" txawv="" ntawm="">
Kev sib tham
Kev txaus siab nyob rau hauvlub raumnormothermic ex-vivo tshuab perfusion cov tswv yim tau nce, tab sis cov pov thawj kho mob tseem txwv nrog tsuas yog ib qho kev kuaj mob NMP txuas ntxiv mus. Cov kev tshawb fawb ua ntej kev kho mob dav dav tau tshawb xyuas lub peev xwm ntawm NMP. Ib plethora ntawm txawvlub raumNormothermic perfusates muaj nyob ntawm ntau pawg tshawb fawb. Txawm li cas los xij, cov lus nug txog seb qhov perfusate muaj pes tsawg leeg cuam tshuam li caslub raum ua haujlwmthiab nws cuam tshuam li cas rau kev txhais lus ntawm cov cim muaj peev xwm muaj peev xwm tseem nyob. Yog li, txoj kev tshawb fawb no tau soj ntsuam qhov cuam tshuam ntawm plaub qhov sib txawv ntawm qhov sib txawv normothermic ex-vivo perfusion daws ib sab ntawmlub raum ua haujlwmthiabmob raumthaum lub sij hawm ntev NMP siv lub porcineraumpub dawb tom qab circulatory tuag qauv.
soj ntsuam caislub raum ua haujlwmua ntej transplantation. Hosgood thiab cov npoj yaig tau muab thawj qhov kev kuaj mob pov thawj ntawm qhov ua tau ntawm kev ntsuam xyuas ua ntej hloov pauv mus rau lub sijhawmlub raumNMP. Lawv cov tshuaj perfusion yog tam sim no siv dav tshaj plaws thaum NMP thiab tau pib tsim los ntsuaslub raum ua haujlwmua ntej hloov pauv hauv 1-2 teev sijhawm [16].Lub raumperfused nrog cov tshuaj no feem ntau qhia cov zis ntau lawm [17]. Tseeb tiag, cov zis ntau tshaj plaws tau pom nyob rau hauv pawg 3, uas yog raws li qhov chaw kho mob UK perfusate, ua rau ntau tshaj qhov tso zis tso tawm ntawm cov ntim ntim ntawm perfusate hauv pawg no thaum 7 teev ntawm NMP. Qhov tsis tu ncua ntawm cov kua dej ntws tawm mus tas li yuav tsum tau them nyiaj los ntawm kev sib txuas ntxiv ntawm cov ntim zoo sib xws ntawm Ringer's lactate, ua raws li cov txheej txheem kho mob rau cov tshuaj perfusion no. Hauv peb txoj kev tshawb fawb, qhov no tau ua rau muaj kev hloov pauv ntawm cov electrolyte muaj pes tsawg leeg thiab pH, vim tias cov zis tsis rov ua dua. Qhov kev tso zis siab no tuaj yeem raug ntaus nqi vim qhov tsis muaj colloid nyob rau hauv tsuas yog cov tshuaj perfusion no. Tag nrho peb lwm pawg 'kev daws teeb meem perfusion muaj ntau npaum li cas ntawm albumin. Nyob rau hauv qhov chaw intravascular, albumin yog lub ntsiab tivthaiv uas tswj ib txwm colloid osmotic siab [18]. Qhov sib npaug ntawm hydrostatic siab thiab colloid osmotic siab ua rau lub physiological ultrafiltration tus nqi tshaj glomerular membrane [19]. Kaths et al. tau pom tias cov zis zis thaum lub sij hawm NMP tsis cuam tshuam nrog kev ua haujlwm tom qab hloov pauv. Lawv xav tias cov zis ntau lawm feem ntau cuam tshuam los ntawm perfusate muaj pes tsawg leeg, tshwj xeeb tshaj yog lub siab oncotic thiab osmolarity, uas yog raws li peb cov txiaj ntsig [20].
CISTANCHE yuav txhim kho lub raum / raum tsis ua haujlwm
Lub luag haujlwm tseem ceeb hauv lub cev rau kev tswj hwm ntawm electrolytes yograumtab sis muaj pov thawj tias covraumnws tus kheej kuj tau txais txiaj ntsig los ntawm qhov sib npaug hauv electrolytes. Nws tau raug tsim los tias qhov tsis txaus ntawm cov poov tshuaj thiab tshwj xeeb yog hypokalemia, tuaj yeem ua rau muaj ntau yam kev hloov pauv hauvlub raum ua haujlwmsuav nrog kev thauj mus los tsis zoo, tsis muaj peev xwm tso zis tsis txaus, hloov pauv sodium reabsorption, thiab intracellular acidosis [21–23]. Txhawm rau suav rau qhov tsis tuaj yeem tso zis poob ntawm qhov tseem ceeb perfusate electrolytes, Weissenbacher li al. thov kom siv cov zis rov ua dua thaum NMP. Lawv tau pom tias nws pab tswj kom zoo ntawm perfusate ntim thiab homeostasis hauv tib neeg pov tseglub raum, txawm tias tom qab 24 teev ntawm NMP [7]. Qhov ntsuas albumin concentration hauv perfusate txo qis thaum lub sijhawm perfusion. Qhov kev txo qis no feem ntau yog tshwm sim los ntawm kev ua raws li albumin rau cov yas perfusion circuit tubing thiab tsuas yog ib qho me me tuaj yeem raug ntaus nqi los ntawm kev poob hauv cov zis, uas kuj tau pom hauv lwm cov kev tshawb fawb NMP [24]. Qhov kev tso zis ntawm albumin no tuaj yeem piav qhia los ntawm qhov sov sov ischaemia-vim kev puas tsuaj rau cov hlwb endothelial nrog kev cuam tshuam ntawm cov lim diaphragms uas ua rau muaj proteinuria, uas yog nyob rau hauv txoj kab nrog peb cov qib ntawm albuminuria thaum NMP [25].
Peb tsis tuaj yeem piav qhia tag nrho cov txheej txheem ntawm qhov sib txawv ntawm cov pab pawg uas peb tau pom hauvraumhnyav nce thaum NMP. Kev kuaj mob histological tsis tau txiav txim siab rau thaj tsam ntawm kev tsim edema. Kev tshawb nrhiav ntxiv yog xav tau los qhia meej txog qhov muaj peev xwm multifactorial mechanisms ntawm qhov hnyav nce hauv kev cuam tshuam nrog perfusion tov siv. Ntau yam perfusion tsis tau ntsuas, qhov twglub raumntws qhia qhov sib txawv tshaj plaws.Lub raumntws hauv pab pawg 3 thiab 4 tau tswj cov qib ruaj khov tshaj plaws thoob plaws hauv 7- teev NMP lub sijhawm. Cov kev daws teeb meem hauv cov pab pawg no tau ntxiv nrog vasodilator thaum cov kev daws teeb meem hauv thawj ob pawg tsis yog. Endogenous vasodilators txhawb vascular du leeg so thiab yog li tswj cov ntshav ntws hauv cheeb tsam [26]. Raws li pab pawg 1 thiab 2 tsis tau ntxiv nrog vasodilator, vasospasms tuaj yeem ua rau txo qis.lub raumarterial ntws. Ntxiv mus, muaj pov thawj tias medullary thiab cortical flow tuaj yeem tswj hwm tus kheej [27,28]. Cov ntaub ntawv tsis tau tshaj tawm ua ntej los ntawm peb pab pawg, raws li qhov tseeb thiab ntau qhov ua haujlwm MRI (ASL) kev ntsuas ntsuas thaum NMP txhawb nqa cov txheej txheem no. Hauv cov kev sim no,lub raumntws thaum thawj teev ntawm NMP feem ntau yog medullar, uas hloov mus rau corticalflow tom qab ntau tshaj li ib teev ntawm perfusion. Qhov kev faib tawm hauv cheeb tsam no tuaj yeem piav qhia txog qhov siab tshaj plaws pom nyob rau hauv perfusions ntawm pawg 1 thiab 2, tejzaum nws yog vim medullary shunting thaum thawj teev. Qhov sib ntxiv ntawm cov vasodilator thaum pib ntawm NMP tuaj yeem txhim kho qhov feem ntau cortical microperfusion tam sim ntawd thaum pib ntawm NMP, ua rau muaj kev ruaj khov dua raws li tau pom hauv pawg 3 thiab 4. Yog li ntawd, yog tias tus qauv ntws ruaj khov thiab muaj peev xwm ua kom lub cev muaj zog feem ntau cortical. perfusion yog xav tau thaum NMP, nws yuav raug nquahu kom ntxiv vasodilator rau cov tshuaj perfusion. Xwb, rov ntxuav RBCs ua ntej perfusion tuaj yeem txolub raumvasoconstriction los ntawm kev txo qis vasoconstrictive kev ua ntawm RBCs [29].
Lub raum ua haujlwmthaum lub sij hawm NMP tau pom tias muaj kev puas tsuaj loj hauv txhua lub porcinelub raum, tejzaum nws tshwm sim los ntawm qhov pib sov ischemic puas thiab tsis muaj lub cev humoral regulatory mechanisms, xws li cov uas tau tsav los ntawm anti-diuretic hormone thiab aldosterone. Creatinine clearance yog tsawg thiab siab qhov tseem ceeb ntawm FENa ntxiv tau pom nyob rau hauv tag nrho cov pab pawg neeg. Kev nce tam sim ntawd hauv FENa ntxiv tom qab 3 teev ntawm NMP hauv pab pawg 2 tuaj yeem yog qhov tshwm sim ntawm qhov tsis muaj cov zis ntau lawm.lub raumntawm t=240 thiab t=300, thaum kawg ntawm perfusionlub raumpib tsim cov zis dua. Cov txiaj ntsig siab ntawm FENa ntxiv yog qhov tshwm sim ntawm tubular necrosis raws li tau tshaj tawm hauv cov kev tshawb fawb yav dhau los [30,31]. Tsis tas li ntawd, in-vivo creatinine tshem tawm thiab FENa ntxiv rau qib tau cuam tshuam los ntawm kev tswj hwm kev lom zem. Raws li kev cai humoral
tsis muaj thaum lub sij hawm NMP thwmsim, physiological creatinine clearance thiab FENa ntxiv theem yuav tsis xav kom nyob rau hauv peb lub NMP teeb.
Yuav kom ntsuas qhov raug mob raulub raumCell, ASAT thiab LDH qib tau ntsuas. Cov qib siab tshaj plaws tau pom hauv pawg 3 thiab 4, qhia tias feem ntau raug mob tshwm sim hauv ob pawg no. Kaths et al. pom tias nce qib ASAT thaum NMP cuam tshuam nrog kev hloov pauv tom qablub raum ua haujlwmthiab yog li ntawd ASAT tej zaum yuav yog ib qho tseem ceeb ntawm lub cev muaj peev xwm soj ntsuam biomarker [20]. Kev cuam tshuam ntawm kev sib txawv perfusate muaj nyob rau hauv ntsuas ASAT theem qhia txog qhov tseem ceeb rau kev sib haum xeeb NMP cov txheej txheem ntawm cov chaw hloov pauv, txhawm rau ua kom muaj kev txhais lus zoo ib yam ntawm NMP cov ntaub ntawv thoob ntiaj teb. Qib ntawm NAG, tus cim rau kev hloov pauv tubular kev ncaj ncees thiab kev puas tsuaj ntawm tubular [32,33], tau siab tshaj plaws hauv pawg 3 uas qhia tias feem ntau cov tubular raug mob tshwm sim hauv pab pawg no. TBARS qib tau ntsuas los ntsuas oxidative kev nyuab siab thaum lub sij hawm perfusion. Cov qib siab tshaj plaws tau pom hauv pawg 1 thiab 4, qhia tiaslub raumHauv cov pab pawg no tau ntsib qhov kev ntxhov siab oxidative siab tshaj plaws, uas tuaj yeem ua rau lub cev tsis muaj zog [34]. Kev hloov pauv hauv Bax/Bcl-2 piv tom qab 7 teev ntawm NMP piv rau kev kuaj ntshav ua ntej NMP yog qhov tshwm sim ntawm thawj lub sijhawm sov sov, tsis yog qhov cuam tshuam uas tshwm sim thaum NMP. Ischemic raug mob tom qab qhov tshwm sim reperfusion ua rau muaj kev tswj hwm apoptosis cascade, uas ua lub luag haujlwm tseem ceeb hauv cov txheej txheem ntawm kev kho ntawm cov tubule puas lawm [35]. Txawm hais tias muaj ntau cov cim kev raug mob los ntawm kev raug mob los ntawm kev kub ntxhov, los txog rau hnub no tsis muaj leej twg tau raug lees paub nyob rau hauv kev sim tshuaj muaj zog. Ib txoj kev tshawb fawb sib cuam tshuam txog ib qho kev cog lus raug mob ntsuas thaum NMP nrog kev hloov pauv tom qablub raum ua haujlwmyuav tsum tau qhia kom meej tias cov biomarkers uas muaj peev xwm yuav tsum tau muab tso rau hauv cov txheej txheem ntsuas kev ntsuas kev muaj peev xwm ua tau zoo li qub.
CISTANCHE yuav txhim kho lub raum / raum kab mob
Peb qhov teeb tsa NMP tau siv ua ke nrog tus qauv porcine ntawm DCDraumpub dawb nyob rau hauv uas slaughterhouselub raumtau siv. Ib qho kev txwv ntawm txoj kev tshawb fawb no yog tias cov txheej txheem tua tsiaj yog ua raws li exsanguination ua raws li lub plawv nres, uas ua rau nws txawv me ntsis ntawm tus qauv DCD tiag tiag uas cov hlab ntsha raug ntes los ntawm lub plawv ischemia thiab / lossis tsis ua haujlwm. Txawm li cas los xij, peb tau pom qhov ntawdlub raumHauv peb txoj kev tshawb fawb pom pom kev raug mob ischemic zoo ib yam li qhov tshwm sim tom qab DCD [36,37]. Yog li ntawd, peb xav tias tam sim no lub tsev tua tsiaj DCD qauv yuav pab txo qis kev siv cov tsiaj sim thaum tswj xyuas qhov tseem ceeb ntawm kev ntseeg siab thiab kev rov ua dua. Txawm hais tias peb cov pab pawg sim tau me me, peb cov pab pawg ntau qhov sib piv nrog rau lwm cov porcineraumKev tshawb fawb tshuab perfusion [17,38–40]. Cov NMP perfusion tsis tau uas peb tau sau tseg hauv pab pawg 3, uas yog raws li British kev kho mob perfusion tshuaj siv los ntawm Hosgood li al., tsis tuaj yeem muab tag nrho piv rau cov txiaj ntsig yav dhau los qhia los ntawm pawg Leicester / Cambridge [6,12]. Hauv peb txoj kev tshawb fawb,lub raumunderwent lub sij hawm ntev ntawm NMP thiab tau perfused nrog siab dua txhais tau tias arterial siab. Ntxiv mus,lub raumperfused los ntawm Hosgood et al. tau transplanted tom qab tshuab perfusion. Txhawm rau kom ntseeg tau qhov sib piv ntawm plaub qhov kev daws teeb meem perfusion, kev kawm yav tom ntej yuav tsum suav nrog kev hloov pauv ntawmlub raumtom qab NMP raws li qhov no yuav tso cai rau kev ua raws li qhov tseeb thiab kev ntsuas kev ua haujlwm hauv vivo.
Hauv kev xaus, perfusion ntawm porcinelub raumua pov thawj ua tau nrog tag nrho plaub txoj kev daws teeb meem. Txawm li cas los xij, muaj qhov sib txawv ntawm cov qib electrolyte,lub raum ua haujlwmparameters, thiab cov cim kev raug mob hauv plaub pawg. Cov kev sib txawv no, ua ke nrog kev sib txawv tam sim no hauv kev siv cov kev daws teeb meem ntawm cov pab pawg, cuam tshuam kev txhim kho ntawm cov qauv kev ntsuas NMP. Peb xav tias nyob rau hauv ob qho tib si kev sim thiab kev kho mob NMP nws yog ib qho tseem ceeb kom ua tib zoo ua ntej qhia meej lub hom phiaj thiab lub sijhawm xav tau ntawm NMP, vim txhua tus tuaj yeem hu rau kev hloov kho tsim nyog hauv perfusate thiab perfusion raws tu qauv. Nws yog ib qho tseem ceeb uas yuav tsum tau hais txog tias txoj kev tshawb no tsom mus rau qhov cuam tshuam ntawm perfusates uas twb muaj lawm tag nrho ntawm cov txiaj ntsig tau ntsuas, tsis yog kev tshawb xyuas lub luag haujlwm ntawm tus kheej perfusate Cheebtsam. Cov kev tshawb fawb ntxiv yuav tsum tau qhia meej txog tus kheej cov kev cuam tshuam thiab kev ua tau zoo ntawm txhua cov khoom xyaw perfusate thaum NMP