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lung perfusion (EVLP) is a technique for graft preservation, evaluation and treatment, that could expand donor pool for transplantation. Nevertheless, the wide spectrum of available platforms has generated disparities in use, outcome, and costs. This study is an attempt to create a national consensus on EVLP use by a group of experts from the Italian Society of Organ Transplantation. The 9-member promoting committee was divided into 3 groups to propose statements. Using the DELPHI method 27 experts (three from each of the 9 lung transplant centres) voted agreement to each statement in 3 rounds. The cutoff for acceptance was set at 80% agreement. In the first vote, 52 statements were proposed, and an agreement was reached for 20 of them (38%). After revision, the second round resulted in a quorum for 36 out of 40 statements proposed (90%). At the third vote, agreement was confirmed for 36 statements (8 indications for use, 19 modalities for use, 13 evaluation parameters). The statements outlined in this document do not represent absolute guidelines, but rather recommendations. The statements selected and presented are therefore aimed to assist Italian clinicians in the use of an normothermic perfusion platform in the right context.

Allograft failure remains a major barrier in the field of lung transplantation and results primarily from acute and chronic rejection. To date, standard-of-care immunosuppressive regimens have proven unsuccessful in achieving acceptable long-term graft and patient survival. Recent insights into the unique immunologic properties of lung allografts provide an opportunity to develop more effective immunosuppressive strategies. Here we describe advances in our understanding of the mechanisms driving lung allograft rejection and highlight recent progress in the development of novel, lung-specific strategies aimed at promoting long-term allograft survival, including tolerance.

Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.

Recently, initial clinical experience has been gained with the xenotransplantation of pig organs such as heart and kidney into terminally ill human patients in an effort to overcoming organ shortage. Here, we investigated the use of normothermic machine perfusion (NMP) to advance xenotransplantation research and develop bridging therapies for acute organ failure such as the use of pig livers as a liver dialysis system. We simultaneously analyzed livers and lungs from genetically modified pigs, carrying a knock-out of the GGTA1 gene, which is essential for xenoreactive αGal-KO-epitopes, by applying clinically established normothermic perfusion systems, solutions and human blood. Experiments involved perfusing organs with cell-free solutions as well as human erythrocyte concentrates for up to six hours, analyzing organ quality using invasive and non-invasive methods, and the isolation and analysis of immune cells from the perfusate. The results obtained show stable flow characteristics with physiological perfusion and oxygenation levels of the organs, and a largely intact organ architecture, confirmed by histological sections before and after perfusion. Overall, this study demonstrates the feasibility of normothermic machine perfusion of xenogeneic organs by an interdisciplinary team, thus paving the way for clinical applications of porcine xenografts involving NMP.

The key goal in lung donation remains the improvement of graft preservation with the ultimate objective of increasing the number and quality of lung transplants (LTx). Therefore, in recent years the field of graft preservation focused on improving outcomes related to solid organ regeneration and restoration. In this contest Ex-Vivo Lung Perfusion (EVLP) plays a crucial role with the purpose to increase the donor pool availability transforming marginal and/or declined donor lungs suitable for transplantation. Aim of this proof of concept is to test the safety, suitability and feasibility of a new tilting dome for EVLP designed considering the dorsal lung areas as the “Achilles’ heel” of the EVLP due to a more fluid accumulation than in the supine standard position.

After lung procurement from Lewis and Fischer 344 rats, the left lung was perfused ex situ , while the right lung was kept statically cold as a control. In addition to thermal imaging, lung histology and analyses of lung weight, key perfusion parameters, blood gas analysis, cytokines, and colloidal oncotic pressure were performed. Figure was created with BioRender.com . Ex situ lung perfusion (ESLP) is used for organ reconditioning, repair, and re-evaluation prior to transplantation. Since valid preclinical animal models are required for translationally relevant studies, we developed a 17 mL low-volume ESLP for double- and single-lung application that enables cost-effective optimal compliance “reduction” of the 3R principles of animal research. In single-lung mode, ten Fischer344 and Lewis rat lungs were subjected to ESLP and static cold storage using STEEN or PerfadexPlus. Key perfusion parameters, thermal lung imaging, blood gas analysis (BGA), colloid oncotic pressure (COP), lung weight gain, histological work-up, and cytokine analysis were performed. Significant differences between perfusion solutions but not between the rat strains were detected. Most relevant perfusion parameters confirmed valid ESLP with homogeneous lung perfusion, evidenced by uniform lung surface temperature. BGA showed temperature-dependent metabolic activities with differences depending on perfusion solution composition. COP is not decisive for pulmonary oedema and associated weight gain, but possibly rather observed chemokine profile and dextran sensitivity of rats. Histological examination confirmed intact lung architecture without infarcts or hemorrhages due to optimal organ procurement and single-lung application protocol using our in-house-designed ESLP system.

Severe discrepancy between availability of donor organs suitable for clinical transplantation and the proportion of patients on the waiting list has resulted in several clinical problems. First, waiting times for a suitable organ match have become increasingly long, leading to higher mortality while awaiting transplantation. Second, to address this issue, more “marginal” donor lungs have been used in the last two decades, inevitably leading to higher risk of perioperative and long-term complications. The ex vivo lung perfusion (EVLP) technology has been used to recondition marginal donor organs for clinical transplantation. There remains a further untapped pool of donor organs that are currently deemed too injured even for reconditioning via currently available EVLP strategies and are therefore discarded without reconditioning attempts. As the clinical use of EVLP has reached its full potential, further adjunct technologies, such as selective NET removal, cytokine removal and cell therapy techniques, may improve reconditioning outcomes and lead to increased number of donor organs transplanted. Moreover, NET removal may significantly improve donor organ quality and, therefore, the outcomes of recipients after lung transplantation. Such adjunct technology may also provide short- and longer-term benefits in reduction in early graft failure (primary graft dysfunction, PGD) and longer-term chronic lung allograft dysfunction (CLAD, previously known as chronic rejection) via more favorable early immune priming of organs. In this article we present current evidence and future perspectives on this novel intervention strategy that can be used on human donor lungs with the view to increase the utilization rate in lung transplantation in the near future.

The pulmonary microbiome has emerged as a significant factor in respiratory health and diseases. Despite the sterile conditions maintained during ex vivo lung perfusion (EVLP), the use of antibiotics in the perfuse liquid can lead to dynamic changes in the lung microbiome. Here, we present the design of a study that aims to investigate the hypothesis that EVLP alters the lung microbiome and induces tissue inflammation. This pilot, prospective, controlled study will be conducted in two Spanish donor centers and will include seven organ donors after brain death or after controlled cardiac death. After standardized retrieval, the left lung will be preserved in cold storage and the right lung will be perfused with EVLP. Samples from bronchoalveolar lavage, perfusion and preservation solutions, and lung biopsies will be collected from both lungs and changes in lung microbiome and inflammatory response will be compared.

Introduction Neuroprotective agents for acute ischemic stroke often fall short in efficacy due to the blood–brain barrier challenges, lack of target specificity, and limited effectiveness. Recently, plant-derived extracellular vesicle-like particles (EVLP) have shown promise in their multifaceted functions. Objectives The neuroprotective advantages that EVLP produced from Houttuynia cordata Thunb against cerebral ischemia/reperfusion injury are investigated. Methods The extraction of HT-EVLP was performed using gradient centrifugation and ultracentrifugation, followed by identification of its particle size, morphology, and exosomal marker proteins. Using behavioral tests and a rat model of middle cerebral artery occlusion (MCAO), the neuroprotective attributes of HT-EVLP were assessed. To evaluate the effect of HT-EVLP on ferroptosis and cell survival, the oxygen–glucose deprivation/reoxygenation (OGD/R) induced HT22 cell model was used. Utilizing bioinformatics analysis and small RNA sequencing, the miRNA composition and downstream target genes of HT-EVLP were predicted. The dual-luciferase reporter gene assay was used to confirm that miR159a bound to long-chain acyl-coenzyme A synthase 4 (ACSL4). The impact of miR159a transfection on OGD/R-induced ferroptosis in HT22 cell was also observed. Results Using a MCAO model, we found that HT-EVLP preserved blood brain barrier integrity, naturally penetrated the infarct core area, reduced cerebral infarct volume, mitigated neuronal apoptosis and ferroptosis, and facilitated recovery of neuronal function. In vitro studies further revealed that HT-EVLP enhanced cell survival and suppressed ACSL4-mediated ferroptosis in OGD/R-treated HT22 cells. Small RNA sequencing indicated that HT-EVLP are rich in miRNAs, with miR159a, among the top 10, potentially regulating ferroptosis-related pathways and directly binding to the 3’UTR of ACSL4. Overexpression of miR159a reduced Erastin-induced ACSL4 expression and alleviated mitochondrial damage in HT22 cells without causing toxicity. Conclusions This study highlights the potential of HT-EVLP as carriers of endogenous miR159a, offering a promising strategy for ischemic brain injury therapy.

Ex vivo lung perfusion (EVLP) is an emerging procedure that allows organ preservation, assessment and reconditioning, increasing the number of marginal donor lungs for transplantation. However, physiological and airflow measurements are unable to unveil the molecular mechanisms responsible of EVLP beneficial effects on lung graft and monitor the proper course of the treatment. Thus, it is urgent to find specific biomarkers that possess these requirements but also accurate and reliable techniques that identify them. The purpose of this study is to give an overview on the potentiality of shotgun proteomic platforms in characterizing the status and the evolution of metabolic pathways during EVLP in order to find new potential EVLP-related biomarkers. A nanoLC-MS/MS system was applied to the proteome analysis of lung tissues from an optimized rat model in three experimental groups: native, pre- and post-EVLP. Technical and biological repeatability were evaluated and, together with clustering analysis, underlined the good quality of data produced. In-house software and bioinformatics tools allowed the label-free extraction of differentially expressed proteins among the three examined conditions and the network visualization of the pathways mainly involved. These promising findings encourage further proteomic investigations of the molecular mechanisms behind EVLP procedure.