WO2000061166A9 - Systeme support metabolique exsanguine d'un organe ou tissu - Google Patents

Systeme support metabolique exsanguine d'un organe ou tissu

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Publication number
WO2000061166A9
WO2000061166A9 PCT/US2000/009894 US0009894W WO0061166A9 WO 2000061166 A9 WO2000061166 A9 WO 2000061166A9 US 0009894 W US0009894 W US 0009894W WO 0061166 A9 WO0061166 A9 WO 0061166A9
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WO
WIPO (PCT)
Prior art keywords
organ
perfusion
tissue
solution
ems
Prior art date
Application number
PCT/US2000/009894
Other languages
English (en)
Other versions
WO2000061166A1 (fr
Inventor
Lauren Brasile
Original Assignee
Breonics Inc
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Breonics Inc filed Critical Breonics Inc
Priority to EP00923303A priority Critical patent/EP1181032A4/fr
Priority to AU43454/00A priority patent/AU4345400A/en
Priority to CA2376607A priority patent/CA2376607C/fr
Publication of WO2000061166A1 publication Critical patent/WO2000061166A1/fr
Priority to US09/849,618 priority patent/US6582953B2/en
Publication of WO2000061166A9 publication Critical patent/WO2000061166A9/fr

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Classifications

    • A—HUMAN NECESSITIES
    • A01—AGRICULTURE; FORESTRY; ANIMAL HUSBANDRY; HUNTING; TRAPPING; FISHING
    • A01N—PRESERVATION OF BODIES OF HUMANS OR ANIMALS OR PLANTS OR PARTS THEREOF; BIOCIDES, e.g. AS DISINFECTANTS, AS PESTICIDES OR AS HERBICIDES; PEST REPELLANTS OR ATTRACTANTS; PLANT GROWTH REGULATORS
    • A01N1/00—Preservation of bodies of humans or animals, or parts thereof
    • A01N1/02—Preservation of living parts
    • A01N1/0236—Mechanical aspects
    • A01N1/0242—Apparatuses, i.e. devices used in the process of preservation of living parts, such as pumps, refrigeration devices or any other devices featuring moving parts and/or temperature controlling components
    • A01N1/0247—Apparatuses, i.e. devices used in the process of preservation of living parts, such as pumps, refrigeration devices or any other devices featuring moving parts and/or temperature controlling components for perfusion, i.e. for circulating fluid through organs, blood vessels or other living parts
    • A—HUMAN NECESSITIES
    • A01—AGRICULTURE; FORESTRY; ANIMAL HUSBANDRY; HUNTING; TRAPPING; FISHING
    • A01N—PRESERVATION OF BODIES OF HUMANS OR ANIMALS OR PLANTS OR PARTS THEREOF; BIOCIDES, e.g. AS DISINFECTANTS, AS PESTICIDES OR AS HERBICIDES; PEST REPELLANTS OR ATTRACTANTS; PLANT GROWTH REGULATORS
    • A01N1/00—Preservation of bodies of humans or animals, or parts thereof
    • A01N1/02—Preservation of living parts

Definitions

  • the invention relates to a metabolic support system including a solution, method and apparatus for sustaining organs for transplantation under near-physiologic conditions. More particularly, the invention relates to use of the system for repair and/or long-term maintenance of organs for transplantation, as a pharmaceutical delivery system and prognosticator of posttransplantation organ function.
  • kidney transplantation is largely dependent upon the availability of organs retrieved from heart-beating cadaver donors.
  • organs for transplantation namely, non- heart-beating cadavers.
  • Non-heart-beating cadavers are accident victims who succumb at the site of an injury and those having short post-trauma survival times.
  • non-heart-beating cadavers result when families are emotionally unable to make the decision to donate the organs of a loved one contemporaneously with making the decision to terminate life support.
  • the organs are not used because the lack of circulating blood supply (warm ischemia) once the heart stops beating, results in an injury cascade.
  • hypothermic conditions presently utilized to preserve organs intended for transplantation. Under these conditions, the lipid bilayer experiences a phase-change and becomes gel-like, with greatly reduced fluidity.
  • the essentially frozen lipid in the cell membranes negates the utilization of 0 : -tension.
  • the metabolic consequence is glycolysis, which is analogous to the state of anoxia. It has been described that below 1 8°C, hypothermia inhibits the tubular and glomerular activities of the kidney and that at 4°C, the utilization of oxygen is approximately 5% of that at normothermia. Hypothermic storage can also produce vasospasm and subsequent edema in an organ.
  • Hypothermically preserved organs can experience giomerular endothelial cell swelling and loss of vascular integrity along with tubular necrosis; phenomenon attributable to the hypothermic conditions employed. Hypothermia can also inhibit the Na/K dependent ATPase and result in the loss of the cell volume regulating capacity. The loss of volume regulation is what causes the cellular swelling and damage. An ample supply of oxygen does not actively diminish the amount of this swelling because the cell membrane is essentially frozen, preventing the effective utilization of oxygen. Without adequate oxygen delivery, the anoxia leads to disintegration of the smaller vessels after several hours of perfusion. The lack of oxygen and the subsequent depletion of ATP stores mean that anaerobic glycolysis is the principal source of energy under traditional preservation conditions.
  • ischemia (whether warm ischemia or cold ischemia) is an injury cascade of events that can be characterized as a prelethal phase, and a lethal phase.
  • hypoxia malnutrition
  • failure to remove toxic metabolic wastes With the lack of circulating blood comes a lack of molecular oxygen.
  • the resulting hypoxia induces depletion of energy stores such as the depletion of ATP stores in mitochondria.
  • Depletion of ATP leads to cellular changes including edema, loss of normal cellular integrity, and loss of membrane polarity.
  • the cellular changes induces the lethal phase of ischemia resulting in accumulation of metabolic wastes, activation of proteases, and cell death.
  • the perfusate solution that represents the current state-of-the-art in hypothermic organ preservation, and provides for optimized organ preservation under hypothermic conditions, contains components which prevent hypothermic induced tissue edema; metabolites which facilitate organ function upon transplantation; anti- oxidants; membrane stabilizers; colloids; ions; and salts (Southard et al., 1990, Transpl. 49:251 ; and Southhard. 1989. Transpl. Proc. 21 : 1 195.
  • the formulation of this perfusate is designed to preserve the organs by hypothermic induced depression of metabolism. While it minimizes the edema and vasospasm normally encountered during hypothermic storage, it does not provide for the utilization of a substantially expanded donor pool.
  • a protective solution disclosed in U.S. Pat. No. 4,415,556. is used during surgical techniques or for organs to be transplanted for preventing ischemic damage to the organ.
  • the protective solution is used as a perfusate to improve aerobic metabolism during the perfusion of the organ.
  • U.S. Patent No. 5,395,314 describes a method of resuscitating a brain by circulating, after interruption of the blood supply, through the brain a hypothermic preservation solution (approximately 8°- 10°C) designed to lower organ metabolism, deliver oxygen, and inhibit free radical damage.
  • a preservation solution useful for initial organ flushing and as a perfusate for in situ or ex vivo preservation of organs for transplantation which employs a warm preservation technology which minimizes, and, in fact, repairs damage due to warm ischemia, and which supports the organ near normal metabolic rate.
  • Portability and automation of the system is important, particularly in situations where the system is used to initiate organ preservation in situ either prior to or immediately following termination of life support or at external sites following an accident where cardiac arrest has occurred.
  • the invention relates to an exsanguinous metabolic support system for maintaining an organ, tissue or section of anatomy in a near normal metabolic state outside of, or at least isolated from the circulatory system of the body.
  • the system comprises an organ chamber for holding an organ, having means to collect organ product generated during perfusion; a perfusion delivery subsystem comprising one or more perfusion fluid paths for circulating and regenerating a warm perfusion solution capable of supporting the organ in a near normal metabolic state; a controlled gassing subsystem for regulation of respiratory gases and pH of the perfusate: a temperature controller for controlling temperature of the perfusate; and a monitoring subsystem for monitoring various parameters of the perfusate.
  • the invention relates to a monitoring subsystem in which the monitoring of various parameters of the perfusion solution is computer controlled.
  • a monitoring subsystem in which the monitoring of various parameters of the perfusion solution is computer controlled.
  • Such a system would include a computer, and sensor means interposed in the perfusate flow path, and coupled to the computer for sensing at least one of the temperature, pH, pressure, flow rate, PaO : PaCO, and osmolarity of the perfusion solution and providing the sensed information to the computer.
  • the invention in another aspect, relates to a method for the maintenance of an organ or tissue for transplantation, comprising the steps of flushing the organ with a buffered physiological solution to remove blood and blood products, establishing and maintaining the organ in the exsanguinous metabolic support system of the present invention, and monitoring the functional integrity of the organ.
  • the invention relates to a method for the effective delivery of an exogenous molecule to a target tissue comprising the steps of removing a target tissue or organ from a living body, flushing the organ with a buffered physiological solution to remove blood and blood products having accumulated in the organ during isolation of the organ, maintaining the target tissue in a recirculating, oxygenated perfusion solution, in a near normal metabolic state at 25-37°C: contacting the target tissue with the exogenous molecule to be delivered in the perfusion solution, and then returning the organ or tissue to the body of the donor or another recipient.
  • the invention relates to a method for the effective delivery of an exogenous molecule to a target tissue comprising the steps of isolating a target tissue or organ from the rest of the circulatory system of a living body, flushing the organ with a buffered physiological solution to remove blood and blood components, maintaining the target tissue in a recirculating, oxygenated perfusion solution, in a near normal metabolic state at 25-37°C, contacting the target tissue with the exogenous molecule to be delivered in the perfusion solution of the invention for a period of time sufficient to effectuate delivery' of the molecule and then returning the organ or tissue to the rest of the circulatory system of the body.
  • the invention relates to a solution to be in employed in an exsanguinous metabolic support system comprising a buffered basal medium which contains essential and non-essential amino acids, carbohydrates, metabolites, inorganic ions, serum proteins, lipids. hormones, nitrogen bases, vitamins, reducing agents and a buffering system and additional components for oxidative metabolism including coenzyme A, FAD, DPN, Cocarboxylase, TPN, 2'-deoxyadenosine. 2'deoxyguanosine, 2'-deoxycytidine, thymidine. adenosine, guanosine, cytidine, uridine, ATP. AMP, and UTP.
  • a buffered basal medium which contains essential and non-essential amino acids, carbohydrates, metabolites, inorganic ions, serum proteins, lipids. hormones, nitrogen bases, vitamins, reducing agents and a buffering system and additional components for oxidative metabolism including coenzyme A, FAD, D
  • the invention in still another aspect, relates to a method for storing a tissue, explant or organ intended for transplantation comprising the steps of flushing the tissue, explant or organ with a non-blood buffered physiological solution to remove blood and blood products; perfusing the tissue, explant or organ in a warm preservation system capable of maintaining the tissue, explant or organ at a near normal rate of metabolism for a period of time sufficient to impart protection to the tissue, explant or organ; and storing the organ at 4-8°C.
  • FIGURE 1 shows an embodiment having a closed loop perfusion subsystem for circulating the perfusion fluid and a dialysis subsystem for reprocessing it.
  • FIGURE 2 shows an embodiment, having a perfusion exchange subsystem and two perfusion paths, which is suitable for preservation of a liver.
  • EMS metabolic support system
  • the EMS perfusion system of the present invention delivers a warm perfusion solution containing all the constituents necessary to reestablish, where necessary, and support oxidative metabolism by the organ.
  • the perfusion system may also reprocess the perfusion solution to ensure a continuous supply of nutrients and chemical energy substrates and remove metabolic by-products.
  • the EMS monitors and controls various parameters of the perfusion including temperature. vascular pressures, perfusion flow rate, OsM, pH, Pa0 2 , PaC0 2 . nutrient delivery and the removal of waste products.
  • organ, tissue or section of anatomy refers to an excised viable and whole section of the body to be maintained as such in the EMS of this invention, and refers to an intact organ including, but not limited to, a kidney, heart, liver, lung, small bowel, pancreas, brain, eye. skin, limb or anatomic quadrant.
  • organ product refers to any substance generated as the result of the secretory function of an organ, frequently a fluid, for example, bile from liver, urine from kidneys, but also includes mechanical functions such as kidney filtration or heart pumping.
  • perfusion solution and "perfusate” are used interchangably and refer to a non-blood buffered physiologic solution that provides means for reestablishing cellular integrity and function in organs which may have experienced ischemic damage prior to or during isolation and further, enables an organ or tissue to be maintained at a near normal rate of metabolism.
  • non-blood is intended to exclude perfusates comprising substantially whole blood or its individual components.
  • the perfusion solution of the present invention may, however, contain a minimal amount of whole blood or a blood component, for example, red blood cells, serum or plasma.
  • normal rate of metabolism and “near normal metabolic rate” are defined as about 70- 100%) of the normal rate of metabolism for a particular organ as determined by measuring and evaluating whether functional characteristics of an organ, such as those described in U.S. Patent No. 5,699.793. are within the range associated with normal function for that particular organ.
  • functional characteristics include, but are not limited to, electrical activity in a heart as measured by electrocardiogram; physical and chemical parameters of organ product, for example, oxygen consumption and glucose utilization which can be ascertained from perfusate concentrations; pancreatic enzymes; heart enzymes: creatinine clearance and filtration functions, and specific gravity of urine and so on.
  • therapeutic agent refers to any molecule used to effect a functional, metabolic, immunogenic or genomic change in an organ or tissue. These include but are not limited to viral vectors, liposomes. episomes. naked DNA, either sense or anti- sense molecules. RNA, chemotherapeutic agents, biologies, such as cyokines and chemokines and the like.
  • the process according to the present invention involves isolating an organ, tissue or specific area of anatomy from the rest of the physiologic system by removing or interrupting the arterial source of blood feeding the desired tissue(s). Likewise, the venous outflow from the organ or section of anatomy is interrupted and the venous effluent is collected. If the tissue is completely excised from the body, then the enervation and lymphatics of the tissue(s) are also isolated. Next, the organ or tissue is flushed through the arterial system with the solution of the present invention at a temperature of about 25 ° - 37°C to remove blood and blood products.
  • Organ function is also monitored, for example, by collecting an organ product, such as urine or bile, and evaluating whether physical and chemical parameters of the organ product are within the range associated with normal function for that particular organ.
  • the invention may optionally include, therefore, a subsystem for evaluating the functional status of the organ. In this way, organ function can be monitored using in-line detection means and in-line testing methodology.
  • Perfusion of the isolated organ or section of anatomy with a solution at near physiologic temperature of about 25°C to 37°C performs a number of functions. It maintains the cellular environment at physiologic pH and maintains near normal oxygenation. temperature, and osmolarity. It maintains the normal barrier function of the tissue to macromolecules. thereby resulting in stable perfusion pressures and stable vasculature flow rates. It adequately dilates and fills the vasculature, delivers adequate trophic factors to maintain a near normal level of metabolism in the isolated organ or section of anatomy and supports the artificially interrupted aerobic metabolism by providing high energy compounds. It supports ongoing oxidative metabolism with supplemental substrates that may include, but are not limited to. glucose, pyruvate.
  • the ongoing oxidative metabolism is further supported by maintaining the adenine compound pool.
  • the citric acid cycle and the electron transport chain are supported by providing adequate substrate delivery to continue metabolic support and function in the isolated organ and tissues.
  • the ongoing metabolism supported by the method and solution of the invention provides adequate metabolites and nutrients to maintain the tissue integrity with tight cellular functions and normal membrane polarity.
  • the method and system of the invention allows for the removal of blood within the organ or section of anatomy and refills the vascular and pericellular spaces with the solution of this invention. Further, the system maintains pH. Pa0 2 . temperature, osmolarity, and hydrostatic pressures and delivers adequate substrate to support the metabolism necessary for cellular integrity.
  • the ongoing metabolism provided by the method, solution and system, in combination, is of sufficient level to support the ongoing function of the specific organ or section of anatomy during the time the tissue(s) are isolated from the body or the circulatory system.
  • the solution is perfused at a systolic pressure appropriate for the tissue(s) being maintained with the EMS organ culture technology of this invention until a flow rate is achieved which is near normal for that particular organ or tissue.
  • a human kidney may be perfused with the solution at a systolic pressure of ⁇ 80 mmHg with a flow rate >80 cc/min.
  • the pH is maintained in a physiologic range by the injection of CO : or 0 2 via an oxygenator. Adequate oxygen is provided to the organ by including an oxygen transporting compound as a component of the solution.
  • the method, solution and system according to the present invention provides the necessary oxygen delivery, nutrients for metabolism, oncotic pressure, pH, perfusion pressures, temperature, and flow rates to support adequate organ metabolism near the respective physiologic range.
  • a near normal rate of metabolism as defined above is about 70- 100% of normal rates of metabolism.
  • the method, solution and system according to the present invention supports a level of metabolism during the period of EMS organ culture which supports sufficient oxidative metabolism to result in the normal functional product of the organ or section of anatomy.
  • exsanguinous metabolic support (EMS) technology of the present invention provides, therefore, a number of advantages over conventional cold preservation methodologies: ( 1 ) Organs intended for transplantation can be maintained in a metabolically active state for a prolonged period of time prior to being transplanted during which the functional integrity of the organ can be assessed and the likelihood of its ability to function posttransplantation can be evaluated.
  • EMS perfusion prior to exposure to cold ischemia in traditional cold storage protocols provides tissue protection and allows for extended periods of cold storage of an allograft as compared to immediate cold storage following harvest of the organ: (4) EMS perfusion provides means for targeted delivery of a therapeutic agent, for example, in chemotherapy or gene therapy.
  • Organ preservation and perfusate solutions are known in the art as comprising a base solution that consists of a buffered physiological solution, such as a salt solution or a cell culture-like basal medium, to which is added a variety of defined supplements.
  • the perfusion solution of the present invention employs such a base solution containing amino acids in quantities sufficient to support protein synthesis by the metabolizing organ, ions, physiologic salts, serum proteins, carbohydrates, and a buffering system for maintaining pH at physiologic levels.
  • the perfusion solution of the present invention has been designed to support the nutritional and metabolic needs of the vascular endotheliu within a graft, thereby maintaining the integrity of the vasculature and, subsequently, the normal permeability of the organ.
  • the buffered basal medium may be any commercially available salt solution or cell culture medium, (e.g., Hank ' s BSS, Earle ' s BSS, Ham's F 12, DMEM, Iscove's,
  • a bicarbonate buffer system is employed.
  • the bicarbonate buffer works in concert with the respiratory gas controller subsystem of the EMS system to automatically maintain the pH of the perfusion solution in a narrow range. 7.0 to 7.6, and more preferably, 7.30 - 7.45, which approximates respiratory control of blood pH by the lungs.
  • a number of supplements including, but not limited to, essential and non-essential amino acids, growth factors, vasodilators, vitamins, and chemical energy substrates, in a physiologially effective amount to support oxidative metabolism by the organ or tissue.
  • Amino acids to be included in the perfusion solution of the present invention include the basic set of 20 amino acids and may be D- or L-amino acids, or a combination thereof, or may be modified amino acids, such as citrulline. ornithine, homocysteine, homoserine. ⁇ -alanine, amino-caproic acid and the like, or a combination thereof.
  • Chemical energy substrates added to the perfusion solution may include pyruvate, glucose, ATP, AMP, coenzyme A, flavin adenine dinucleotide (FAD), thiamine pyrophosphate chloride (cocarboxylase), ⁇ -nicotinamide adenine dinucleotide (DPN), ⁇ -nicotinamide adenine dinucleotide phosphate (TPN), uridine 5' triphosphate (UTP) chloride.
  • the chemical energy substrates comprise from about 0.01 % to about 90%> by volume of the combination of supplements added to the base solution in preparing the perfusion solution of the present invention.
  • nucleic acids for DNA repair and synthesis including 2' deoxyadenosine, 2'deoxyguanosine, 2'deoxycytidine, adenosine, thymidine, guanosine, cytidine and uridine.
  • the solution of the present invention may further comprise hormones, such as insulin, and thyroid stimulating hormone (TSH) and growth factors (GF), such as platelet-derived growth factor (PDGF), fibroblast growth factor (FGF- 1 , FGF-2), insulin-like GF I and II, epithelial GF, epidermal GF, brain- derived FGF, somatomedins Al , A2, B and C, nerve growth factor ( GF), vascular endothelial growth factor (VEGF), heparin-binding growth factor (HBGF), endothelial cell growth factor (ECGF), transforming growth factor (TGF), glucocorticoids and urogastone.
  • cytokines such as IL- 1. colony stimulating factor (CSF), and erythropoietin.
  • the perfusion solution of the present invention also comprises serum albumin and/or mucopolysaccharides such as chondroitin sulfate B, heparin, petastarch, hetastarch, and plasma expanders as a source of colloid, and lipids, such as linoleic acid, arachidonic acid, linolenic acid, eicosapentaenoic acid, docosahexaenoic acid, oils. Additionally, attachment factors, antioxidants, vasodilators and impermeants may be included in the perfusion solution of the present invention.
  • serum albumin and/or mucopolysaccharides such as chondroitin sulfate B, heparin, petastarch, hetastarch, and plasma expanders as a source of colloid
  • lipids such as linoleic acid, arachidonic acid, linolenic acid, eicosapentaenoic acid, do
  • the high osmolar solution of the present invention is used for the initial organ flushing, and as a perfusate for long term maintenance of an organ in the EMS system using warm preservation technology ( 18°- 35 C C) without extreme hypothermia.
  • the solution has been designed to support the nutritional and metabolic needs of the vascular endothelium within a graft, thereby maintaining the integrity of the vasculature and subsequently the normal permeability of the organ.
  • the solution of the present invention was specifically designed to potentiate the simultaneous growth of microvessel and large vessel endothelial cells, to support the integrity of vascular endothelium within a graft: and to support normal permeability and metabolism without extreme hypothermia.
  • the enhanced ability of the solution to serve as a preservation solution for organs for transplantation using a warm preservation technology may be attributed to supplementation with serum albumin as a source of protein and colloid, vasodilators to ensure adequate dilation of the vasculature, trace elements to potentiate viability and cellular function, pyruvate and adenosine for oxidative phosphorylation support; transferrin as an attachment factor; insulin and sugars for metabolic support; and glutathione to scavenge toxic free radicals as well as a source of impermeant; cyclodextrin as a source of impermeant, scavenger and potentiator of cell attachment and growth factors; a high Mg concentration for microvessel metabolism support; mucopolysaccharides, comprising primarily chondroitin sulfates and heparin sulfates, for growth factor potentiation and hemostasis; and ENDO GROTM as a source of colloid, imper
  • the preservation solution of the present invention has been found to preserve organs without extreme hypothermia, and does not present the common problems encountered with cold perfusates, namely, edema, vasospasm, depletion of ATP stores, shutdown of ion pumps, glycolysis, and the generation of cold-induced toxic free radical intermediates.
  • the preservation solution of the present invention provides for more efficacious preservation thereby presenting the potential to utilize an expanded donor pool, namely, the non-heart beating cadaver donors. It will be appreciated by those skilled in the art that other components may be substituted for a functionally equivalent compound to achieve the same result.
  • Table 1 lists components of one embodiment of the perfusion solution of the present invention.
  • the perfusion solution contains one or more oxygen transporting compounds ("oxygen carrying agents") that function to provide molecular oxygen for oxidative metabolism to the organ.
  • oxygen carrying agents are well known to those skilled in the art and include, but are not limited to, hemoglobin, stabilized hemoglobin derivatives (made from hemolyzed human erythrocytes such as pyridoxylated hemoglobin), polyoxethylene conjugates (PHP), recombinant hemoglobin products, perfluorochemical (PFC) emulsions and/or perfluorochemical microbubbles (collectively referred to as "perfluorochemical").
  • hemoglobin stabilized hemoglobin derivatives (made from hemolyzed human erythrocytes such as pyridoxylated hemoglobin), polyoxethylene conjugates (PHP), recombinant hemoglobin products, perfluorochemical (PFC) emulsions and/or perfluorochemical microbubbles (collectively referred to as "perfluoro
  • perfluorochemical such as perflubron emulsion (perfluoroocytl bromide, PFOB).
  • perfluorochemical emulsions said to be useful as oxygen carrying agents are described, for example, in U.S. Pat. Nos. 5,403,575; 4,868,318: 4,866,096; 4.865,836; 4,686,024; 4,534,978; 4,443,480; 4,423,077; 4,252,827; 4, 187,252; 4, 186,253; 4, 1 10,474; and 3,962,439.
  • Such liquid PFC emulsions include, but are not limited to perfluorooctyl bromide, perfluorooctyl dibromide, bromofluorocarbons, perfluoroethers, Fluosol
  • oxygen carrying agents comprise from about 0% to about 59% by volume of the supplements which are added to, and dissolved in, the base solution in preparing the perfusion solution of the present invention; or about 0% to about 20% of the total perfusion solution (v/v).
  • red blood cells may be used as an oxygen carrier in an effective amount to support metabolism by the organ being perfused (about 0.1 % to 5%.) Generally, about 5cc of RBC per 500ml of perfusion solution (that is, about 1 %) is an effective amount. When compared to perfluorochemical emulsion or conjugated hemoglobin. RBC provides oxygen concentrations equivalent to the oxygen consumption by the metabolizing organ. This generally occurs at the rate of 0.1 - 0.3cc/min/gm. Additionally, after 24 to 48 hours of perfusion, there was no evidence that the RBC were cretinated. Therefore, an amount of RBC in this range does not present the problem of mechanical damage to the organ associated with blood-based perfusates.
  • RBC (5cc per 500ml of perfusate) were added to the circulating perfusate until a Pa0 2 of >200mmHg was obtained. Stable perfusion pressures, vascular flow rates and diuresis were achieved (See Table 2).
  • the perfusion solution of the present invention may additionalh comprise vasodilators, in a physiologically effective amount which provide a means to adequate! ⁇ dilate large vessels via smooth muscle cell relaxation, as well as to adequately dilate microvessels. To insure that normal permeability of the vasculature is maintained, the vasodilation is controlled in an endothelial cell-dependent manner.
  • Vasodilator components for use in the perfusion solution of the present invention include (i) substrates for endothelial cell mediated vasodilation, such as acetylcholine, dopamine, bradykinin, and arginine; (ii) substrates for microvessel vasodilation. such as prostacyclin (and analogs, e.g. carbacyclin) and Mg " : and (iii) adenosine (and analogs, e.g. cyclohexyladenosine), and verapamil for their combined effects on vascular dilation mediated by calcium channel blocking.
  • Other calcium channel blockers encompassed by the invention include fiunarizine, nifedipine.
  • vasodilators ensures that the vasculature is well dilated while simultaneously retaining its integrity and normal barrier function.
  • the vasodilators comprise from about 1% to about 50% by volume (w/v) of the combination of supplements which are added to the base solution in preparing the perfusion solution of the present invention.
  • FIGURE 1 is a diagram of one embodiment of the organ perfusion circulation path of the present invention. In most instances, only one perfusion path is necessary. When the organ to be metabolically maintained is a liver, however, two perfusion circuits are required. These are illustrated in FIGURE 2 and described in more detail below. All perfusate available for circulation through the system is propelled through the circulation path 10 by a pump 12. The direction of flow of the perfusion solution is indicated by arrows within the flow path. While any pump may be used to circulate the perfusion fluid of the instant invention, a pulsatile pump such as Model No. MOX- 100TM, (Waters Instruments, Inc., Rochester, Minn.) is preferred. Before the perfusate enters the organ chamber 32.
  • MOX- 100TM Model No. MOX- 100TM
  • the heat exchanger 14 is controlled by a temperature controller 16 which receives input from a temperature sensor 18 situated in the perfusate path 10.
  • the temperature controller is a single unit comprising a thermocouple which senses the temperature of the perfusate and a heat exchanger which is activated by the thermocouple, when required, to maintain the temperature in the desired range.
  • the perfusate which contains an oxygen carrier, is also oxygenated prior to contact with the organ via a hollow fiber or membrane oxygenator 20, for example, a pediatric size oxygenator. such as those available from Sarnes, to provide a partial pressure of oxygen, in most cases, in the range of 100 - 240 mmHg.
  • a pediatric size oxygenator such as those available from Sarnes
  • the partial pressure is maintained in the range of 80 - 140 mmHg.
  • the oxygenator 20 is situated in the perfusion solution flow path 10 between the heat exchanger 14 and pH sensor 22.
  • the oxygentator may be an independent unit or may be combined with another component of the system to form a single unit, for example, combined with the heat exchanger, or as part of the organ chamber.
  • the pH and PaC0 2 of the perfusion solution are controlled by automatic intermittent gassing of the perfusate with C0 2 to provide a circulating perfusate having a pH in the range of 7.30 - 7.45 and a partial pressure of C0 2 of 30-60 mmHg.
  • the perfusate is debubbled in a conventional bubble trap 30 just prior to entering the organ chamber 32.
  • the perfusate leaves the organ as venous effluent and, in one embodiment, drains by gravity directly into an effluent reservoir 38 situated beneath the compartment of the organ chamber 32 which holds the organ.
  • the effluent is directed to the effluent reservoir 38 by means of tubing 43 which connects to a conventional non-traumatic cannula which has been inserted into the vein of the organ 40.
  • the specifications of the organ chamber 32 used depend on the organ to be maintained. For example, when the organ is a liver, the organ chamber must have more than one perfusate inlet to accommodate two simultaneously operating perfusion flow paths (FIGURE 2).
  • an open vertical tube extending upward from the perfusate flow path above the point of entry of perfusate into the heart, provides a column of perfusate, such that sufficient pressure is maintained to counter the expulsion of the perfusate by the beating heart.
  • the organ chamber comprises a container 32, adequate in size to accommodate the organ 40 to be maintained, and having a removable cover 34.which is made of a rigid material and has means, such as a translucent panel, for viewing the interior of the chamber.
  • the organ chamber 32 has means 36 for supporting the organ 40 within the chamber 32 and further comprises one or more perfusate inlets 42, means 48 for collecting organ product from the organ 40 and. in one embodiment, a reservoir 38 for the perfusate effluent having an effluent outlet 45.
  • Organ support means 36 may be of a rigid material such as stainless steel, or preferably, of a mesh-like fabric which suspends the organ in a sling-like fashion.
  • the support means 36 may have one or more openings 37 which allow passage of perfusate to the reservoir below.
  • the organ chamber 32 has one or more effluent outlets which direct the perfusate to a perfusate reservoir which is separate from the organ chamber.
  • the perfusate reservoir 38 of the instant invention additionally comprises means 46 for perfusate exchange.
  • the organ chamber may be a disposable single-use unit or of a suitable material, such as stainless steel, which can be sterilized and reused.
  • the venous effluent from the organ is collected by gravity flow directly into the reservoir 38 of the organ chamber 32 through openings 37 in the support means 36 or, in a preferred embodiment, by cannulating the vein using a non-traumatic cannula and connecting a length of tubing 43 to conduct the effluent away from the organ.
  • the effluent is filtered through a filter 44 having a pore size of 0.22 microns, such as those available from Millipore Corp., to remove debris and any bacterial contaminants.
  • the perfusate would eventually be exhausted without some replenishment or regeneration.
  • the ingredients necessary to support metabolism can be replenished by perfusate exchange, that is, removing a portion of the spent perfusate via means 46 in the reservoir and replacing it with fresh perfusate.
  • the perfusate is exchanged by means of two volume- regulatable pumps 47 and 49; pump 47 is connected to means 46 in the reservoir to extract depleted perfusate. and pump 49 is situated in the perfusate path 10 just prior to the oxygenator 20. Removal of depleted perfusion solution by pump 47 is immediately followed by introduction of an equal volume of fresh perfusate into the system by pump 49. Exchange in this manner can be continuous or intermittent. The rate of exchange is dependent upon temperature and/or metabolic rate of the organ being perfused. By introducing fresh perfusate into the perfusion path just prior to the oxygenator 20 and pH control system, the Pa02 and pH of the perfusate remain constant. In this way, metabolic by-products are removed and fresh solution is administered to maintain ongoing metabolism by the organ without acidosis developing. Perfusate volume remains constant as does perfusate osmolarity.
  • the perfusate is continuously regenerated by dialysis, alone or in combination with perfusate exchange.
  • the perfusion dialysis subsystem of the EMS as shown in FIGURE 1. comprises an effluent reservoir 50 in fluid communication with the perfusion flow path 10 and one or more nutrient reservoirs Dl, D2, D3, Dn.
  • Nutrient reservoirs, Dl, D2, D3, Dn are in communication with the effluent reservoir 50 via semi-permeable membranes Ml, M2, M3, Mn of varying molecular weight cut-offs in the range of 1.000 - 80,000 daltons. These nutrient reservoirs contain concentrated amounts of components necessary to regenerate the perfusion solution, which are allowed to diffuse into perfusate in the effluent reservoir 50.
  • the nutrient reservoirs are arranged in order of decreasing molecular size, so that the perfusate flow ing by is contacted first, by the nutrient with the largest molecular size, followed by nutrients with increasingly smaller molecular weight. This ensures that any components which might be lost at the first dialyzer unit are replenished by exposure to subsequent units before leaving the perfusion dialysis system.
  • the system further comprises means for regulating the volume of the perfusion solution, so that an equilibrium is maintained between the effluent reservoir and the nutrient reservoirs.
  • the perfusion solution monitor subsystem performs a plurality of functions, using standard components and hardware to monitor various parameters of the perfusion solution. Temperature is sensed and controlled by a thermocouple 18 linked to the heat exchanger.
  • One or more manometers 31 situated in the perfusion solution flow path are used to monitor the vascular resistance to the perfusate and the partial pressures of the respirator ⁇ ' gases.
  • a flowmeter 52 for example, an ultrasonic device, such as those available from Transonic, for detecting flow rate having a sensor 54, which clips onto the tubing carrying the perfusate, is used to monitor the flow rate of the perfusate.
  • the flowmeter is situated in the flow path between the bubble trap and organ chamber.
  • Osmolarity of the perfusate is assessed using the conventional freezing point depression method. Alternatively, osmolarity may be monitored using in-line detection means to assess the concentration of major constituents of the perfusion solution. A sample of perfusate may be removed via the bubbletrap 30 or some other means situated in the perfusion flow path for this determination. It should be understood that a microprocessor and suitable software can also be utilized for control purposes; all are within the skill of the ordinary artisan. Components of the control subsystem may be combined or provided as separate parts which are implemented in the system as a matter of design choice.
  • the perfusion solution is continuously oxygenated by introducing 100% oxygen 28 via a membrane or hollow fiber oxygenator 20 to maintain a partial pressure of 0 2 (Pa 0 2 ) of 100-250mmHg.
  • the system of the instant invention includes a novel mechanism for maintaining a perfusate pH between 7.32 and 7.38 and the level of C0 2 in the perfusate at a partial pressure of 30-60mmHg. Regulation of pH and C0 2 levels of the perfusate is achieved by the controlled intermittent gassing of the perfusion solution with C0 2 .
  • the system continuously monitors the pH, for example, by a pH electrode or sensor 22 in the perfusion path 10.
  • the pH sensor 22 is operatively connected to a controller 24 and solenoid 25 for regulation of the C0 2 26 gassing required to maintain tight control of the pH.
  • one or more pH meters 21, for example, Model HI 871 1 by Hanna Instruments monitors the pH of the circulating perfusate by way of sensors or electrodes 22 situated in the perfusion flow path 10.
  • An in-line controller 24, such as the Datalogger by Breonics, Inc. receives inputs from the pH sensors 22 via a pH meter 21 connected to the controller 24 and operates a valve interface 23 by way of solenoid 25 to release C0 2 26 into the perfusion solution
  • the gassing system is activated by way of valve interface 23 and solenoid 25, and C0 2 26 is injected into the perfusion solution until a pH of 7.35 again is reached, at which point the system is deactivated and the gas is turned off.
  • the intermittent gassing of the perfusion solution with C0 2 in this manner when used in conjunction with a perfusion solution having a bicarbonate buffer system is especially effective in mimicking the tight physiologic control of blood pH by the respiratory system.
  • a sufficient amount of the perfusion solution is slowly introduced by infusion via a cannula into the major arterial blood supply for the particular organ to be perfused until the effluent is free of blood.
  • the amount of the perfusion solution sufficient for use in flushing the organ may depend on the particular organ type and size, as well as the length of time the organ was deprived of blood flow. For example, 200 to 600 mis of the perfusion solution may be sufficient to flush a human kidney which has been deprived of blood flow for a period of 1 -3 hours. In this way, any ischemic blood and acidotic products which have accumulated in the vascular space are removed. Further, pH is restored and fresh substrate is delivered to support anaerobic metabolism and other cellular pathways necessary for cellular integrity and function.
  • the organ After flushing, the organ is immobilized within the interior space of the organ chamber, for example, by suspending in a sling-like mesh or by encasing in a gelatinous coating which fills or nearly fills the interior space of the chamber, so as to prevent the organ from moving around in the chamber, particularly during transport.
  • An additional benefit of the coating is that the risk to the organ of contamination by contact with air is minimized.
  • the organ is then connected to the perfusion solution path by a short length of tubing connecting the cannulated artery to an inlet port of the organ chamber. It is desirable that all the tubing used in the instant invention be made of an inert, sterilizable material, for example, silicon or Tygon* tubing.
  • the organ is perfused, while the perfusion solution is maintained at a temperature in the range of 25°C to 37°C.
  • the system regulates the Pa0 2 PaCO, and pH of the perfusate with the gassing subsystem, and monitors the flow rate vascular pressure and osmolarity.
  • the functional integrity of the organ is also monitored.
  • Various physiologic and metabolic parameters can be used as indicia of functional integrity.
  • Use of a perfusate of a known formulation, such as that illustrated in Table 1 can facilitate measurement of certain aspects of metabolic function.
  • the rate at which the glucose concentration is depleted, in relation to time, in the perfusate as it circulates through the organ is one measure of organ function. Relative to a selected time point, a glucose concentration that is below the range of a normal level of glucose utilization may be an indicator of organ damage or inhibited metabolism.
  • Another example of a measure of organ function is the amount of oxygen consumption as the perfusate circulates through the organ. Inadequate oxygen consumption, i.e.
  • a low oxygen consumption compared to the normal range may be indicative of tissue hypoxia.
  • a measure of organ function is the vascular flow rate of perfusate circulating through the organ using a standard perfusion pressure.
  • a low flow rate, compared to the normal range may be indicative of vasoconstriction, edema, vascular endothelial cell sw elling and loss of vascular integrity in a damaged organ.
  • the system of the present invention also provides a second monitoring subsystem for evaluation of other indicators of an organ's functional integrity.
  • means located on the organ chamber for extracting organ product from the organ during the perfusion period make it possible to monitor organ function by tracking organ output and evaluating physical and chemical parameters of the product of the perfused organ relative to ranges indicative of normal organ function.
  • One of skill in the art can readily determine, based on the organ to be preserved, what characteristics to monitor. For example, where the organ is a kidney, overall renal function, as well as individual aspects of kidney physiology, can be determined by measuring parameters including the rate of diuresis, urine osmolality, specific gravity, creatinine clearance and so on.
  • the nature of the monitoring subsystem will be dependent on the organ being perfused and may include means for measuring bile enzymes, heart enzymes, electrocardiographic activity, and so on.
  • Example 1 Canine kidneys were isolated, the renal artery was cannulated and the solution was applied with the process and system of the present invention. All blood was removed from the kidneys and the kidneys were perfused with the solution. The kidneys were maintained with the support of the EMS organ culture technology at 32°C for three days. Similarly, a physiologic pH, osmolarity, pressures, flow rates, and oxygen consumption were maintained during the period of the EMS organ culture. The kidneys remained intact and continued to metabolize during the period of organ culture. The ongoing metabolism in the kidneys remained sufficient to result in continued function, that is, the kidneys continued to produce urine through out the period of the organ culture. The results of the culture of intact whole kidneys is listed in Table 2. There was no deterioration in metabolism or function in any parameter category during the period of the EMS organ culture. Similarly, no edema developed, nor was any necrosis observed following histologic evaluation.
  • bovine kidneys were also tested. Bovine kidneys were placed in EMS organ culture for three days using the same techniques described in Example 1 . Similar to the results using canine kidneys, the bovine kidneys could be maintained in EMS organ culture, intact for three days without loss of ongoing metabolism or resulting function. Similar to the results obtained with canine kidneys, the bovine kidneys exhibited stable perfusion pressures, flow rates and lack of edema during the period of organ culture. Upon histologic evaluation, the bovine kidneys appeared normal, with excellent preservation of all components of the kidney architecture.
  • Example 3 Hearts from rats were excised and the aorta was cannulated. The hearts were placed in EMS organ culture with the present invention and maintained for 24 hours. The results of the testing using the rat hearts are listed in Table 3.
  • Example 4 Human placentas with the umbilical cords still attached were collected. A cannula was placed in the umbilical cord vein and the organ was flushed of its blood with the solution of the present invention. Once the organ was flushed of blood and the vascular compartment was filled with the solution, the organ was placed in EMS organ culture. The organ was maintained intact with the EMS organ culture technology for approximately 22 hours.
  • the flow rate of the solution through the placenta was 92 cc/min with a systolic pressure of 80 mmHg.
  • the intact placentas were evaluated histologicalK . Isolated cells were then obtained from both the umbilical cord and the placenta itself. The results are listed in Table 4.
  • Viable cells could be isolated from the whole organ following 22 hours in EMS organ culture. Tissue from both the umbilical cord vein and the intact placenta were isolated by collagenase digestion. The cells isolated from the intact organ retained their ability to attach to the culture flask surface and the ability to replicate in standard tissue culture. The isolated cells continued to replicate in standard tissue culture and were eventually passaged three times. Therefore, the intact organ was successfully maintained in the EMS organ culture and was therefore metabolically active. The subsequent viability and function in cells isolated from the whole organ following a period of organ culture supports this interpretation.
  • Example 5 Intact bov ine limbs w ere procured
  • the femoral arteries were cannulated and the intact limb was flushed of its blood
  • the solution of the present inv ention was used to refill the v ascular compartment and the limbs were maintained in EMS organ culture for two da ⁇ s
  • the limbs were ev supered histologicall ⁇
  • the results of these ev shions indicated the limb cellular components were well preserved without an ⁇ observed necrosis
  • Cells isolated from the intact limb following two days in EMS organ culture were likewise viable
  • the cells isolated from the intact limbs attached to the flask surface in standard tissue culture The cells continued to proliferate and were passaged three times Similar to the results obtained w ith whole organs, sections of anatomy such as the intact limbs could be maintained in the EMS organ culture technology of the present invention
  • Example 6 The EMS organ culture technology of the present invention was used to maintain human umbilical cords measuring approximately 2 - 2 5 feet in length
  • the human umbilical cords were maintained intact in EMS organ culture for at least seven days
  • the umbilical cord vein was cannulated on one end On the other end, the vein and the two arteries were connected with silicon tubing connected to a y-connector to form a closed circuit
  • the luminal surface of the umbilical cord blood vessels were digested with collagenase
  • the isolated endothelial cells were viable and attached to the flask surface in standard tissue culture
  • the isolated cells demonstrated normal characteristics of endothelial cells in tissue culture, i e they attached, replicated and expressed factor VIII antigen
  • the EMS whole organ culture technology of the present invention can be used for in vivo applications
  • a specific organ can be isolated via isolation of the major arterial source feeding the organ and simultaneous isolation and collection of the venous outflow
  • An in vivo application of the organ culture technolog ⁇ entails physiologic maintenance of the enervation and lymphatic systems.
  • the artery feeding the targeted organ or section of anatomy is cannulated, the vein receiving the organ effluent is likewise cannulated, and blood is flushed from within the tissues.
  • the vascular compartment is refilled with the solution of the present invention.
  • the organ or section of anatomy is maintained in vivo but is "off-line" from the physiologic system and is maintained by the EMS organ culture technology.
  • Example 7 Canine kidneys were isolated by cannulating the renal arteries and veins, flushing the kidneys of blood and refilling with the solution of the present invention.
  • the kidneys were maintained in situ at 37°C with the EMS organ culture technology for 8 hours.
  • the kidneys continued to metabolize as determined by oxygen and glucose consumption calculations. Likewise, the metabolism was of sufficient levels to result in continuous diuresis.
  • the kidneys while isolated from the rest of the vascular system and maintained with EMS organ culture technology, continued to produce urine and fill the connected bladder.
  • the cannulas were removed and the kidneys reperfused with blood. The kidneys continued to function normally. All 10 canines demonstrated normal serum chemistries following EMS organ culture of the kidneys.
  • Example 8 Isolated organ or regionalized tissue perfusion is well suited for high-dose chemotherapy delivery while attempting to reduce whole body toxicity. Recent attempts at several cancer institutes to perform isolated organ perfusion to deliver chemotherapeutic agents have carried a high risk of causing damage to non-target tissues. Target organs can be maintained with the organ culture technology of the present invention, without causing any damage. The advantage of using the organ culture technology to deliver chemotherapy is the opportunity to deliver much higher doses while simultaneously reducing or even eliminating the usual systemic side- effects.
  • the efficacy of the EMS organ culture as a drug delivery technology was established with nontransplantable human kidneys.
  • the kidneys were nontransplantable because of renal tumors identified as renal cell carcinoma.
  • the human kidneys demonstrated stable perfusion pressures, vascular flow rates and oxidative metabolism during the EMS perfusion.
  • the human kidneys also consumed oxygen and glucose, produced urine and cleared creatinine.
  • Biopsies of the kidneys were taken both pre- and post-EMS whole organ culture perfusion for histologic evaluations. There were no observed histologic changes following 18 hours of EMS organ culture. Therefore, the EMS organ culture maintains kidneys with renal cell carcinoma without causing damage, thereby providing a deliver ⁇ ' system for targeted drug therapies.
  • Example 9 Ischemic insult secondary to occlusive disease such as heart attack and stroke represents another in vivo application of the EMS organ culture technology.
  • Recently developed thrombolytic agents hold great promise for patients suffering a stroke or heart attack.
  • the efficacy of these therapies is dependent upon being able to administer the drugs within a short period of time following the occlusive phenomenon.
  • the tissues downstream from the obstruction are deprived of blood resulting in ischemic damage.
  • the EMS organ culture technology can be used to reperfuse and maintain the tissue downstream from an obstruction, thereby providing an expanded window of opportunity to implement thrombolytic therapies.
  • EMS organ culture technology of the present invention can be implemented to sustain tissue integrity and function in vivo in the resuscitation from shock. Normovolemia can be restored with the acellular solution of the present invention at physiologic temperatures, thereby minimizing the development of a secondary reperfusion injury in patients experiencing a life-threatening hemorrhage.
  • the EMS organ culture technology maintains isolated organs or may be used to maintain the whole patient.
  • Example 10 The addition of appropriate growth factors and hormones to the perfusion solution of the present invention supports cellular repair processes in damaged organs.
  • Kidneys experiencing 60- 120 min of warm ischemia were maintained in the EMS whole organ culture technology of the present invention. Following 6-8 hours of organ culture with the organ culture technology of the present invention, mitotic figures were observed in the distal tubules of the thick ascending limb of the loop of Henle. There was no evidence of reparative procedure in the areas in the kidney without apparent damage, i.e., the proximal tubules and glomeruli. These studies demonstrate the substantial potential of the EMS organ culture technology in the repair and regeneration of damaged tissues.
  • PNF primary nonfunction
  • kidneys were repaired. Perfusion pressures and vascular flow rates normalized, oxygen consumption increased to a mean of 0.22cc/min/gm and urine flow was reinstituted. Normalization of these parameters indicated that the kidneys were resuscitated and repaired sufficiently to change the outcome from PNF to that of viable organs with moderate acute tubular necrosis. Two of these kidneys were transplanted following the determination of viability following 8 hours of EMS perfusion. The third kidney was reimplanted following 18 hours of EMS perfusion.
  • EMS technology can resuscitate and repair organs from an ischemic insult that today in clinical transplantation is considered to be irreparable damage
  • the period of EMS perfusion directly correlates with the degree of repair, in that the longer a kidney is perfused the more repaired it becomes Eight hours of EMS perfusion repaired PNF kidneys sufficiently to become transplantable with peak serum creatinine values on the fourth posttransplant day and normalization on day 12 & 13 Eighteen hours of EMS perfusion provided additional repair that resulted in a slight elevation in serum creatinine value, peaking on day 2 and was normal on the third posttransplant da ⁇ .
  • Example 1 1 The effectiveness of the EMS organ culture technology to preserve livers at near physiologic temperature and the ability to resuscitate liver function following 60 minutes of postmortem warm ischemia (WI) was examined. Measurement of selected parameters indicative of liver viability and metabolic function were made, including oxygen consumption, and standard liver enzymes indicative of acute damage. Metabolic function assessment included measurement of bile production and evaluation of the concentration of enzymes and bilirubin in the bile.
  • the liver perfusion system described in FIGURE 2 differs from the kidney and heart system because of the need to support both the arterial and venous vascular systems.
  • the system described in this invention is unique in delivering a high PaOon(l 00 - 240 mmHg) via the hepatic artery with a lower vascular flow rate ( ⁇ 250cc/min) and simultaneously providing a low Pa0 2 , (( 140mmHg) and correspondingly high vascular flow rate (>240cc/min) via the portal system.
  • the net effect is to provide a more physiologic perfusion, such that the biliary tree is protected and bile production during perfusion is maximized.
  • the effluent reservoir 38 has a second effluent outlet 62 which allows perfusate to be drawn by means of a pump 64, into a second perfusion path 60 carrying perfusate to the portal vein 66 of the liver.
  • the EMS system controls the temperature, perfusion pressure, vascular flow rate, osmolarity, pH, PaO z , PaC0 2 , nutrient delivery and the removal of waste by-products of the perfusion. This may be done by monitoring and controlling perfusate parameters in the two flow paths independently of each other or by regulation of the perfusion path supplying the hepatic artery only.
  • the flow path for the portal system may further comprises its own temperature controller, oxygenator and respiratory gas controller, pH controller, bubbletraps, and means for sensing flow rate, vascular resistance, OsM, Pa0 2 , and PaC0 2
  • the perfusion temperature of the portal vein flow path is maintained in the range of 25 -37°C.
  • One or more in-line oxygenators and oxygen carrier provides the oxygen tension described above for the hepatic artery and portal supplies.
  • One or more pH electrodes, controllers and solenoid systems control the entry of C0 2 to maintain pH of perfusate in both flow paths in the range of 7.30 - 7.45.
  • long-term liver preservation is achieved by replenishing the depleted nutrients in the perfusate by perfusate exchange, dialysis, or a combination thereof, and by removing the accumulation of metabolic waste products by dialysis.
  • the synthetic properties unique to the liver provide regenerative opportunities by synthesizing protein and generating new cell growth.
  • calf livers were excised.
  • the suprahepatic vena cava was isolated at the diaphragm. Starting from the top left side, the livers were dissected cutting the lymphatic tissue, gastric artery and common bile duct. The portal vein and hepatic artery were isolated and cannulated with a 12 and 5 mm cannula. respectively.
  • the livers were perfused for approximately 4 hours at 34°C.
  • samples of the perfusate were collected at 2 and 4 hours of perfusion for measurements of bilirubin, ALT, AST, ALP and blood gases.
  • the contents of the gallbladder were likewise collected at 2 and 4 hours of perfusion. There was no edema or discoloration demonstrating the ability of the EMS organ culture technology to repair livers.
  • Livers subjected to 30 minutes of postmortem WI all demonstrated high rates of oxygen consumption following resuscitation with EMS. When the WI insult was extended to 60 minutes, no significant difference in the rates of oxygen consumption were detected.
  • Livers subjected to 30 minutes of postmortem WI demonstrated mean arterial pressures (MAP) of 31 mmHg (combined hepatic artery and portal vein) with corresponding combined flow rates of 320 cc/min following re-establishment of metabolism. The vascular resistance was 0. 1.
  • the MAP was lowered to 20 mmHg and the flow rates increased to a mean of 420 cc/min.
  • the resulting vascular resistance was 0.06.
  • liver function screen was performed testing for ALT, AST, Alkaline phosphatase (ALP) and total/direct bilirubin.
  • ALP Alkaline phosphatase
  • livers injured by 30 minutes of postmortem WI, except in one liver at 2 hours demonstrated normal values of ALT, ALP and bilirubin at both time points tested (Table IV).
  • the WI insult was increased to 60 minutes postmortem, after 2 and 4 hours of EMS perfusion, the ALT, ALP and bilirubin values were normal.
  • Livers resuscitated with EMS following 30 minutes of postmortem WI produced bile throughout the period of warm perfusion. Variation in the rate of bile flow was observed, ranging from 1.5 - 6 cc/hr. The color of the bile was either dark green or a greenish - yellow.
  • a normal, control consisting of bile removed from the gallbladder at the time of excision revealed 315 mg/dL of total bilirubin, 18 IU/L of ALP and was negative for AST and ALT.
  • the livers injured by 30 minutes of postmortem WI produced bile with a wide range of bilirubin concentration - 1 .1 - 418 mg/dL(Table V).
  • the mean values were close to the normal bile concentration of bilirubin.
  • the concentration of ALP in the bile of the test livers were similar to that of normal bile. Similar to the results observed for the concentration of liver enzymes in the EMS perfusate described above, the bile AST levels decreased by half between 2 & 4 hours of perfusion in livers with 30 min WI, while the bile AST levels remained constant in the livers damaged by 60 minutes of WI. ALT was found in the bile from two of the livers following 30 minutes of WI insult at 2 hrs. of perfusion. The bile produced by livers subjected to 60 minutes of postmortem WI also contained ALT at both 2 & 4 hours of EMS perfusion. Likewise, the restored liver function was sufficient to support continuous bile production.
  • liver function tests provide additional evidence that livers could be resuscitated from as much as 60 minutes of WI damage.
  • EMS perfusion prior to exposure to cold ischemia provides tissue protection and allows for extended periods of cold storage of an allograft.
  • an allograft is routinely stored clinically for only 24 hours by cold storage. Extending the period of cold storage leads to a high rate in delayed function, in many cases necessitating support of the patient by dialysis until the kidney can recover function.
  • cellular protection from the cold damage is provided.
  • the present invention therefore, also provides a method for storing a tissue, explant or organ intended for transplantation comprising the steps of flushing the tissue, explant or organ with a non-blood buffered physiological solution to remove blood and blood products; perfusing the tissue, explant or organ in a warm preservation system, such as the one described herein, capable of maintaining the tissue, explant or organ at a near normal rate of metabolism for a period of time sufficient to impart protection to the tissue, explant or organ: and storing the organ at 4-8°C.
  • a period of time sufficient to impart protection is one in which the organ has had the opportunity to normalize perfusion parameters, for example, flow rate and vascular resistance. Generally, a perfusion period in the range of 30 mins to 24 hours is sufficient.
  • the test group kidneys were placed on EMS perfusion upon excision, prior to cold storage.
  • the excised kidneys were flushed of blood with EMS perfusion solution and placed on EMS perfusion at 32°C - 34°C for 6 hours.
  • the kidneys were flushed again with approximately 200cc of ViaSpanTM at 4°C double bagged and stored statically packed in ice for 48 hours.
  • the contralateral kidneys were nephrectomized.
  • the test and control kidneys were then autotransplanted using an end-to-side anastomosis made between the renal artery and the aorta, and the renal vein to the vena cava.
  • the canine was closed and allowed to recover. Each morning the canine had blood drawn from the forelimb and chemistries were performed to determine the clinical course.
  • Results EMS perfusion prior to cold storage provided for better outcomes in that the time to recovery of normal function was halved following 48 hours of static cold storage.
  • the kidneys of the control group reperfused slowly and no urine was produced on the table. Very little urine was produced during the first evening posttransplantation.
  • Control group dogs experienced a period of reversible acute tubular necrosis (ATN).
  • ATN reversible acute tubular necrosis
  • the 24 hour posttransplant serum creatinine values were all elevated above normal values, 5.3, 2.6, & 2.8 mg/dL, respectively.
  • the serum creatinine values continued to rise, peaked and then slowly declined, normalizing on day 7, 9 &12 respectively.
  • kidneys produced urine on the table within minutes of reperfusion. The kidneys continued to produce urine throughout the posttransplant period.
  • the 24-hour posttransplant serum chemistries were elevated, with serum creatinine values of 2.2 & 2.5 mg/dL.
  • serum creatinine values normalized on day 5 and 6. respectively.
  • the kidneys appeared normal macroscopically. Histologic studies also revealed normal renal pathology.
  • EMS perfusion prior to reimplantation therefore, provides protection against cold ischemia induced damage, in that the warm perfused test kidneys experience ATN that is less severe and of shorter duration.
  • EMS perfused test group kidneys also had lower 24-hour posttransplant serum creatinine values when compared to the control group kidneys without EMS perfusion.
  • EMS perfused kidneys also had normalized serum creatinine values sooner (5.5 vs. 9.3 days) than the control group kidneys that were immediately placed into cold storage.
  • EMS perfusion can be used to deliver a drug to an organ, section of anatomy or tissue in a targeted fashion.
  • the EMS supported ongoing metabolism and function can be monitored providing a mechanism to quantify the impact of the drug and any corresponding cellular response to it.
  • a compound known to cause the up-regulation of the heat-shock protein, hemeoxygenase- 1 was administered to an isolated kidney being perfused in accordance with the technology of the present invention.
  • the EMS technology provided adequate support of renal metabolism and function during ex vivo perfusion to increase expression of the hemeoxygenase- 1 (HO- 1 ) enzyme within six hours.
  • CoPP cobalt protoporphyrin
  • Metabolic and functional evaluations consisted of quantification of the ex vivo kidney function during the period of HO- 1 induction.
  • kidneys were maintained in a metabolicalK active state bv perfusion at near ph ⁇ s ⁇ olog ⁇ c temperature K ⁇ dne ⁇ S weighing approximately 70 - 90 gm were procured following brain death with concomitant warm ischemia of no more than 15 minutes
  • the kidneys w ere then transitioned to EMS perfusion at 32°C to 34°C
  • the kidneys were evaluated for oxidative metabolism, vascular dynamics and organ function The organ parameters were allowed to stabilize for one hour prior to the evaluation of function
  • Samples from the arterial and venous lines were collected, along with the urine produced during the perfusions PO2 measurements for the arterial and venous samples were made with a Radiometer ABL5
  • the ex vivo oxidative metabolism of the kidneys was comparable with all three concentrations of CoPP and remained stable during the six hours of EMS perfusion.
  • the restored oxidative metabolism, as measured by oxygen consumption, ranged from 0.17 to 0.23 cc/min/gm.
  • the oxygen consumption was highest at all time points in the kidneys perfused with 25 ⁇ M CoPP.
  • the perfusion pressures, vascular flow rate and the vascular resistance were also comparable in the three CoPP concentration groups.
  • CoPP treatment during EMS perfusion did not adversely affect the vascular dynamics or the cellular oxidative metabolism.
  • differences in urine flow, creatinine clearance and development of proteinuria were observed as the concentration of CoPP induction increased.
  • EMS perfusion effectively supported ongoing metabolism and function sufficiently for a cellular response to the CoPP leading to an increased expression of hemeoxygenase- 1 Furthermore, during EMS perfusion the administration of CoPP did not adversely affect perfusion characteristics or cellular metabolism However, organ function was found to be affected, in a dose dependant fashion as the concentration of the CoPP was increased, in terms of compromised urine flow, glomerular filtration rate and development of proteinuria Therefore, any drug-induced toxicity can be detected during administration via EMS perfusion At therapeutic doses, EMS perfusion was effective in supporting CoPP induction of HO- 1 expression
  • EMS technology for Gene Therapy
  • a related use of EMS technology is as a targeted gene delivery system
  • the long-term benefit of gene therapies is hampered by the problem of delivering the desired gene to a specific location
  • Organ culture technology provides a mechanism for delivering genes to the desired location
  • Gene therapy is particularly appealing in the context of transplanted organs because an exogenous gene can be transferred prior to transplantation.
  • the pharmaceutical agent is a gene therapy vector
  • the construct may functionally encode for endogenous or exogenous proteins, which can then be expressed in the target after transplantation. Such gene transfer will allow for the expression of various proteins by the target tissues.
  • a perfusion system is particularly applicable for gene transfer and pharmaceutical administration into a number or organs, as long as the target organ has a suitable blood circulation system, for example, kidney, liver, heart and so on.
  • the most obvious benefit of gene delivery via a perfusion system is the enhanced efficiency, target specificity for gene transfer, and the possibility of using only a small amount of vector material.
  • extracorporeal perfusion systems diminish the risk of administering a large amount of foreign genetic material into the general circulation of the subject, especially important for immunocompetent individuals.
  • the EMS technology of the present invention can be used to achieve targeted gene transfer, either ex vivo or in situ.
  • the EMS maintains the organ or tissue to be transfected in a metabolically active state before, during and following the transfection period.
  • the ability to interface directly with targeted tissue over extended periods of time under near physiologic conditions without exposing non-target tissues presents the opportunity to use alternative transfection procedures: including eliminating the need for viral vectors.
  • liposome complexes or viral vectors and vascular endothelial cell-specific promoters can be introduced in the perfusion system to transfer the therapeutic DNA at a near physiologic temperature to facilitate higher incorporation rates.
  • An additional benefit of preserving metabolism during EMS is the feasibility of establishing the functional status of the organ or tissue prior to transfection, in contrast to using hypothermia, which inhibits metabolism and alters cell membrane potential. This is of particular importance where the organ was obtained from a donor other than a beating heart donor and may have experienced some ischemic injury. Furthermore, it is feasible to monitor the organ ' s metabolism during transfection, and in the case of an intact organ, to quantify the resulting organ function, i.e. diuresis, etc. Because the cell membranes are in their normal fluid state, normal barrier function is maintained providing the ability to target a gene(s) therapeutic directly to the vascular cells.
  • the ability of the EMS perfusion to preserve the integrity and normal barrier functions of the vessel wall within kidneys provides a mechanism for effecting transfection restricted to the vascular cells.
  • the ability to target a gene(s) therapeutic to the vascular cells within an organ provides several important benefits.
  • the reporter gene product is in direct contact with the bloodstream, thereby providing an efficient gene therapy delivery system. Since the vascular endothelium represents the immunologic interface in organs, gene therapies present opportunities for organ specific immunomodulating therapies, in both transplantation and autoimmune diseases.
  • the EMS is acellular and provides the milieu for optimal transfection of a gene(s) therapeutic to the nucleus without eliciting an early immunological response. Therefore, the EMS represents a high efficiency delivery vehicle for targeted gene delivery for in situ or ex vivo application and allows for the simultaneous monitoring of metabolism and function.
  • a gene of interest may be delivered to the targeted tissue via a host of currently known vehicles.
  • Gene therapy by the homogenous recombination between exogenous DNA and the genome of the target tissue results in the modification of a particular locus within the genome.
  • Some methods of transfection include delivery by viral vector containing the gene, liposomes, plasmid DNA and the like.
  • delivery of episomal DNA by the method of the invention is feasible and circumvents the need for genomic integration of the delivered gene due to episomal replication of the targeted gene vector independent of the genome.
  • an organ containing the target tissue is isolated from a living body, is flushed of blood with warm EMS solution and then placed on EMS perfusion. The perfusion is conducted for a period of time sufficient to establish baselines of function.
  • An exogenous molecule for example, a viral vector, is infused into the system and perfusion continued for a period of time sufficient to deliver a pharmaceutically effective amount of the exogenous molecule.
  • Organ function is monitored for a period of time after delivery, prior to returning the organ to a recipient.
  • Example 12 A replication defective adenovirus (Adeno CMV5-GFP) encoding a green fluorescence protein (GFP) gene was used to evaluate the effectiveness of the EMS perfusion system to support gene transfer to intact bovine kidneys during ex vivo perfusion at 34°C. Bovine kidneys were flushed of blood with warm EMS solution and then placed on EMS perfusion. The perfusion was conducted for approximately 60 minutes to establish baselines of function. The viral vector ( 1 x 10 9 PFU) was infused into the system and perfusion was continued for 2 hours. Administration of the viral vector and the resulting infectivity during EMS perfusion did not adversely affect organ metabolism or function.
  • a replication defective adenovirus Addeno CMV5-GFP
  • GFP green fluorescence protein
  • Control kidneys consisted of kidneys flushed and perfused at 4°C using a ViaSpan-based cold perfusate. Since metabolism and function are inhibited at 4°C, any effect of the viral vector on the metabolism or function of the control kidneys could not be determined.
  • the kidneys were copiously flushed via the renal artery to remove any residual circulating viral particles.
  • the lumen of the vasculature was then filled with a collagenase solution to isolate the vascular cells within each kidney and the identity of these cells was confirmed morphologically.
  • the expression of the transfected gene encoding the green fluorescence protein is described in TABLE 7.
  • the EMS perfusion provided for enhanced infection rates, with 40% of the vascular cells in culture expressing the GFP by 18 hours versus 17% in the cold perfused control kidneys.
  • the endothelial cells isolated from the EMS perfused kidneys demonstrated strong expression of the GFP in 60% of the cells. In contrast, no increased level of expression was detected in the control kidneys were the transfection was conducted in the cold.
  • Parenchymal cells were isolated from the EMS perfused kidneys, following the isolation of the vascular endothelial cells by collagenase digestion. The isolated parenchymal cells were found to be negative for the expression of GFP at 24 and 48 hours in tissue culture. These results suggest that the infectivity and transfer of the GFP encoding gene during EMS perfusion were limited to the vascular cells within the blood vessels of the kidneys. Therefore, better transfection rates and higher reporter gene expression was observed at both time points in the test kidneys perfused with the EMS and evidence of transfection was only found in the vascular cells.
  • the EMS warm preservation technology of the present invention preserves organs without inflicting damage and supports metabolism at a level sufficient to result in immediate normal function upon organ reimplantation (following ex vivo organ perfusion), or reperfusion (following in situ perfusion). For these reasons, EMS perfusion is particularly well suited for delivery of a therapeutic agent including, for example, in gene therapy, where delivery of a nucleotide is desired. Furthermore, the EMS warm preservation technology of the present invention provides a gene delivery /transfection system that is superior to current methodologies.
  • U.S. Patent No. 5,871 ,464 to Tryggvason et al, discloses a perfusion apparatus and methods for pharmaceutical delivery and describes successful gene transfection, both in situ and ex vivo.
  • the results suggest that substantial kidney damage occurred, evidenced by excessive diuresis (800cc during the first hour of perfusion). Additionally, diuresis increased dramatically over the second hour to 1 ,200 cc/hr, another indication that the kidney was damaged during the perfusion.
  • the in situ perfusion did not extend past 2 hours, there was no urine production listed at subsequent times, and, in the case of ex vivo perfusion, the kidneys were not reimplanted. Thus, no post-treatment renal function is described.
  • the ability to support organs at near physiologic metabolism for days represents a unique ability to synthesis the protein product encoded by the transfected gene prior to reimplantation or reperfusion, something not possible with existing technology.
  • the following examples demonstrates the superior ability of the EMS technology to preserve organ integrity during gene delivery and transfer. Paired kidneys were excised from calves. The excised kidneys were flushed of blood, and one of the pair was placed on EMS perfusion and the other was placed on perfusion using the system and solution described by Tryggvason. During the perfusion, the oxidative metabolism was evaluated by calculating the oxygen consumption in terms of 0 2 consumed per minute per gram, diuresis and corresponding organ function.
  • Organ function was determined as the ability of the glomeruli to retain its normal barrier function and retain large molecules in the vascular compartment.
  • organ function was the ability to produce urine without protein leak of the colloid, serum albumin, and since the Tryggvason patent does not include a colloid, the ability to retain the red blood cells in the vascular compartment, i.e. urine negative for red blood cells.
  • Perfusion in accordance with the methods described in the '464 patent that is, on a Gambro machine with an in-line oxygenator, using Krebs Ringers supplemented with red blood cells to yield a hematocrit of 17%. results in organ edema, elevated perfusion pressures as determined with a manometer, low oxygen consumption and loss of barrier function resulting in urine with a hematocrit equivalent to the perfusate. Histology provided additional data supporting the development of organ damage. In contrast, EMS perfusion prevents edema, maintains stable perfusion pressures and oxygen consumption and results in urine production that filters out protein. Histology confirmed the preserved integrity of the kidney during EMS perfusion. Comparison of EMS with Tryggvason Patent
  • EMS technology can be used to preserve organs ex vivo for extended periods in a metabolically active state and at near physiologic temperature.
  • 10 canine kidneys were preserved ex vivo for 24, 48 & 72 hours.
  • perfusion pressures, vascular flow rate, vascular resistance, oxygen consumption, glucose consumption and diuresis remained stable.
  • the kidneys appeared to be normal upon histologic evaluations.
  • Hours of Perfusion 24 48 72 mean perfusion pressure 43mmHg 43mmHg 43mmHg mean flow rate 112cc/min 115cc/min 118cc/min oxygen consumption 0.24cc/min/g 0.23cc/min/g 0.26cc/min/g

Abstract

L'invention concerne un système support métabolique exsanguiné permettant de maintenir presque normal le rythme métabolique d'un organe ou tissu. Le système utilise une solution de perfusion chaude capable de supporter le métabolisme d'un organe ou tissu, ce qui lui conserve son intégrité fonctionnelle. Le système surveille également les paramètres de la solution de perfusion circulante, par exemple pH, température, osmolarité, débit, pression vasculaire et pression partielle de gaz respiratoires, et les régule afin que l'organe se maintienne dans des conditions presque physiologiques. L'invention traite également de l'utilisation du système aux fins d'une conservation de longue durée d'organes pour greffe, réanimation et reconstitution d'organes ayant subi des lésions ischémiques chaudes, comme système d'administration pharmaceutique et pronostiqueur de fonction de post-greffe d'organe.
PCT/US2000/009894 1999-04-14 2000-04-13 Systeme support metabolique exsanguine d'un organe ou tissu WO2000061166A1 (fr)

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CA2376607A CA2376607C (fr) 1999-04-14 2000-04-13 Systeme support metabolique exsanguine d'un organe ou tissu
US09/849,618 US6582953B2 (en) 1999-04-14 2001-05-04 Organ chamber for exsanguinous metabolic support system

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US8946304B2 (en) 2012-12-23 2015-02-03 Liveleaf, Inc. Methods of treating malnutrition
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CA2847723A1 (fr) 2000-10-19
AU4345400A (en) 2000-11-14
CA2376607C (fr) 2014-06-10

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