Organ Preservation

1
Organ Preservation with Histidine-Tryptophan-Ketog
lutarate (HTK) Solution Clinical Results
Charles M. Miller MD Director, Liver
Transplantation Program Professor of
Surgery Cleveland Clinic
2
Organ Preservation Solutions

• Preservation solutions are used to maintain
  the hypothermic organ in optimal condition from
  the time of explantation until implantation

3
Principles of Organ Preservation

• Exsanguination to reduce intravascular thrombosis
• Hypothermia to reduce cellular metabolism
• Maintain cell membrane integrity to avoid
  cellular swelling
• Susceptibility to cold ischemic injury vascular
  endothelium gt parenchymal cells

4
Ischemia

• Decreased mitochondrial function
• Anaerobic conditions - depletion of ATP
• Alterations in ion permeability
• Accumulation of lactate
• Accumulation of hypoxanthine
• Cell swelling
• Cytosolic calcium accumulation

5
Reperfusion

• Generation of reactive oxygen species
• Increased oxidative stress
• Lipid peroxidation of cellular membranes
• Free radical formation leads to cellular
  destruction
• Results in macrophage/Kupffer cell activation
• Increased serum tumor necrosis factor (TNF)
• Damage can lead to prolonged hypoxia after
  reperfusion

6
History of Organ Preservation

• Simple cooling with cold solution
• Continuous hypothermic perfusion
• Collins (1967)
• Euro-Collins (1980)
• University of Wisconsin - ViaSpan (1986)
• HTK - Custodiol (1980s)
• Celsior - 1994

7
Euro-Collins Solution

• High potassium, glucose, and phosphate-based
  solution
• Designed to mimic composition of intracellular
  fluid
• Low cost
• Poor preservation quality
• Short preservation times achievable

8
UW Solution
Use of impermeant molecules, lactobionate and
raffinose, in preventing cell swelling First
developed for and applied in preservation of
canine pancreas Hydroxyethyl starch to minimize
interstitial edema during machine perfusion, not
necessary during cold storage High K, low
Na
9
Southard and Belzer
10
UW Solution Disadvantages
Glutathione is oxidized during storage
addition of fresh GSH immediately before use
other additives High viscosity Solution
cannot be released into circulation (high K
content) Huge particles 100 µm in diameter
contained in original solution must use in-line
filtration with 40 µm pore size.Particles caught
in capillary bed of perfused organ, resulting in
vascular constriction, impeded reperfusion, and
reduction of functional recovery
11
Crystals in UW solution stored at sub-zero
temperature (a ) perfused livers (b)
pancreas (c) kidneys (d)
Tullius et al AJT 2627
12
HTK Solution (Custodiol)

• Developed as cardioplegia
• Low potassium
• High buffering capacity of histidine
• No colloid - viscosity equal to that of pure
  water from 1 to 350C, with mean flow rate 3X that
  of UW solution at equal perfusion pressure -
  organs exsanguinate and cool down to lower
  temperatures more rapidly than with UW

13
M.M. Gebhard, H.J. Kirlum, C. Schlegel. Organ
preservation with the solution HTK
14
Component UW HTK
Sodium (mmol/L) 40 15
Pottasium (mmol/L) 120 10
Lactobionate (mmol/L) 100 -
Phosphate (mmol/L) 25 -
Raffinose (mmol/L) 30 -
Adenosine (mmol/L) 5 -
Ketoglutarate (mmol/L) - 1
Histidine (mmol/L) - 198
Starch (gm/L) 50 -
Mannitol (mmol/L) - 30
Tryptophan (mmol/L) - 2
Osmolality (mOsm/L) 320 310
15
Randomized Controlled Trials

• Kidney 1 European, 3-year follow-up
• 1998, n 650 transplants, Deceased donors
• Pancreas 1 European
• 2009, n68 transplants
• Liver 3 European
• 1994 (n60) Deceased donors
• 2003 (n30) Living donors
• 2005 (n40) Deceased donors

16
Kidney Preservation
Transplants HTK 332, UW 312 DGF Need for
dialysis 2 or more times during first 7-days
post-transplant Flush volume HTK 5 6
L UW 1 2 L EC 4 L
16
17
Kidney preservation
de Boer, et al, Transpl Proc, 1999 31 2065
17
18
Kidney preservation
18
de Boer, et al, Transpl Proc, 1999 31 2065
19
Kidney preservation
19
Lynch RJ, et al. AJT 2008 8567-73
20
Kidney preservation
Post-transplant kidney graft survival Living
Donor HTK n475 UW n475 Deceased
donor HTK n317 UW n317
20
Lynch RJ, et al. AJT 2008 8567-73
21
Pancreas preservation
Transplants randomized 68 transplants over 18
months at 4 centers Outcomes 6-month graft
survival NO DIFFERENCE Graft function NO
DIFFERENCE Fasting BG C-peptide
level HbA1c Insulin requirement Flush
volume HTK 5 8 L n41 UW 3 L n67
21
22
Pancreas preservation
Figure 1. No insulin requirement
Figure 2. Serum amylase level
Figure 3. Serum lipase level
22
23
Pancreas preservation
Figure 4. C-peptide level
Figure 5. Units exogenous insulin
Figure 6. HbA1c
23
24
Pancreas preservation
Indiana University, 2003 to 2007-- Largest center
in USA
N 310 HTK 262, UW 48 Simultaneous,
retrospective 1-year graft survival 91 (U.S.
79-86)
24
25
Liver Transplantation

• Hatano et al Hepatic preservation with
  histidine-tryptophan-ketoglutarate solution in
  living-related and cadaveric liver
  transplantation. Clinical Science (1997), 9381
• Evaluated graft oxygenation state after
  reperfusion in LRLT using near-infrared (NIR)
  tissue spectroscopy
• LRD liver HTK (15) vs UW (49)
• CAD liver HTK (30) vs UW (18)

26
E. Hatano, et al. Tissue oxygenation in living
related liver transplantation (Clinical Science,
1997)
LRLT
Intraoperative changes in mean value of oxygen
saturation of Hb at 10 points in liver graft
After reflow
of operation
27
Biliary Complications Develop up to 30 of
Patients After Liver Transplantation
28
Post-liver Transplant Biliary Strictures

• Biliary strictures after liver transplantation
  10-30
• Adequate flushing of peri-biliary arterial tree
  is important
• High viscosity preservation solutions might not
  completely flush the small donor peri-biliary
  plexus

29
Peri-Biliary Vascular Plexus

• Alpini et al.

30
Pirenne et al. Liver Transplantation, 7540-545,
2001
Pirenne et al. Liver Transplantation, 7540-545,
2001

• Two group of liver recipients
• Group 1 (24) Donor aortic flush with Marshall
  solution
• Portal vein
  with UW
• Group 2 (27) Donor aortic flush with UW
• Portal vein
  with UW
• CIT 692190 ( group 1) vs. 535129, (group 2),
  (P.001)
• Preservation cost 1.9 times greater in the UW
  than in the Marshall group

31
Pirenne et al. Liver Transplantation, 7540-545,
2001

• Recipient surgeon Same surgeon
• All biliary reconstruction duct-to-duct except in
  one patient
• One-year patient and graft survival 92 (1) and
  100 (2)
• Biliary stricture 1/24 (4.1) group 1
• 8/27 (29.2)
  group 2
• Biliary stricture in group 1 4 months after LTX
  and anastomotic
• Biliary strictures in group 2 1-12 months after
  LTX and anastomotic, extrahepatic, intrahepatic
  or a combination of intra-and extrahepatic

32
HTK and UW for Liver PreservationHannover (1988
- 2000) n 1068

• HTK UW
• n 461 607
• PF 439 578
• INF 22 29
• INF 4.8 4.8
• p 1.00

33
HTK and UW for Liver PreservationHannover (1988
- 2000) n 1068

• CIT gt15 hours HTK UW
• n 36 154
• PF 34 143
• INF 2 11
• INF 5.6 7.1
• p 1.000

34
Liver Transplant Patient Survival Hannover (1988
- 2000)

HTK (n 400)
UW (n 4 92)
P lt 0.0331 (LogRank)
years
35
Liver Transplants Graft Survival Hannover (1988
- 2000)

HTK (n 461)
UW (n 607)
P lt 0.0029 (LogRank)
years
36
HTK and UW for Liver PreservationHannover (1988
- 1998) n 836

• Biliary Tract Complications HTK
  UW
• n 305 531
• BTC 39 65
• BTC 12.8 12.2

37
HTK vs. UWUniversity of Gottingen Patients and
Methods
Patients 123 120 Adults, 3 Children
Age 1 - 70 years Transplantations Total
134 Cadaveric 123 primary, 10 secondary, 1
tertiary 114 standard orthotopic, 5 split, 4
partial Living donation 11 (right
lobe) Combined 6 kidney transplantation 1
bone marrow transplantation 1 heart and
kidney transplantation Preservation solution 63
HTK und 71 UW
38
HTK vs. UW University of Gottingen Initial
Liver Function
HTK UW OLT total 63
71 Initial function (IF) 45 (71.5) 43
(60.5) Initial dysfunction (IDF) 13
(20.6) 26 (36.6) Initial nonfunction (INF)
5 (7.9) 2 (2.8)

39
HTK vs. UW University of Gottingen Biliary
Complications
HTK UW Bile duct necrosis 3 (16, 17,
485 d) 3 (44, 10, 8, 46 d) Localized
strictures 2 (72, 150 d) 2 (210, 305
d) Diffuse strictures (ITBL) - 3 (610, 210,
365 d) Total 5 8 ITBL ischemic type
biliary lesion
40
HTK vs. UW University of Gottingen Biochemical
Parameters
HTK UW AST max (U/l) 1320 1254
1389 1214 pod 7 (U/l) 26.7
17.5 24.3 18.4 AP pod 7 (U/l) 159.7
94.6 214.8 109.2 GGT pod 7 (U/l)
81 52.9 84.6 59.5 Bilirubin pod 14
(mg/dL) 9.5 9.7 13.8 12.6

41
HTK vs. UWUniversity of Gottingen Comparative
Analysis

• - Similar ischemic damage (AST) in both
  groups.
• Similar length of ICU stay in both groups.
• The rate of IDF/INF was similar in both groups.
• - Bilirubin was higher in UW group
• (13.8 vs. 9.5 mg/dL pod 14).
• Biliary complications significantly higher in
  UW
• group (8/71 vs. 5/63). No ITBL in the HTK
  group.

42
HTK solution for organ preservation in human
liver transplantationA prospective multi-center
observation study

• Pokorny et. al. Transplant International 2004
  17256-260 (Austria, Germany)
• 214 patients in 4 European centers (1996-1999)
• 5 liters of HTK for preservation CIT 444 224
• All vascular anastomoses completed before
  reperfusion
• No pre-reperfusion flush
• PNF 2.3, Initial dysfunction 6.5
• Graft dysfunction not correlated with CIT
• 1-year patient and graft survival 83 and 80
  (unrelated to CIT)
• HTK safe and effective and easy to use.
• Comparable to UW with less cost.

43
HTK vs. UW in LDLT

• Chan et. al. Liver Transplantation 2004
  101415-1421 (Hong Kong)
• UW
  HTK
• Number of patients 30
  30
• Age 38.5
  35.5
• CIT 112 (79
  334) 111.5 (75 222)
• Biliary stricture 10 (33)
  6 (20)
• Pre-reperfusion flush Yes
  No
• Graft loss 0
  1
• Hospital mortality 0
  0
• Biochemistry No significant differences
• Cost analysis UW 137.6 higher than
  HTK/patient
• Not significant

44
Liver Preservation
45
Liver Preservation
Indiana University, 2001 to 2008
All adult, deceased donor n1013 HTK 632, UW
381 Simultaneous, retrospective
46
Liver Preservation
Indiana University, 2001 to 2008
All adult, deceased donor Simultaneous,
retrospective n1013 HTK 632 UW 381
Serum ALT
Serum Bilirubin
47
Liver Preservation

• 3 Randomized Studies
• 1. Erhard J, et al. Comparison of HTK versus UW
  for organ preservation in human liver
  transplantation A prospective, randomized study.
  Transplant International 1994 7 177-81.
• 60 deceased donor liver transplants (HTK n30
  and UW n30)
• No difference in early and late graft survival,
  even for 7 donor livers with cold ischemia time
  gt15 hrs
• More late biliary complications in UW group.
• Higher initial transaminases in HTK group.
• 2. Testa G, et al. HTK versus UW in living donor
  liver transplantation results of a prospective
  study. Liver Transplantation 2003 9(8) 822-26.
• 30 consecutive living donor right lobe
  transplants flushed alternately with HTK (n16)
  or UW (n14)
• Patients were randomly allocated based upon
  timing of transplantation
• 1-year post-transplant, there is no difference
  in graft and patient survival, liver enzymes and
  complications
• 3. Nardo B, et al. Preliminary results of a
  clinical randomized study comparing Celsior and
  HTK solutions in liver preservation for
  transplantation. Transpl Proc 2005 37320-2.
• European randomized trial comparing Celsior and
  HTK.
• No difference in initial function or survival up
  to 1-year post-transplant.

48
HTK vs. UW in liver transplantationA meta
analysis
Feng et.al. Liver Transplant, 2007
49
HTK vs. UW in liver transplantation A meta
analysis
P 0.87 RR 1.01
Patient Survival
P 0.86 RR 1.01
Graft Survival
Feng et.al. Liver Transplant, 2007
50
HTK vs. UW in liver transplantationA meta
analysis
Feng et.al. Liver Transplant, 2007
51
HTK vs. UW in liver transplantationA meta
analysis

• Cost HTK cheaper than UW
• Biliary complications
• Trend for less biliary strictures with HTK
• PNF, PDF, DGF No difference
• Graft survival No difference
• Patient survival No difference
• Biochemical values No difference

Feng et.al. Liver Transplant, 2007
52
Recent retrospective database reviews
Conclusion of all 3 These results suggest that
the increasing use of HTK for abdominal organ
preservation should be reexamined.
53
Recent retrospective database reviews

• Data review
• Usually large database is better to increase
  numbers
• In large transplant research, single center
  better to maintain homogeneous patient, donor and
  management factors
• Database review
• Selection bias
• Do surgeons who use HTK differ from those that
  use UW ?
• CONFOUNDING database differences likely just
  highlight differences in practice patterns
  between surgeons who use HTK and those who use UW
  
• Kidney study exclude all machine pumped kidneys
• Pancreas study unable to differentiate high
  risk grafts
• Liver study no ability to analyze steatosis,
  hypernatremia, etc

53
54
Histidine-Tryptophan-Ketoglutarate Solution Vs.
University of Wisconsin Solution for Deceased
Donor Liver Transplantation Analysis of SRTR
Database

• Cleveland Clinic

55
Purpose

• This analysis aims to evaluate the impact of the
  organ preservation solutions (OPS)
  ,(Histidine-Tryptophan-Ketoglutarate (HTK) vs.
  University of Wisconsin (UW) solution) on the
  outcome of adult deceased donor liver
  transplantation (DDLT) using the Scientific
  Registry of Transplant Recipient (SRTR) database.

56
Materials and Methods

• Only adult first liver-only transplants from
  2002-2006 for whom both flush and storage
  solutions were the same. Risk-unadjusted graft
  survival was estimated non-parametrically by the
  method of Kaplan and Meier, and parametrically by
  a multiphase hazard decomposition method

57
Statistical Analysis

• Risk factors for graft survival were determined
  using nonproportional, multiphase, multivariable
  hazard methodology. This methodology allows
  modeling of recipient, donor, and procedure
  variables in all phases of the hazard model
  simultaneously. Bootstrap aggregating was used
  for variable selection with a probability for
  inclusion of 0.001 variables appearing in at
  least 50 of bootstrap analyses were considered
  reliably statistically significant at plt0.001.

58
Patients

• The data set included 20,908 patients, 17,559
  (84) with UW and 3349 (16) with HTK solutions.
  Mean follow-up was 2.9 1.5 years (3.0 1.5
  years for UW and 1.9 1.0 years for HTK). We
  defined an early phase (EP) shortly after DDLT
  followed by a constant phase (CP) of hazard for
  graft failure.

59
Results

• Significant predictors of graft failure in the EP
  after DDLT include the following recipient
  factors older age, race either White or Black,
  portal vein thrombosis, last creatinine and last
  MELD for the transplant (tx) candidacy, on life
  support just prior to tx, and previous kidney tx.

60
Risk Factors for Graft Failure - Early Phase
Risk Factor P Bootstrap
Early hazard phase
Older recipient age (years) lt.0001 93
Recipient race White or Black .0005 69
Recipient portal vein thrombosis lt.0001 95
Recipient previous abdominal surgery lt.0001 48
Candidate last creatinine (used for MELD) lt.0001 86
Candidate last MELD lt.0001 71
Recipient on life support just prior to tx lt.0001 100
Recipient previous kidney transplant lt.0001 90
Donor race non-White lt.0001 67
Donor donation after cardiac death lt.0001 100
Donor risk index lt.0001 46
61
Risk Factors for Graft Failure - Constant Phase
Risk Factor P Bootstrap
Constant hazard phase
African American recipient lt.0001 97
Recipient tumor (incidental) at transplant lt.0001 88
Recipient primary diagnosis for tumors lt.0001 87
Recipient hepatitis C virus lt.0001 100
Donor age (years) lt.0001 97
Donor history of diabetes lt.0001 77
62
Results

• Significant donor factors in the EP are race
  other than White, donation after cardiac death
  (DCD) and donor risk index (DRI). OPS did not
  appear as a statistically significant predictor
  of graft failure. Hospital death, re-transplant
  rates (overall and within 14 days of initial
  transplant) and relisting rates (overall and
  within 30 days of tx) were similar (pgt0.05).

63
Patient Survival - Donor gt65

• Donor Age gt  65
• N1698 UW
• N  311 HTK
• p.46  log rank test

64
Patient Survival - Donor lt65

• Donor Age lt65
• N15861 UW
• N 3038 HTK
• p.28 log rank test

65
Patient Survival - DCD Donor

• DCD Donor
• N570 UW
• N159 HTK
• p.73  log rank test

66
Patient Survival - Non-DCD Donor

• Non-DCD Donor
• N16989 UW
• N3190 HTK
• p.55  log rank test

67
Patient Survival - DRI gt2.5

• Donor DRI gt2.5
• N8663 UW
• N1682 HTK
• p.25  log rank test

68
Patient Survival - DRI lt2.5

• Donor DRI lt2.5
• N6600 UW
• N1218 HTK
• p.37  log rank test

69
Graft Survival - Donor Age gt65

• Donor Age gt65
• N1698 UW
• N  311 HTK
• p.64  log rank test

70
Graft Survival - Donor Age lt65

• Donor Age lt65
• N15861 UW
• N 3038 HTK
• p.045  log rank test

71
Graft Survival - DCD Donor

• DCD Donor
• N570 UW
• N159 HTK
• p.17  log rank test

72
Kaplan-Meier Adult Graft Survival Primary
Deceased Donor Liver Transplants 2000-2006
SRTR
Includes adult, primary, liver alone transplants
73
Graft Survival - Non-DCD Donor

• Non-DCD Donor
• N16989 UW
• N3190 HTK
• p.23  log rank test

74
Graft Survival - DRI gt2.5

• Donor DRI gt2.5
• N8663 UW
• N1682 HTK
• p.053 log rank test

75
Graft Survival - DRI lt2.5

• Donor DRI lt2.5
• N6600 UW
• N1218 HTK
• p.15 log rank test

76

• Used casewise deletion of missing data, i.e.
  threw out cases that were missing any of the
  predictor variables they were studying. It means
  they are using only patients for whom all
  variables were reported - doing this can
  potentially bias results

77
SRTR Information Flow
SSDMF
OPTN
SRTR
Analysis File Creation
Reorganization for Research Cleaning and
Validation Analysis Variables Added
Data Use Agreements

Public Release
External Research
78
Implications of Casewise Deletions

• While they do say that data were missing for less
  than 4 of covariates, if the missing values were
  scattered over 20 of patients, then 20 of total
  data might have been deleted.
• Example
• SRTR CIT data 100 complete
• UNOS CIT data 86 complete

79
Critique

• Last transplant included was 2/28/08 - the paper
  was submitted on 7/17/08.  Assuming that it
  took 45 days to analyze and write the paper, then
  the data cutoff would have been 6/1/08. Given
  that the first recipient follow-up form required
  by UNOS is at 6 months and then they only release
  data after a 60 day period for completion, they
  only have data for transplants performed before
  11/1/07

80
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81
Other Considerations

• Slightly different timeframes
• is there a change in clinical practice?
• is there a learning curve for new users of HTK?
• Do the conclusions make sense?
• Recipient age 18-34 HR 1.14
• COD - CVA, HR 1.04 (SRTR HR 1.16)
• COD - DCD, HR 1.97 (SRTR HR 1.51)

82
Does Not Fit Clinical Impressions

• Cleveland Clinic DCD experience
• 15 controlled DCD LTX preserved with HTK since
  2005
• Heparin could not be given prior to declaration
  of death
• Mean donor age was 38 12 years
• Mean WIT and CIT was 25 9 min and 427 97 min,
  respectively
• No recipient developed ITBS. PNF was seen in one
  recipient who was salvaged with retransplantation

83
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84
Summary and Conclusions

• All randomized controlled trials large single
  center case series, across multiple organs,
  countries and time periods demonstrate no
  difference in clinical outcomes between HTK and
  UW
• Question of appropriate flush volume - of
  particular importance to the pancreas
• There is a clear cost benefit in the use of HTK
• Recent database reviews of tens of thousands of
  patients likely reflect difference in practice
  patterns between surgeons who use HTK and those
  who use UW. It is less likely to represent a
  true difference in the clinical outcomes of the
  two solutions when the vast majority of high
  quality studies show no difference.

84
85
Thank You