History of Organ Preservation
History of Organ Preservation
The History of Organ Perfusion and Preservation
by Richard Palmer, CTOP IV
When the topic of organ perfusion and preservation surfaces, many people begin to think about the early 50's, 60's, and 70's when Lapchinsky, Lillehei, Malinin, Belzer, Najarian, and several others were considered the pioneers of the business. Not to discredit these wonderful individuals for their sacrifices and contributions to this field, but to know the true history of organ perfusion and preservation we need to go back to the mid to late 1800's.
The first recorded attempts at perfusion of an isolated organ was by Loebel, who published his studies in 1849. In 1895, Langendorf devised a simple organ-perfusion technique as well. The Langendorf apparatus consisted of a medium reservoir and a siphon tube connected to the organ. The system was non-pulsatile; the medium was infused by gravity and did not recirculate. (Malinin, 1979)
In the early 1900's, Martin (John's Hopkins University ) devised a method to perfuse coronary artery's in vitro. While attempts to maintain renal function by perfusion were not successful, it was demonstrated that kidneys attached to heart-lung preparations and perfused with blood secreted urine. (Malinin, 1979)
In 1902, Carrel published his first scientific paper on blood-vessel suturing and the transplantation of organs in French. In 1905, he published, "Anastomosis and Transplantation of Blood Vessels," in English in American Medicine. Around 1930 he became seriously concerned with the problems of cultivating organs. So, he had Heinz Rosenberg construct him a perfusion apparatus that would circulate fluid through an organ regulated by an automatic mechanism. The pump was made out of metal and glass and it was highly efficient and mechanically perfect. However, the findings resulted in the same outcome as many experiments performed in the past by other individuals, it could not be readily sterilized and organs placed in the pump became contaminated with bacteria. (Malinin, 1979)
In the early 1930's Charles Lindbergh's sister-in-law (Elizabeth Morrow) contracted pneumonia and was found also to have rheumatic fever. Lindbergh asked her doctor if there was some type of operation that could be performed to repair the damaged heart valve. Her doctor said an operation could not be performed on her heart, because the heart could not be stopped long enough for surgeons to work on it. Lindbergh asked why a mechanical pump could not be used for circulating the blood while the heart was artificially stopped. No one seemed to know whether or not this was possible. Carrel and Lindbergh become friends through a mutual friend (Dr. Paluel Flagg). Lindbergh used Carrel's laboratories and facilities to design and create the new perfusion pump. Through many modifications of his original plans and the assistance of staff members at the Rockefeller Institute, Lindbergh finally completed his all-glass apparatus which produced sterile pulsating circulation in 1935. From April 1935 to May 1939, a total of 898 individual experiments were carried out in Carrel's laboratories, using the Lindbergh-Rockefeller Institute perfusion apparatus. Once slight modifications in the pump had been made, it did so well that no experiment had to be interrupted because of its malfunction. (Malinin, 1979)
In 1937 Carrel and Lindbergh became fascinated with decreasing body temperatures (hypothermia). Lindbergh was living abroad and did not return to the United States until April 1939. In July 1939 Carrel no longer had a laboratory where such experiments could be performed. So their hypothermia experiments were not carried out. After Carrel's death in 1944, Lindbergh remained in touch with his wife, and maintained an interest in Carrel's ideas and his work. It was largely through Lindbergh's efforts and encouragement that the organ perfusion experiments performed by Carrel and his associates in the late 1930's were repeated in the 1960's. This re-established the validity of the method and dispelled unwarranted criticism by investigators who could not reproduce the experiments. (Malinin, 1979)
Prior to the Lindbergh organ-perfusion apparatus resurfacing in the 1960's, the Soviet Union was working on several experiments dealing with the transplantation of preserved limbs and kidneys. In 1953, Lapchinsky started transplanting limbs and kidneys that were preserved at +2C and +4C. These experiments showed that a true survival of grafted limbs and kidneys were possible with autografts preserved by cooling at these temperatures for 28 hours. Lapchinsky also worked on experiments where artificial circulation was used for only one hour after the beginning of preservation (by cooled blood with the cooling of the organ) and one hour at the end of the preservation period (by heated blood with heating of the organ prior to transplantation). In 28 experiments on the transplantation of extremities preserved for more than 24 hours in the refrigerator unit by the technique described above, 12 dogs survived without any toxic effects. From the 12 surviving dogs, three died from later complications; six others rejected their grafts postoperatively, and the remaining three obtained prolonged functional survival. (Lapchinsky, 1960).
In the mid 1960's an effort was made at the Naval Medical Research Institute to repeat some of Carrel's experiments with the Lindbergh organ-perfusion apparatus. A duplicate of the perfusion pump was constructed, but it was impossible to make the apparatus function as originally described by Lindbergh. Therefore, Lt. V.P. Perry, the officer in charge of the project, wrote Lindbergh for help. Lindbergh came to the laboratory and with little effort made the pump function properly. The operation of the pump was demonstrated at the meeting of the Tissue Culture Association in Miami in 1964. After the demonstration, the authenticity of the descriptions of Carrel and Lindbergh's original performance was no longer questioned. Perry and Malinin continued to do extensive research in the field of organ perfusion and preservation. Along with Lindbergh, together they published several papers on pulsatile perfusion of mammalian organs. (Malinin, 1979)
In June 1964, Lillehei, Manax, Bloch, Lyons, Eyal, and Largiader published an article discussing the significance of organ perfusion prior to transplantation. They stated that the purpose of the article was to focus on some of the key factors in maintaining cell life outside the body during a period of ischemia, namely, the prevention of lethal changes in cellular hydration. Pilot studies show when a kidney is removed and replaced within a one-hour period, perfusion in vitro is probably unnecessary. Any disturbed metabolism quickly corrects itself upon restoration of circulation. In contrast, when a kidney is held in vitro for two hours or longer and then replaced without perfusion, it functions poorly and may not remain viable. Stagnant hypoxic blood retained in the kidney apparently is responsible for the in vitro damage. They concluded this article by stating that successful use of human cadaver organs for the purpose of hemotransplantation demands a method of organ preservation during the in vitro ischemic period (Lillehei, Manax, Bloch, Lyons, Eyal, and Largiader, 1964).
In July 1964, Lillehei, Manax, Bloch, and Longerbeam published another article which dealt with the successful 24 hour in vitro preservation of canine kidneys by using a combination of hyperbaric oxygenation and hypothermia. They summarized their article by stating that a series of experiments are reported in which canine kidneys have been removed, preserved in vitro for 24 hours by combining hypothermia (0 to 4C) with three atmospheres of oxygen and then replaced in the neck of the donor canine. Kidneys so preserved and replaced apparently function normally and are able to sustain the life of the dog after contralateral nephrectomy (Lillehei, Manax, Bloch, and Longerbeam, 1964).
In 1965, Hoffman, Berger, and Persky published an article dealing with extracorporeal renal storage. In their article they stated, "With the use of external cooling combined with mannitol therapy, canine kidneys were successfully stored extracorporeally for 12 hours. In two animals simple cooling was accomplished for 24 hours with ultimate kidney survival and function at a moderately depressed level. Mannitol administration prior to the removal of the dog kidney and immediately following its reimplantation appears to enhance the survival of kidneys stored for 12 hours." (Hoffman, Berger, and Persky, 1965)
In 1964, Najarian had started a kidney transplant program with living-related donors in San Francisco. In 1966, Englebert Dunphy (Chairman of the Department of Surgery at the University of California) suggested that Belzer work on the kidney transplant program with Najarian. Belzer's major task was to develop a cadaver kidney transplant program that would supplement the living-related program. The problem was that brain death had not yet been clinically accepted by the medical profession or the public. At this point cadaver kidneys were typically recovered after a cardiac arrest. The problem being that the kidneys would experience warm ischemic time. To decrease the ischemic time between the kidney procurement and the kidney transplant, Belzer would start the procurement at the donor hospital and if the kidney appeared to be transplantable he would call Najarian at the recipient hospital (University Hospital) and Najarian would start the recipient operation. The kidney would be rushed from the donor hospital to the recipient hospital to keep the ischemia times to a minimum. Because this process was so strenuous, Belzer decided to work on a more effective method of procuring and preserving cadaveric kidneys for transplantation. (Belzer, 1988)
With Bob Hoffman and Glenn Downes assisting him in his studies, Belzer decided to abandon his old studies and switch to studying hypothermic perfusion of the kidneys. In previous studies they found that perfusing the kidneys with whole blood was possible, but only for short periods of time. They started doing studies with plasma as the perfusate. By using plasma as the perfusate they found that it created a delay in the rising pressure of the kidneys approximately six to 10 hours. However, no kidney was viable in a dog after 24 hours of perfusion. They incorporated a membrane oxygenator into the perfusion system and used a pulsatile pump. This delayed the rise in perfusion pressures even further, but consistent viability was never obtained. (Belzer, 1988)
Prior to performing a perfusion experiment, the frozen plasma was removed from the freezer and left out overnight to thaw. Belzer went to the lab one morning and noticed that there was no plasma left out the night before for the experiment that morning. Rather than postponing the experiment, they decided to thaw out some frozen plasma by running it under hot water. To their surprise, the plasma was very turbid. They filtered the plasma in order to get a clear fluid and remove unstable lipoproteins. They named this new solution cryoprecipitated plasma (CPP) and used it to preserve dog kidneys for up to 72 hours with 100 percent survival after autotransplantation. (Belzer, 1988)
In August of 1967, a middle-aged man with amyloidosis presented with renal failure had not been considered for dialysis or for kidney transplantation because of his systemic disease. Belzer had just recovered a cadaveric kidney and placed it on the perfusion machine in his laboratory. He discussed the option of transplanting this kidney with the patient; the patient accepted the kidney. The transplant was performed with a total preservation time of 17 hours. The kidney functioned immediately, although not perfectly, and hypothermic perfusion preservation of a human kidney had become a reality. (Belzer, 1988)
With the help of Chester Truman from the instrument shop at Moffin Hospital, the laboratory equipment was modified to fit onto a portable cart. The membrane oxygenator, one of the first built by the Waters Company, consisted of a silastic envelope in which the fluid was oxygenated. This moved with a rocking motion. The pulsatile pump, organ chamber, and arterial and venous reservoirs were all made in the laboratory but functioned surprisingly well. It took two or three people to move the machine, and with a rented AVIS truck and a forklift they were able to travel to any hospital in the general vicinity. This machine, although heavy and very large, was very reliable. It was used clinically until 1974. With the help of Truman, a miniature portable preservation machine was developed in 1971. It was put through extensive testing in the laboratory prior to being used clinically. (Belzer, 1988)
In December 1971, Belzer recovered two cadaveric kidneys. One was being used locally and the other was going to be transplanted in the Netherlands. Belzer procured the kidneys and placed the one going to the Netherlands on the miniature portable perfusion machine. He boarded an aircraft and headed to the Netherlands. After 37 hours of preservation the kidney was transplanted into a 42 year-old truck driver with polycystic kidney disease. The recipient apparently returned to a normal lifestyle with excellent kidney function until he died 17 years later from a ruptured Berry aneurysm. The miniature portable perfusion machine was then produced commercially by Edwards Laboratory in California for several years as the Mini-Belzer unit and with some minor modifications is still used today for clinical kidney preservation at the University of Wisconsin. (Belzer, 1988)
In the late 1960's and early 1970's, Belzer's group attempted to use the same method of preservation developed for the kidneys for two other organs - livers and hearts. Their interest was stimulated by three liver transplants performed by Delormer and Belzer in the early 1970's. While working in their laboratory, Trunkey did a large number of experiments with dog heart transplants, none which was successful. Hoffman, May, and Belzer did more than 120 porcine liver transplants without achieving consistently successful survival after 24-hour preservation. Because clinical liver transplants were also quite dismal at that time, they decided to abandon further attempts at preserving liver and hearts. (Belzer, 1988)
In 1969 Collins et al. developed the simple cold storage organ preservation method. Collins developed a preservation solution based on previous work concerning organ preservation at hypothermic conditions. The solution contained a high level of potassium and it was developed to mimic the intracellular composition of the kidney. It also contained a high level of glucose which acted as an effective osmotic agent. This surpressed cell swelling. Magnesium was added to act as a membrane stabilizer, but in the presence of phosphate, the magnesium phosphate formed a precipitate. To eliminate the problem, a modified Collins solution was developed in Europe (Euro-Collins) that omitted the magnesium and used mannitol in place of glucose. Both types of Collins solutions are effective for preservation of kidneys up to about 48 hours with the simple cold storage preservation method. Both types of Collins solutions are still being utilized in simple cold storage organ preservation today (Hoffman, Southard, and Belzer, 1996).
Because of the simplicity of Collins cold storage preservation methods, it was rapidly adopted by many clinical transplant centers throughout the world. For the next two decades very little was added to clinical preservation. Most studies that appeared during that period attempted to either credit or discredit both preservation methods (simple cold storage and pulsatile perfusion). (Belzer, 1988)
In 1974 the clinical requirements for successful kidney preservation were relatively well met by either simple cold storage or continuous machine. Now Belzer and his staff turned their research attention to understanding problems in organ preservation, specifically related to basic mechanisms of hypothermic-induced cellular injury and methods to prevent the injury. They did extensive research on several different preservation solutions and perfusion solutions. It was in 1979 that they finally formulated what they thought was the ideal perfusate. The solution contained all the ingredients that eventually became the University of Wisconsin (UW) solution. However, the UW solution didn't guarantee successful kidney preservation. A modified version containing gluconate was developed for human kidney perfusion preservation in 1984. It provided safe three-day preservation of the kidney and replaced cryoprecipitated plasma. (Belzer, 1988)
In the early to mid 1980's, immunosuppressive agents were introduced to the field allowing pancreas and liver transplantation to become feasible. Liver and pancreas transplantations were performed on an emergency basis and it was obvious again that there was a great need for successful preservation of these organs for longer than 24 hours. The success that Belzer's group had with kidney perfusion preservation in the past, led them to initiate studies in the perfusion preservation of these two organs. Due to the cumbersome process and inconsistent results of perfusion preservation, Belzer and his colleagues turned to studies on simple cold storage. The first solution tested was the UW solution minus the additives that supported aerobic metabolism. It was quite effective and provided consistent 72 hour preservation of the canine pancreas. Clinical pancreas preservation with the UW solution was begun in 1987. (Belzer, 1988)
In the summer of 1987, Belzer and his colleagues started using the UW solution for clinical liver preservation. However, they still kept the preservation time under six hours, and the operations were still performed as emergency surgeries. Later that summer, a patient with end-stage liver disease was preparing to receive a liver transplant. The liver was coming out of Texas, and because the recipient required a number of diagnostic procedures, the transplant was scheduled for 8:00am the next morning. The liver was successfully transplanted after 20 hours of preservation time; the recipient was extubated the next day and transferred to the transplant unit on the second postoperative day with excellent liver functions. He is alive and well today. Elective and scheduled liver transplantation became a reality and the operation is performed on a scheduled basis unless the recipient's condition requires an emergency liver transplantation. The experience with UW solution in clinical liver and pancreas transplantation was soon tested at other centers and its efficacy confirmed. It is one of the most widely used organ preservation solutions used in the United States today. (Belzer, 1988)
The last 15 years have been characterized as a period of exponentially increasing recipient waiting times and relatively static organ donation rates. Consequently, increasing efficiencies of organ utilization has become a primary strategy for improving access to transplantable organs. In the field of renal transplantation, current organ perfusion modalities have contributed to these efficiencies. Among these, the non-heart-beating kidney perfusion protocols of Hoffman and D'Alessandro ( Wisconsin ), Koostra ( Maastricht ), and Gage and Light ( Washington , D.C. ) have made access to this population of donor organs a routine modality. In addition, Polyak, Arrington, Stubenbord, and Kinkhabwala's (Cornell) investigations of the role of novel pharmacologic agents, gene expression, apoptosis and reperfusion injury in the setting of organ perfusion have provided models to increase utilization of kidneys deemed unsuitable for transplant by conventional criteria.
The expansion of organ perfusion from kidneys to other solid organs became a reality in 2004 when Guarrera, Arrington and Kinkhabwala became the world's first team to successfully transplant a machine-perfused liver into a human. The early success of liver perfusion promises to mark the next stage in the science and technology of organ preservation.
(photo courtesy of New York Presbyterian Hospital-Cornell Organ Preservation Unit)
Organ perfusion and preservation has come a long way. However, this field still remains in its infancy. There are literally hundreds of different studies taking place today in order to expand the preservation time of organs and to increase the availability of transplantable organs. To give hope to the people that need a transplant in order to survive, we must continue to give our very best while striving for the future in our field. Please support the International Society for Organ Preservation by becoming a member today.
Malinin, T.I. (1979). Surgery and Life: The Extraordinary Career of Alexis Carrel, copyright 1979 (Reproduced by permission of Harcourt, Inc.). New York, NY: Harcourt Brace Jovanovich, Inc.
Lapchinsky, A.G. (1960). Recent Results of experimental Transplantaion of Preserved Limbs and Kidneys and Possible use of this Technique in Clinical Practice. New York, NY.
Lillehei, R.C., Manax, W.G., Bloch, J.H., Lyons, G.W., Eyal, Z., and Largiader, F. (1964). Organ Perfusion before Transplantation. Minneapolis, MN.
Lillehei, R.C., Manax, W.G., Bloch, J.H., and Longerbeam, J.K. (1964). Successful 24 hour in vitro preservation of canine kidneys by the combined use of hyperbaric oxygenation and hypothermia. Minneapolis, MN.
Hoffman, A., Berger, C., and Persky, L. (1965). Extracorporeal Renal Storage. Cleveland, OH: Williams and Wilkins
Belzer, F., (1999, May 6). Early Experience in Kidney Transplantation. [On-line]. Available http://www.stanford.edu/dept/HPS/transplant/html/belzer.html
Hoffman, R., Southard, J., and Belzer, F., (1996). Organ Preservation. Richmond, VA: UNOS
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