Ex vivo Lung Perfusion: Extending the Reach of Lung Transplantation

Ex vivo Lung Perfusion: Extending the Reach of Lung Transplantation

Ex vivo Lung Perfusion:
Extending the Reach of Lung
Transplantation
Shaf Keshavjee MD MSc FRCSC FACS O. Ont.
Director, Toronto Lung Transplant Program
Surgeon-in-Chief, University Health Network
James Wallace McCutcheon Chair in Surgery
Professor, Division of Thoracic Surgery and Institute of Biomaterials
and Biomedical Engineering, University of Toronto
DISCLOSURE

Vitrolife, XVIVO Perfusion – Research grant and
clinical trial

Founding member and Chief Scientific Officer,
Perfusix Canada Inc. Perfusix USA Inc. and
XOR Labs Toronto.
3 Fundamental Problems with the Current
Approach to Donor Organ Management
1.
Focus has been on slowing down death, rather
than on facilitating recovery and regeneration
2.
Static cold preservation hinders the possibility of
active metabolic processes and repair
3.
Find out how the organ works AFTER we implant it
TORONTO EX VIVO LUNG
PERFUSION (EVLP) SYSTEM
Perfusion : 40% CO
Ventilation: 7cc/kg, 7BPM, PEEP 5, FiO2 = 21%
Cypel/Keshavjee J Heart Lung Transplant 2008;
27(12):1319-25.
HUMAN EX VIVO LUNG PERFUSION
DEVELOPMENT OF A STABLE AND RELIABLE
EX VIVO LUNG PERFUSION TECHNIQUE
Cypel/Keshavjee. Technique for Prolonged Normothermic Ex Vivo Lung
Perfusion. J Heart Lung Transplant 2008;27(12):1319-25.
MANIPULATE PRESERVATION TEMPERATURE
ACCORDING TO ORGAN / CLINICAL NEEDS:
HYPOTHERMIA - NORMOTHERMIA
Time to accurately assess, diagnose (improve utilization)
 Opportunity to diagnose, recover, treat, repair (targeted)
 Opportunity to reassess  confirm results of treatment

IMPROVING OUTCOMES IN TRANSPLANTATION:
ORGAN RESUSCITATION AND REPAIR
Good
Better
PARADIGM SHIFT IN ORGAN MANAGEMENT:
EX VIVO ORGAN OPTIMIZATION / REPAIR
Donor Management
Organ Procurement
Cold Preservation
Decision
Ex vivo Evaluation
Ex vivo Organ-Specific
Injury Repair
Transplantation
Decline
HELP II TRIAL
CLINICAL TRANSPLANTATION OF EX VIVO
PERFUSED LUNGS
N = 130 EVLP to date
Toronto General Hospital OR
Bronchoscopy
LUNG X-Ray
Stable or Improved Lung X-ray
1h
3h
14
April 14th 2011, vol. 364, no. 15, pp. 1431-1440.
Outcomes with clinical EVLP
p=0.70
EVLP Activity /Year
1983-2013
16
Ontario Donors vs. LTx/Year
1991-2013
1000
28%
Number of LTx
133
100
87
59
50
50
27 27 25 24
32 30 31 33
38
64
102 104
102
100
86
600
84
68
400
54
42
0
200
91
92
93
94
95
96
97
98
99
'00
'01
'02
'03
'04
'05
'06
'07
'08
'09
'10
'11
'12
13
0
LTx/Year
17
800
Year
Deceased Donors (ON)
Number of Donors
150
Operative (30-d) Mortality by year
1983-2013
133
Number of TX
120
100
100
Death <=30‐d
87
Number of transplants
80
68
60
54
50
42
36
40
20
32
27 2725 24
30 31
15 1314
6
1 2 6
0
Year
18
64
59
33
38
102 102
85
84
104
The Future of Ex Vivo
Lung Perfusion:
“Personalized Medicine for
the Organ”
I.
Advancing Ex vivo Therapies
II. Advancing Diagnostics – the
“omics”
EX VIVO TREATMENT OPPORTUNITIES
DONOR LUNG INJURIES

1- Pulmonary Edema

2- Brain death associated inflammation

3- Infection, Pneumonia

4- Aspiration

5- Pulmonary emboli

6- Ischemia-reperfusion injury

7- Immunologic preparation
RESOLUTION OF PULMONARY EDEMA
1h EVLP
DURING EVLP
Donor P/F 230
3h EVLP
Recipient P/F 420
Ex Vivo Antibiotic Treatment
for Infection
0h
6h
120
100
80
60
40
20
0
106 CFU/L
106 CFU/L
100
40
20
0
0h
22
6h
12h
6h
0h
6h
6h
12h
Enterobacter (n= 1)
6
5
4
3
2
1
0
0h
120
100
80
60
40
20
0
12h
E Coli (n= 2)
Trichosporon (n= 3)
60
106 CFU/L
0h
12h
80
control
106 CFU/L
control
106 CFU/L
106 CFU/L
120
100
80
60
40
20
0
St Maltophilia (n= 3)
S Aureus (n= 3)
Ps Aeruginosa (n= 4)
12h
120
100
80
60
40
20
0
control
0h
6h
12h
SURGICAL EXTRACTION OF LARGE CLOTS
OF VARYING AGE IN DONOR LUNG PA
SIGNIFICANT IMPROVEMENT OF PULMONARY
HEMODYNAMICS AFTER TREATMENT
Alteplase
diagnosis
treatment
Response monitoring
EX VIVO LUNG BIOPSY: QUICK SECTION
PATHOLOGIC EXAMINATION
No evidence of chronic
vascular abnormalities
FUNCTIONAL REPAIR OF HUMAN DONOR
LUNGS BY EX VIVO IL-10 GENE THERAPY
PaO2/FiO2
300
*
200
100
0
-100
EVLP/AdIL-10
PVR
(dynes.sec.cm-5)
(mmHg)
Change from Baseline
Delivery of IL-10 by EVLP Ad Gene Therapy to injured human donor lungs
resulted in improved lung function
600
400
200
0
-200
-400
-600
*
EVLP
M Cypel, M Liu, M Rubacha, J C Yeung, S Hirayama, M Anraku, M Sato, J Medin, BL
Davidson, M de Perrot, TK Waddell, A S Slutsky, S Keshavjee. Sci Trans. Med 1:4ra9; 2009.
ADIL-10 GENE THERAPY DECREASES HUMAN
DONOR LUNG INFLAMMATION DURING EVLP
Reduced inflammatory cytokine expression
IL-8
IL-1
IL-10
6000
50
4000
0
2000
-50
0
20
-100
-2000
0
-150
-4000
*
60
*
-20
IL-6
EVLP
EVLP/AdhIL-10
4000
20
20
*
40
IL-12p40
TNF-
2000
Ad
hI
L10
10
Ad
hI
L-
ro
nt
-6000
C
on
tro
l
-40
-4000
-1
0
-40
-2000
hI
L
-20
0
Ad
-20
C
on
tro
l
0
l
0
Co
Change from baseline (pg/mg
protein)
100
Cypel/Keshavjee et al. Science Translational Medicine Oct 28, 2009.
T cell allo response is significantly
attenuated by ex vivo AdhIL-10 at day 7
* p = 0.05
** p < 0.05
28
LENTIVIRAL GENE THERAPY
LONG TERM INTRA - GRAFT LOW LEVEL
GENE EXPRESSION
Hirayama/ Keshavjee et al. Human Gene Therapy 2012.
Flow of Information from DNA to Phenotype
DNA
histones
Genotyping
Exome sequencing
Genome sequencing
intron
exon
Epigenetics
how information
encoded in the genome flowsRNA
from DNA through various Phenotype
steps to
Epigenomics
Traits
ultimately influence
Transcriptomics
Disease risk
phenotype
Non-coding
Drug response
RNA
Protein
Phenomics
proteomics
Systems Biology
Bioinformatics
Metabolite
Metabolomics
Cappola TC and Margulies KB. Circulation 2011;124:87-94
0.4
Fail vs Control (CIT)
t−test (limma): FDR ≤ 0.05 (1330 genes)
0.2
Sample
0
−2
0
2
Row Z−Score
Fail
Control T
Control R
Genes
Density
Color Key
and Density Plot
Nanostructured Microelectrode (NME)
Chip Assay
 Current Protocol:
Soleymani, L., Fang, Z., Sargent, E. H., & Kelley, S. O. (2009) Nature nanotechnology 4, 844-848.
a
Nanostructured
Microelectrode (NME)
Chip Lung Transplant
Assay
b
a) Lung assessment
workflow.
assay
b) FraCS chip (left) and SEM
images of sensors following
electrochemical
deposition
(white bars represent 20 um).
c
c) Assay readout (PNA probe
and DPV signal (blue), target
mRNA
hybridization
and
resulting DPV signal (red).
Metabolomic Profile Assessment
Solid Phase Micro-Extraction (SPME)
34
HOW CAN WE APPLY THIS CLINICALLY?

Transplant Center - Centric Model
HOW CAN WE APPLY THIS CLINICALLY?

Organ Repair Center Model
Hospital Run?
 OPO Run?

THE “ORGAN REPAIR CENTER”
Lung
Heart
Liver
Kidney
Steps to Personalized Medicine for the Organ
DONOR LUNG
Clinical
Assessment
Fails
Excellent
Current Practice
TRANSPLANT
No
Transplant
Steps to Personalized Medicine for the Organ
DONOR LUNG
Clinical
Assessment
Ex Vivo Lung
Perfusion (EVLP)
Fails
Good
Function
Fails
Excellent
Current Toronto Practice
TRANSPLANT
Available
Clinical
Therapies
No
Transplant
Steps to Personalized Medicine for the Organ
DONOR LUNG
Clinical
Assessment
Ex Vivo Lung
Perfusion (EVLP)
Fails
Good
Function
Fails
Excellent
Bio-profiling
Accuracy,
Confirmation,
Safety
Available
Clinical
Therapies
Favourable
TRANSPLANT
No
Transplant
Personalized Medicine for the Organ
DONOR LUNG
Clinical
Assessment
EVLP
Fails
Functional
Assessment
Suitable
RapidBioprofiling
Bioprofiling
Rapid
Diagnostic
Accuracy,
Confirmation,
Safety
Fails… or
Could be
Improved
Fails
Ex vivo
Repair
Strategies
Reassess
TRANSPLANT
Fails
No Transplant