Medical Minute 7-25: Preserving Donor Livers: The New Technique

By: Vanessa Welch Email
By: Vanessa Welch Email

Ellen Litinger is all about family. A family that's no stranger to hard times. Ellen battled with breast cancer seven years ago -- followed by a uterine cancer diagnosis. She thought the war was over, but right before grandson Jason was born, she found out she needed a new liver.

"It was just one thing after another and after that I really started to go downhill," said Ellen Litinger.

"She became more and mo re upset, somewhat depressed; you start to lose everything you had in your life," said Neil Litinger, Ellen's Husband.

Research by New York Presbyterian's Doctor James Guarrera is helping people like Ellen start living again.

Liver preservation times are short, under 12 hours. A technique called hypothermic machine perfusion is preserving donor livers in a new way.

"The technique really allows the organ to be healthier, to function more rapidly," said James V. Guarrera, M.D., Surgical Director, Adult Liver Transplantation New York-Presbyterian Hospital/Columbia.

Data of the study suggests this technique can increase the time safely by at least 50-percent and possibly even double it in the future. It works like a dialysis machine for kidneys. Doctors connect special tubing to the artery and vein of the liver, while a mini cardiopulmonary bypass pump keeps circulation going. Unlike cold storage, HMP simulates liver function in the body by providing a continuous flow of oxygen and key nutrients.

"In the cold storage we put the organ in a cooler, all the waste products build up and aren't circulated out and neutralized by the medications that we have in our solution that we also developed with the machine," said James V. Guarrera, M.D., F.A.C.S.

Thanks to a donor -- and HMP-- Ellen is back on her feet and back to spending time with the people who matter most.

"I'm disease-free. I have a brand new liver and a new lease on life."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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BACKGROUND: Enough people to populate a small city need an organ transplant to save their lives. That's more than 100,000 people. About 17 people every day die waiting for an organ, and about one-fourth of the people on the waiting list will not receive an organ. One donor could improve the lives of 50 people waiting on an organ. Organ donors can be of any age and health, but children under 18 have to have parental consent in order to donate. In order for organs to be transplanted from the body of a deceased person to the patient in need, the organs must be removed within 60 minutes, which can sometimes be an issue. A major issue with organ transplant is the donor banks because they typically do not have the ability to store organs for any significant length of time.
(SOURCE: Christus Hospital)

STANDARD ORGAN PRESERVATION: The standard means of preserving a soon-to-be transplanted organ is via cold storage. Cold storage first flushes the organ with a cleansing fluid immediately after removal from the donor body, and the fluid remains in the organ until transplanted. The organ is then placed in hypothermic storage to be transported to the organ recipient. While in hypothermic storage, many of the wastes build up because they are not being circulated by the blood.
(SOURCE: http://www.preservationsolutions.com/products_costorsol.html)

HYPOTHERMIC MACHINE PERFUSION: Hypothermic machine perfusion is a new organ storage device that offers advantages over traditional cold storage. It protects better against cold ischemia, inadequate blood supply for too long. Hypothermic machine perfusion also allows for the organ to be preserved longer, perform quicker, and be healthier than one preserved with cold storage. Doctors connect a metal hose to the vein and artery of an organ. That keeps blood circulation going, allowing for the organ to get oxygen and nutrients. This method will hopefully allow for the donor pool to be expanded and transplants to be more successful.
(SOURCE: Transplantation Proceedings)

FOR MORE INFORMATION, PLEASE CONTACT:
Wade Bryan Dotson
Director, Media Relations
New York-Presbyterian Hospital/Columbia
(212) 305-5587
Brd9005@nyp.org

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THE FOLLOWING IS AN IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE:

James V. Guarrera, MD, FACS, Surgical Director, Adult Liver Transplantation - New York-Presbyterian Hospital/Columbia, tells us about a new way to preserve donor organs.

What is HMP?
Dr. Guarrera: HMP is a hypothermic machine preservation, which is a technique to enhance the health of the liver during the period of transit from the donor to the recipient during liver transplant. So, HMP is a technique where we use the machine and we circulate a specialized solution that has antioxidants, medications and mediators to help prevent the injuries that are typical of cold preservation injury. You see typically you know lots of stories where you know the organ is in transit and it’s in a cooler. The machine that we worked on and developed we adopted some of the technology from that kidney transplant experience. But basically what happens is the liver is placed by its vasculature which is calculated and started on an actual dynamic machine that circulates a solution. This, in turn, keeps the organ more healthy and allows the organ potentially last longer and it also allows transplantation of organs that we had previously been turning down due to poor quality and early chances that the graft would not function well right after transplantation. The technique really allows the organ to be healthier, to function more rapidly. It’s kind like when you start your car and in the winter you’ve got to warm your car up, sometimes transplant is like that. It take a little while for the organ to warm up. The things that go in to how quickly the organ warms up and wakes up and works well organ preservation is one really important variable and that’s a variable that now we’re starting to control with this new technique that we’ve been working on.

So does HMP use any of the cold technique at all? Is the solution that goes through it cold?
Dr. Guarrera: We still do use cold temperatures so the H for the HMP is hypothermic so we are still using typical temperatures of cold preservation.

What is that?
Dr. Guarrera: Which is like four degrees centigrade, so with that we you know the real innovative aspect to it is the circulation of the solution which brings waste products away from the direct contact with the tissue with the organ, with the vasculature, with the endothelium and really allows like a direct washout. I typically sort of use the analogy it’s kind of like if you order takeout in your apartment, if you’re a takeout person if you throw your garbage bag away every night you know basically you’ll have a nice clean kitchen. And if you let them pile up for a whole week obviously that’s a buildup of waste product. So the difference is in the cold storage when we just put the organ in a cooler all the waste products build up and aren’t circulated out and neutralized by the medications that we have in our solution that we also developed with the machine. So the important components are the circulation and the solution that allow better health of the organ after the transplant.

Why can you use this on livers you wouldn’t normally accept? Do they have toxins in them before and this way you can wash them out?
Dr. Guarrera: Right. The things that typically are associated with worse outcomes are advanced donor age, donors that are not brain dead so that they have cardiac death. They typically have a period of ischemia whereby the organ is not getting any blood flow prior to the recovery. These have very notable for results that are inferior. And also steatotic livers, livers that are, have fatty infiltration also have high rates of slow function after transplant. By improving the cold ischemic period with HMP we suspect that’s going to allow us to use those organs more safely and get better outcomes to patients who are receiving these organs. There’s a tremendous organ shortage and its really brought all of us to the point where we really have to push the limits. I mean just in the last twenty four hours the three transplants I’ve done one was a seventy nine year old, one was a heart/liver transplant of a patient who required two organs so obviously he was very sick. And then the third was we took the donor liver from the heart patient who had a very rare disease called amyloid and actually transplanted that liver into another patient who happens to be a seventy five year old patient with a tumor. So as the society ages so too does the donor supply ages in terms of median donor age and as well our patients continue to get older and sicker. So to do this big surgery liver transplant we really need to optimize the variables that we can optimize because we can’t optimize all of them. So the new preservation technique gives us hope that we’re going to improve that one variable which hopefully will allow us in conjunction with better medications and improved surgical techniques to have the best outcome as possible and transplant as many patients as possible.

Do you see a difference in the OR with this type of preservation?
Dr. Guarrera: Yes, the one thing we have noticed and we’ve done now forty cases and two different trials and we have noticed that the liver does really start up much quicker than with standard cold storage. And it’s really impressive you know, as soon as we plug in the artery you know we see really robust bile production from coming out of the liver, and we do see that sometimes with cold storage as well but typically with the more healthy, younger grafts. Now with these older grafts that we’ve really been focusing on in these extended criteria grafts we’re amazed to see an eighty year old liver that is you know just pouring bile out and looks and is behaving and the patients behave as if they’re receiving a liver that’s much younger and has very short cold ischemia times. We’re really excited in that our preliminary results really have been excellent and there’s a lot of interest in the transplant community in terms of expanding this to a multicenter trial and developing a more portable machine that can be brought to the donor hospitals and allow everybody to kind of use this technology and hopefully gain the benefits that we’ve been seeing.

Did you create this machine?
Dr. Guarrera: Actually, we adopted this machine, it’s actually the actual hardware machine is a machine that’s used for cardio pulmonary bypass an ECMO but myself and my preservationist developed some of the techniques to manage this machine and to connect to a liver outside the body rather than connecting it to a patient. In our development of this, we found that this machine really was you know an ideal device for this machine perfusion. There are devices out there already for kidney transplant and this technique has been used in kidney transplant extensively and you know for whatever reason people had looked at this technique in animal models but had not actually brought it to a clinical trial. And so we were the first to bring it out to clinical trial. So there are some other people looking at different types of machines and there are companies and groups that looking to develop machines that are more portable that are really specialized for this purpose. So really what our contribution was, was to adopt the technique that we’ve seen that had benefits in kidney transplantations and prove that it was safe and effective in liver transplantation and also you know work out some of the kinks in the system and get it out to the fact that we know now that its safe and has benefits and a pretty good amount of patients, forty patients. So that’s really where we’re at now and we continue to do our research and work on even improving the technique further and hopefully getting a device that’s more specialized in terms of doing this and allowing us to take it on planes and take it in vehicles much easier than our current device which is a little bit more stationary.

Do you remember Ellen?
Dr. Guarrera: Yes.

Do you remember when her liver came back to life?
Dr. Guarrera: I do. She did great. As soon as we took the clamps off the liver pinked up immediately and was beautiful, it started making bile in several minutes after re perfusion.

Does it surprise you how well your patients are doing?
Dr. Guarrera: We like to think that we’re doing this and we’re good surgeons and you know all our patients are going to do well. But having done many of the cases and even you know I think what’s more interesting is when my partners and other surgeons I work with do the cases that they notice the difference. Because you know I’ve been very invested and involved in this for a long time and so whenever we do one of these cases I always feel like, oh yeah see this liver perked up much quicker than livers that we don’t use the pump for. But what really has been exciting is when other surgeons who have been involved, our fellows and our anesthesia staff you know say, wow you really can tell the difference. You know and even I’ve had anesthesiologist that call on the phone when we’re getting ready to do cases and like say, oh you pumping this liver, oh I hope you’re pumping this liver. Because the results intra-operatively seem to be improved as well as after and post-operatively.

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact:

Wade Bryan Dotson
Director, Media Relations
New York-Presbyterian Hospital/Columbia
(212) 305-5587
Brd9005@nyp.org


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