The role of perfusion washout in limb revascularization procedures

Amputated rat hindlimbs were subjected to either normothermic (26 degrees C) or hypothermic (4 degrees C) ischemia. Experimental limbs had their microcirculation washed out (either before or after the ischemic insult) with a physiologic acellular plasma substitute previously reported to enhance flap survival following extended periods of warm ischemia. Control limbs were not washed out; i.e., stagnant blood remained in these limbs. Following the ischemic interval, amputated limbs were replanted. Monastral blue B, a colloidal pigment capable of labeling leaky blood vessels, was administered systemically to all rats just prior to vascular declamping. Limb biopsies of skin and muscle were harvested 30 minutes following revascularization in order to assess Monastral labeling and, therefore, the functional integrity of the microcirculation. Results confirm that stagnant blood under conditions of warm ischemia is detrimental to the functionality of the microcirculation in both skin (p less than 0.03) and muscle (p less than 0.007). Accordingly, perfusion washout, when performed prior to the ischemic period, enhances limb survival following 6 hours of warm ischemia (p less than 0.01). Hypothermia protects against the detrimental effects of stagnant blood; perfusion offers no benefit if hypothermic conditions prevail. Physiologic mechanisms responsible for these findings are discussed.     

Experimental Appraisal of Factors Involved in Provision of Donor Livers

The results of a series of porcine orthotopic liver homotransplants have shown that hepatic damage is related almost entirely to the period of warm ischaemia following death. Low flow perfusion with modified plasma would seem to be a satisfactory method of preserving cadaveric livers for at least six hours.In man it would appear possible to use cadaver livers derived from patients who had or had not been treated with artificial ventilation during life, provided the period of warm ischaemia is not longer than 25 to 30 minutes.     

Agonal phase,ischaemic times,and renal vascular abnormalities and outcome of cadaver kidney transplants.

A retrospective study of 250 cadaver kidney transplants was carried out to determine the effects of the agonal period, the warm and cold ischaemic times, and the use of kidneys with vascular anomalies on the primary success and failure and the subsequent level of function of the transplants. Kidneys with vascular anomalies or from non-ventilated donors had a primary failure rate of over 30%, whereas those with normal vasculature or from ventilated donors had a rate of 17%. An initial warm ischaemic time of more than 60 minutes was associated with a primary failure rate of 57% and a cold ischaemic time of over 550 minutes with a primary failure rate of 47%. The interrelationship between the warm and cold ischaemic times in the primary success or failure of the transplants was examined and criteria defined for selecting potentially viable cadaver kidneys for transplantation, as follows: (1) The donor should be (a) ventilated, (b) aged 6-50 years, and (c) have normal ante-mortem renal function and have secreted more than 1-5 1 of urine in the 24 hours before death (or an equivalent volume if the urinary output was recorded for less than 24 hours before death); (2) the kidney should have normal renal vasculature enabling single arterial and venous anastomoses to be performed; (3) kidneys with I.W.I.T.s of longer than 60 minutes should not be used; (4) for kidneys with I.W.I.T.s of less than 20 minutes the C.I.T. is not critical but should not exceed 12 hours; (5) for kidneys with I.W.I.T.s of 20-60 minutes the C.I.T. should not exceed 450 minutes.     

Ionic shift in cerebral ischemia

Electrolyte and water contents were measured in gerbil brain after unilateral cerebral ischemia. Increase of Na⁺ and water, and decrease of K⁺ occurred after an ischemic period of 30 minutes. However, these abnormalities disappeared within 3 hours. When the ischemic period was extended to 3 hours, the abnormalities observed after ischemia for 30 minutes were again encountered, but more significant alterations occurred immediately after re-establishment of blood flow. In addition to more pronounced increase of Na⁺ and decrease of K⁺, Ca²⁺ became significantly elevated after recirculation for 15 minutes and progressively increased during recirculation for 3 hours. The steady rise of Ca²⁺ appears to be related to the irreversibility of cerebral ischemia.     

Early and late effects of ischemic preconditioning on microcirculation of skeletal muscle flaps

The present study was designed to investigate the early and late effects of ischemic preconditioning on muscle flap perfusion and reperfusion-induced skeletal muscle damage. Thirty-six Sprague-Dawley rats were divided into six experimental groups of six animals each. The cremaster muscle flap model and the intravital microscopy system were used to observe microcirculatory changes associated with ischemia-reperfusion injury and ischemic preconditioning. In groups 1, 2, and 3, microcirculatory measurements were taken on the same day; however, in groups 4, 5, and 6, measurements were taken a day after surgery. Group 1 served as a control. The cremaster muscle was prepared as a tube flap, subjected to an hour of perfusion without ischemia. In group 2 (ischemic preconditioning + ischemia group), the cremaster muscle tube flap was subjected to 30 minutes of ischemia and 30 minutes of reperfusion, followed by 4 hours of total ischemia. In group 3 (ischemia alone), the flap was submitted to 4 hours of ischemia alone. In group 4 (control), the cremaster muscle flaps were dissected out, preserved in the subcutaneous tunnel, and submitted to 24 hours of perfusion only. In group 5 (ischemic preconditioning + 24 hours of perfusion + 4 hours of ischemia), the ischemic preconditioning protocol was followed by 24 hours of perfusion and 4 hours of ischemia. In group 6 (24 hours of perfusion + ischemia), the same protocol was used as in group 5 without ischemic preconditioning. Functional capillary perfusion, and the diameters of the arterioles of the first, second, and third order were significantly increased in the ischemic preconditioning group during the early period, but not after 24 hours of perfusion. No differences in the red blood cell velocities of arterioles of the first, second, or third order were found in either the early-effect or late-effect groups. The numbers of rolling, adhering, and transmigrating leukocytes, however, were significantly lower in the ischemic preconditioning group at both early and late follow-up. Ischemic preconditioning of the skeletal muscle flap has both an early and a late protective effect against reperfusion injury. Ischemic preconditioning at the early interval significantly improves muscle flow hemodynamics of the flap and attenuates leukocyte-mediated reperfusion injury. After 24 hours of reperfusion, however, ischemic preconditioning failed to improve the flow hemodynamics of the flap, yet it still protected the skeletal muscle flap from leukocyte-mediated reperfusion injury.     

Preservation of Human Kidneys for Transplantation: Preliminary Results with a Gambro Perfusion Machine

Twenty-six human cadaveric kidneys have been preserved for up to 36 hours by continuous perfusion with 4·5% albumin solution on a Gambro machine. Of these, 20 kidneys were transplanted, and six were discarded owing to poor perfusion characteristics during storage. Immediate function was obtained with four kidneys, of which two had been preserved for over 30 hours.Satisfactory renal function has been obtained with 17 kidneys, and three kidneys were lost owing to rejection or technical complications. It is our experience that human kidneys can be successfully preserved for up to 36 hours by this technique.     

Delayed microcirculatory hyperpermeability following perfusion washout

Recent experimental data have demonstrated improved flap survival following perfusion washout with a synthetic, chemically defined, mammalian plasma. In an effort to define the physiology responsible for the efficacy of perfusion, the method of "labeling" hyperpermeable blood vessels with Monastral blue B in rat epigastric vascular island flaps was utilized. Results confirmed that capillary and venular hyperpermeability is an early and progressive pathophysiologic event in ischemic flap tissue and one which is reversible prior to a critical ischemic period. Perfusion washout with a physiologic, acellular plasma substitute delays the onset of vascular hyperpermeability. This may be a mechanism responsible for improving tissue survival following extended periods of warm ischemia (12 hours). It is implied that stagnant blood and products of hemolysis in the microcirculation may be detrimental to the functional and anatomic integrity of the endothelial wall.     

Metabolomic Perfusate Analysis during Kidney Machine Perfusion: The Pig Provides an Appropriate Model for Human Studies

Introduction

Hypothermic machine perfusion offers great promise in kidney transplantation and experimental studies are needed to establish the optimal conditions for this to occur. Pig kidneys are considered to be a good model for this purpose and share many properties with human organs. However it is not established whether the metabolism of pig kidneys in such hypothermic hypoxic conditions is comparable to human organs.

Methods

Standard criteria human (n = 12) and porcine (n = 10) kidneys underwent HMP using the LifePort Kidney Transporter 1.0 (Organ Recovery Systems) using KPS-1 solution. Perfusate was sampled at 45 minutes and 4 hours of perfusion and metabolomic analysis performed using 1-D ¹H-NMR spectroscopy.

Results

There was no inter-species difference in the number of metabolites identified. Of the 30 metabolites analysed, 16 (53.3%) were present in comparable concentrations in the pig and human kidney perfusates. The rate of change of concentration for 3-Hydroxybutyrate was greater for human kidneys (p<0.001). For the other 29 metabolites (96.7%), there was no difference in the rate of change of concentration between pig and human samples.

Conclusions

Whilst there are some differences between pig and human kidneys during HMP they appear to be metabolically similar and the pig seems to be a valid model for human studies.     

Lengthening versus shortening dark periods and blossoming in sugar cane as affected by temperature

Sugar cane, an intermediate day plant, clearly received a stronger stimulus to flower during lengthening nights than during shortening nights. Flowering was vigorous under warm, lengthening nights (21°) but less so under cool, lengthening nights (16-17°). Warm or cool shortening nights either failed to induce flowering altogether or reduced it substantially. Under the warmer nights the inductive dark period was 10 hours 57 minutes to 11 hours 26 minutes whether the nights were lengthening or shortening. Under cooler conditions, it was longer by from 20 minutes to nearly 2 hours.     

Ice Storage versus Perfusion for Preservation of Kidneys before Transplantation

The results of simple ice storage and prolonged perfusion storage of kidneys were compared in two series, each of 100 cadaver kidney transplants. There was a similar warm ischaemia time for both groups, but the average total storage time was 17 hours for the perfused kidneys as compared to three and a half hours for those stored in ice. The results of transplantation (as shown by transplant function at three and 12 months) were the same for both groups. There was no evidence of damage due to prolonged perfusion. The extra time, however, enabled a more convenient operation time to be chosen and more extensive tissue matching to be undertaken.     

The Efficacy of Antioxidants Administered during Low Temperature Storage of Warm Ischemic Kidney Tissue Slices

Accumulation of products of lipid peroxidation (malondialdehyde, conjugated dienes, lipid peroxides, and Schiff bases) was evaluated in rabbit kidney cortex slices made ischemic for 60 min followed by 18 h storage at 5°C in UW Na gluconate solution and 210 min normothermic reoxygenated incubation. In addition, the effect of adding Trolox (1 mM), deferoxamine (1 mM), and ascorbate (1 mM) as supplemental antioxidants to the UW gluconate solution was evaluated. Lipid peroxidation was slightly increased after hypothermic storage compared to slices subjected to ischemia alone but was not significantly different than ischemic slices during subsequent incubation at normothermia. The addition of either deferoxamine or Trolox to the storage solution substantially reduced lipid peroxidation both during hypothermic storage and subsequent to normothermic incubation. Ascorbate had a mild prooxidant effect as a sole additive to the UW gluconate solution but was clearly prooxidant when combined with either deferoxamine or Trolox. These results suggest that supplemental antioxidants added to the UW gluconate solution under conditions analogous to machine perfusion preservation have a potential role in reducing oxidative stress in kidney tissues harvested after warm ischemia and that hypothermia may be a valuable adjunct to resuscitative therapeutic regimens developed for salvage of ischemic kidneys for transplantation.     

Shifts in nuclear and cytoplasmic nucleic acid content in temperature-synchronized Tetrahymena pyriformis (HSM)

Nuclei were isolated by exposing temperature synchronized Tetrahymena pyriformis (HSM) to Triton-X-100. Cell division synchrony was induced with a repetitive 12-hour temperature cycle (9.5 hours at 13°, 2.5 hours at 29°). Increase in nucleic acid content was biphasic: primarily during the last two hours of the cold period well in advance of the synchronous burst of division and secondarily in the last hour of the warm period. Nuclear RNA content rises almost two hours ahead of cytoplasmic RNA which shows a maximum 0.5 hour before the onset of the warm period. The DNA content reaches a peak 30 minutes later. On the basis of these shifts there appears to be not net synthesis of nucleic acids during cell division. The changes in RNA/DNA of the isolated macronuclei and micronuclei suggest enhanced RNA turnover, loss to the cytoplasm and enhanced ribonuclease activity prior to cell division. Cytoplasmic RNA also appears to be subject to enzymic degradation.     

The influence of storage temperature during machine perfusion on preservation quality of marginal donor livers

Background

Although non-heart-beating donors have the potential to increase the number of available organs, the livers are used very seldom because of the risk of primary non-function. There is evidence that machine perfusion is able to improve the preservation of marginal organs, and therefore we evaluated in our study the influence of the perfusate temperature during oxygenated machine perfusion on the graft quality.

Methods

Livers from male Wistar rats were harvested after 60-min warm ischemia induced by cardiac arrest. The portal vein was cannulated and the liver flushed with Lifor® (Lifeblood Medical, Inc.) organ preservation solution for oxygenated machine perfusion (MP) at 4, 12 or 21 °C. Other livers were flushed with HTK and stored at 4 °C by conventional cold storage (4 °C-CS). Furthermore two groups with either warm ischemic damage only or without any ischemic damage serve as control groups. After 6 h of either machine perfusion or cold storage all livers were normothermic reperfused with Krebs–Henseleit buffer, and functional as well as structural data were analyzed.

Results

Contrary to livers stored by static cold storage, machine perfused livers showed independently of the perfusate temperature a significantly decreased enzyme release of hepatic transaminases (ALT) during isolated reperfusion. Increasing the machine perfusion temperature to 21 °C resulted in a marked reduction of portal venous resistance and an increased bile production.

Conclusions

Oxygenated machine perfusion improves viability of livers after prolonged warm ischemic damage. Elevated perfusion temperature of 21 °C reconstitutes the hepatic functional capacity better than perfusion at 4 or 12 °C.     

兔脑微栓塞模型脑血流动力学的CT灌注动态变化

目的探讨兔脑微栓塞模型CT灌注成像（CT perfusion imaging,CTPI）脑血流动力学的动态变化规律。方法 30只新西兰兔,随机分成两组,A组：假手术对照组5只,B组：微栓塞组25只。经颈外动脉向颈内动脉注入直径约0.5 mm的SiO2颗粒10枚,分别于栓塞后30 min、3 h、6 h、12 h及24 h行CTPI,24 h处死动物取脑组织行HE染色。根据HE染色结果将模型分为缺血组和梗死组,分别观察其脑血流量（cerebral blood flow,CBF）、脑血容积（cerebral blood volume,CBV）和平均通过时间（mean transit time,MTT）的动态变化规律。结果 A组CTPI及HE染色均未见明显异常。B组3只因实验意外死亡,1只因下肢静脉穿刺失败导致CTPI失败,21只行CTPI,其中18只灌注异常,3只未见明显异常。18只灌注异常的兔中,HE染色10只脑梗死,7只脑缺血,1只未见明显异常。30 min时7只缺血兔脑不同程度低灌注,表现为CBF降低,MTT延长,CBV无显著变化,3～6 h低灌注进一步加重,CBV值略降低,12 h低灌注不同程度恢复,24 h进一步恢复。30 min时10只梗死兔脑明显低灌注,表现为CBF及CBV显著降低,MTT显著延长,3只兔低灌注分别在3 h、6 h及12 h不同程度恢复,然后下一时间又迅速降低并随着时间延长进一步加剧,其余7只兔低灌注程度随时间延长逐渐加剧或在一定水平上波动。结论脑缺血3～6 h低灌注最明显,12～24 h低灌注不同程度恢复,而脑梗死随时间延长低灌注程度不断加重或一过性恢复后再次加重。脑缺血的特征是CBF和CBV的不匹配,缺血组织CBF显著降低,CBV无显著变化,而脑梗死则表现为这两个参数的一致性下降。     

Biliary excretion of 110mAg and its kinetics in the isolated perfused liver in rats

The biliary excretion of 110mAg in rats after i.v. administration of an aqueous solution of 110mAgNO3 (4.57 micrograms; 16kBq per rat) was studied for a period of 24 hours. The maximum rate of excretion was reached in 30th minute after the metal administration and over 70% of the silver dosed was excreted during 24 hours. Using the method of isolated perfused liver it was observed that 110mAg is rapidly taken up in the liver. During the five minutes period of the perfusion less than 50% of silver administered was found in the perfusion medium. In following minutes the level of the metal in the medium remained approximately constant. It was suggested that the rate of excretion of silver and its high uptake in the liver tissue is in connection with an unusual binding of it in the bile.     

Assessment of a test of renal viability.

A test of renal viability using the uptake of 125I-iodohippurate by kidney biopsy specimens has been developed. It is applicable to all kidneys irrespective of the method of storage. The uptake of 125I-iodohippurate in experimental kidneys correlated well with warm or cold ischaemia time and subsequent renal function. The test was used for human cadaver kidneys offered for transplantation and there was good correlation between iodohippurate uptake and warm ischaemic time. With this test, prediction of renal function was accurate in 85% of human cadaver kidneys transplanted. Pulsatile perfusion had no effect on cadaver kidneys as measured by this test.     

Function of Cadaver Renal Homografts in Relation to Age of Donor,Cause of Death,and Ischaemia Time

Twenty-six renal grafts four months or more after transplantation have been shown to function satisfactorily when the donor''s age has varied from 10 to 64 years and the period of warm ischaemia has been between 26 and 133 minutes. It is suggested that a more lenient view be adopted with respect to the age of the donor, but that a warm ischaemia time of two hours should not be exceeded.     

The effects of the perfusion of various solutions on the no-reflow phenomenon in experimental free flaps.

The effects of solution perfusion in the free epigastric flap of the rabbit, after normothermic ischemic periods of 8 hours or 12 hours, have been examined by operative microscopic and histological methods. A smaller group of animals was also studied in which the perfusion was done before the ischemic insult. An ischemia-related obstruction to the peripheral blood flow occurred in the absence of stagnant ischemic blood in this model. Although the 3 perfusion fluids studied were shown to penetrate to all levels of a flap after such an ischemic period, none of them had a beneficial effect on skin survival. However, the solution containing mannitol did have a protective effect on fat survival. Analogies between these experimental findings and the clinical situation are made, and the importance of the early diagnosis and treatment of ischemia in a flap is emphasized.     

Functional preservation of the mammalian kidney. IV. Functional effects of perfusion with dimethyl sulfoxide (DMSO) at normothermia

Rabbit kidneys were perfused at 37 °C with various concentrations of DMSO in a K⁺-Mg²⁺-rich perfusate. The effects of DMSO on various functional parameters of the rabbit kidney perfused for 60 min were compared with the functional effects of perfusion without DMSO under the same conditions. DMSO produced deviations in vascular resistance and perfusate flow rate from control values. In kidneys perfused with 1.4 and 2.8 m DMSO these vascular changes resulted in changes in GFR at relatively unchanged filtration fractions. The closely parallel relationship between changes in GFR and urine flow rate in all groups indicates that perfusion per se or perfusion with DMSO may shift the regulation of urine flow rate from tubular reabsorption, which obtains in the in vivo situation, to glomerular filtration. This view was supported by the relatively unchanged parameters of Na⁺ reabsorption and fractional water excretion during perfusion with all concentrations of DMSO. Additionally, DMSO perfusion resulted in significantly greater weight gains than those observed in kidneys perfused without DMSO, and significantly depressed clearances of PAH, with 2.1 and 2.8 m DMSO.