Abstract

Liver transplantation is a highly successful treatment, but is severely limited by the shortage in donor organs. However, many potential donor organs cannot be used; this is because sub-optimal livers do not tolerate conventional cold storage and there is no reliable way to assess organ viability preoperatively. Normothermic machine perfusion maintains the liver in a physiological state, avoids cooling and allows recovery and functional testing. Here we show that, in a randomized trial with 220 liver transplantations, compared to conventional static cold storage, normothermic preservation is associated with a 50% lower level of graft injury, measured by hepatocellular enzyme release, despite a 50% lower rate of organ discard and a 54% longer mean preservation time. There was no significant difference in bile duct complications, graft survival or survival of the patient. If translated to clinical practice, these results would have a major impact on liver transplant outcomes and waiting list mortality.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Change history

  • 23 April 2018

    The Source Data files originally published with this article were missing for Extended Data Figures 3 and 4. This has now been corrected.

References

  1. 1.

    Annual Report on Liver Transplantation 2016/2017 (NHS Blood and Transplant, 2017).

  2. 2.

    APPHG. Liver disease: today’s complacency, tomorrow’s catastrophe. The All-Party Parliamentary Hepatology Group (APPHG) inquiry into improving outcomes in liver disease. (March, 2014).

  3. 3.

    Todo, S. et al. Extended preservation of human liver grafts with UW solution. J. Am. Med. Assoc 261, 711–714 (1989).

  4. 4.

    Clavien, P. A., Harvey, P. R. & Strasberg, S. M. Preservation and reperfusion injuries in liver allografts. An overview and synthesis of current studies. Transplantation 53, 957–978 (1992).

  5. 5.

    Chouchani, E. T. et al. Ischaemic accumulation of succinate controls reperfusion injury through mitochondrial ROS. Nature 515, 431–435 (2014).

  6. 6.

    Watson, C. J. et al. Preimplant normothermic liver perfusion of a suboptimal liver donated after circulatory death. Am. J. Transplant. 16, 353–357 (2016).

  7. 7.

    Mergental, H. et al. Transplantation of declined liver allografts following normothermic ex-situ evaluation. Am. J. Transplant. 16, 3235–3245 (2016).

  8. 8.

    Perera, T. et al. First human liver transplantation using a marginal allograft resuscitated by normothermic machine perfusion. Liver Transpl. 22, 120–124 (2016).

  9. 9.

    Ravikumar, R. et al. Liver transplantation after ex vivo normothermic machine preservation: a phase 1 (first-in-man) clinical trial. Am. J. Transplant. 16, 1779–1787 (2016).

  10. 10.

    Brockmann, J. et al. Normothermic perfusion: a new paradigm for organ preservation. Ann. Surg. 250, 1–6 (2009).

  11. 11.

    Xu, H. et al. Excorporeal normothermic machine perfusion resuscitates pig DCD livers with extended warm ischemia. J. Surg. Res 173, e83–e88 (2012).

  12. 12.

    Eisenbach, C. et al. An early increase in gamma glutamyltranspeptidase and low aspartate aminotransferase peak values are associated with superior outcomes after orthotopic liver transplantation. Transplant. Proc 41, 1727–1730 (2009).

  13. 13.

    Olthoff, K. M. et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 16, 943–949 (2010).

  14. 14.

    Organ Donation and Transplantation Activity Report 2016/17 (NHS Blood and Transplant, 2017).

  15. 15.

    Angelico, R. et al. Normothermic machine perfusion of deceased donor liver grafts is associated with improved postreperfusion hemodynamics. Transplant. Direct 2, e97 (2016).

  16. 16.

    Leithead, J. A. et al. Hepatic ischemia reperfusion injury is associated with acute kidney injury following donation after brain death liver transplantation. Transpl. Int 26, 1116–1125 (2013).

  17. 17.

    Jay, C. L. et al. Ischemic cholangiopathy after controlled donation after cardiac death liver transplantation: a meta-analysis. Ann. Surg. 253, 259–264 (2011).

  18. 18.

    Mourad, M. M., Algarni, A., Liossis, C. & Bramhall, S. R. Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation. World J. Gastroenterol. 20, 6159–6169 (2014).

  19. 19.

    Reddy, S. et al. Non-heart-beating donor porcine livers: the adverse effect of cooling. Liver Transpl. 11, 35–38 (2005).

  20. 20.

    Abstracts of the 18th Congress of the European Society for Organ Transplantation, 24–27 September 2017, Barcelona, Spain. Transpl. Int. 30 (Suppl 2), 5–576 (2017).

  21. 21.

    Schulz, K. F., Altman, D. G. & Moher, D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Br. Med. J 340, c332 (2010).

  22. 22.

    Kootstra, G., Daemen, J. H. & Oomen, A. P. Categories of non-heart-beating donors. Transplant. Proc 27, 2893–2894 (1995).

  23. 23.

    Makowka, L. et al. Surgical technique of orthotopic liver transplantation. Gastroenterol. Clin. North Am 17, 33–51 (1988).

  24. 24.

    Glanemann, M. et al. Clinical implications of hepatic preservation injury after adult liver transplantation. Am. J. Transplant 3, 1003–1009 (2003).

  25. 25.

    Gaffey, M. J. et al. Predictive value of intraoperative biopsies and liver function tests for preservation injury in orthotopic liver transplantation. Hepatology 25, 184–189 (1997).

  26. 26.

    Karayalçin, K. et al. The role of dynamic and morphological studies in the assessment of potential liver donors. Transplantation 57, 1323–1327 (1994).

  27. 27.

    Hilmi, I. et al. The impact of postreperfusion syndrome on short-term patient and liver allograft outcome in patients undergoing orthotopic liver transplantation. Liver Transpl 14, 504–508 (2008).

  28. 28.

    Nasralla, D. et al. A multicentre randomised controlled trial to compare the efficacy of ex-vivo normothermic machine perfusion with static cold storage in human liver transplantation. Protoc. Exch. https://doi.org/10.1038/protex.2018.027 (2018).

  29. 29.

    Guidelines on Medical Devices. Clinical Investigations: Serious Adverse Event Reporting. Report No. MEDDEV 2.7/3 (European Commission, 2010).

  30. 30.

    Dindo, D., Demartines, N. & Clavien, P. A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 240, 205–213 (2004).

Download references

Acknowledgements

This study was performed by the Consortium for Organ Preservation in Europe (COPE). We thank the European Commission for their support through the Seventh Framework Programme. The following organisations, groups and individuals also made substantial contributions without which this trial could not have been completed successfully: NHS Blood and Transplant; the Surgical Intervention Trials Unit, University of Oxford; the Clinical Trials and Research Governance unit, University of Oxford; Centre for Evidence in Transplantation, Royal College of Surgeons of England; the Liver Transplant Coordinators, anaesthetists and liver unit physicians at the Queen Elizabeth Hospital, Birmingham, Addenbrooke’s Hospital, Cambridge, King’s College Hospital, London, the Royal Free Hospital London, Hospital Clinic, Barcelona, University Hospitals, Leuven, University Hospital, Essen; M. Soo, S. Morrish, C. Morris, L. Randle, R. Macedo Arantes, R. Morovat, A. Elsharkawy, G. Hirschfield, P. Muiesan, J. Isaac, J. Grayer, B. Buchholz, H. Vilca-Melendez, A. Zamalloa, D. Chasiotis, S. Khorsandi, B. Davidson, D. Sharma, A. Esson, D. Monbaliu, S. Mertens, S. Swoboda, J. Neuhaus, T. Benkö, V. Molina, R. Kumar, A. Bradley, M. Laspeyres, B. Patel, A. Mukwamba, S. Banks, the COPE Transplant Technicians, the Specialist Nurses in Organ Donation and, of course, all of the donors and their families. This study was funded by a European Commission Seventh Framework Programme (FP7) Grant (No 305934).

Reviewer information

Nature thanks S. Schneeberger, S. G. Tullius and the other anonymous reviewer(s) for their contribution to the peer review of this work.

Author information

Affiliations

  1. Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

    • David Nasralla
    • , M. Zeeshan Akhtar
    • , Carlo D. L. Ceresa
    • , Simon R. Knight
    • , Peter J. Morris
    • , Reena Ravikumar
    • , Annemarie Weissenbacher
    • , Rutger J. Ploeg
    •  & Peter J. Friend
  2. Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK

    • Constantin C. Coussios
  3. Queen Elizabeth Hospital Birmingham, Birmingham, UK

    • Hynek Mergental
    • , Darius Mirza
    •  & M. Thamara P. R. Perera
  4. Target Discovery Institute, University of Oxford, Oxford, UK

    • M. Zeeshan Akhtar
  5. University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK

    • Andrew J. Butler
    •  & Chris J. E. Watson
  6. Centre for Statistics in Medicine, University of Oxford, Oxford, UK

    • Virginia Chiocchia
  7. Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

    • Virginia Chiocchia
  8. Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK

    • Susan J. Dutton
  9. Department of Hepatobiliopancreatic and Transplant Surgery, Hospital Clinic, Barcelona, Spain

    • Juan Carlos García-Valdecasas
    •  & Mihai Pavel
  10. Institute of Liver Studies, King’s College Hospital, London, UK

    • Nigel Heaton
    • , Wayel Jassem
    •  & John Karani
  11. Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, UK

    • Charles Imber
    •  & Massimo Malagò
  12. Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium

    • Ina Jochmans
    •  & Jacques Pirenne
  13. Laboratory of Abdominal Transplantation, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium

    • Ina Jochmans
    •  & Jacques Pirenne
  14. Department of Radiology, King’s College Hospital, London, UK

    • John Karani
  15. Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK

    • Simon R. Knight
    •  & Peter J. Morris
  16. Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany

    • Peri Kocabayoglu
    •  & Andreas Paul
  17. Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK

    • Arvind Pallan
  18. OrganOx Limited, Oxford, UK

    • Leslie Russell
  19. Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK

    • Sara Upponi
  20. National Institute of Health Research (NIHR), Cambridge Biomedical Research Centre, Cambridge, UK

    • Chris J. E. Watson

Authors

  1. Search for David Nasralla in:

  2. Search for Constantin C. Coussios in:

  3. Search for Hynek Mergental in:

  4. Search for M. Zeeshan Akhtar in:

  5. Search for Andrew J. Butler in:

  6. Search for Carlo D. L. Ceresa in:

  7. Search for Virginia Chiocchia in:

  8. Search for Susan J. Dutton in:

  9. Search for Juan Carlos García-Valdecasas in:

  10. Search for Nigel Heaton in:

  11. Search for Charles Imber in:

  12. Search for Wayel Jassem in:

  13. Search for Ina Jochmans in:

  14. Search for John Karani in:

  15. Search for Simon R. Knight in:

  16. Search for Peri Kocabayoglu in:

  17. Search for Massimo Malagò in:

  18. Search for Darius Mirza in:

  19. Search for Peter J. Morris in:

  20. Search for Arvind Pallan in:

  21. Search for Andreas Paul in:

  22. Search for Mihai Pavel in:

  23. Search for M. Thamara P. R. Perera in:

  24. Search for Jacques Pirenne in:

  25. Search for Reena Ravikumar in:

  26. Search for Leslie Russell in:

  27. Search for Sara Upponi in:

  28. Search for Chris J. E. Watson in:

  29. Search for Annemarie Weissenbacher in:

  30. Search for Rutger J. Ploeg in:

  31. Search for Peter J. Friend in:

Consortia

  1. for the Consortium for Organ Preservation in Europe

    Contributions

    D.N., S.R.K., R.J.P., C.C.C. and P.J.F. designed this study with help from other authors. R.J.P is Coordinator of the COPE Consortium. M.Z.A. and R.J.P. oversaw the collection of samples and establishment of the trial biobank. D.N., C.D.L.C., A.W., H.M., M.T.P.R.P., D.M., W.J., N.H., C.I., M.M., R.R., A.J.B., C.J.E.W., I.J., J.P., P.K., A.Pau., M.P. and J.C.G.-V. were responsible for the clinical conduct of the study at the respective trial sites. D.N., S.R.K., V.C. and S.J.D. were responsible for statistical design and analysis. L.R. and C.C.C. provided device support and expertise to all trial sites. D.N., S.U., A.Pal. and J.K. were responsible for MRCP image analysis. P.M., S.R.K. and S.J.D. provided governance oversight to ensure the study adhered to all regulatory and ethical requirements. All authors reviewed the manuscript.

    Competing interests

    P.J.F. is a co-founder, chief medical officer and consultant to OrganOx Limited and also holds shares in the company. C.C.C. is a co-founder, chief technical officer and consultant to OrganOx Limited and also holds shares in the company. Neither P.J.F. nor C.C.C. were involved in the selection, recruitment or transplantation of patients in this study.

    Corresponding authors

    Correspondence to David Nasralla or Constantin C. Coussios or Peter J. Friend.

    Extended data figures and tables

    1. Extended Data Fig. 1 Forest plot for subgroup analysis of peak AST by donor type.

      Geometric mean ratio and 95% confidence interval are reported for each subgroup and overall for all groups. DBD group, n = 87 NMP, n = 80 SCS; DCD group, n = 33 NMP, n = 20 SCS.

    2. Extended Data Fig. 2 Post-reperfusion syndrome.

      a, Kaplan–Meier plot for one-year survival of patients with two-sided log-rank test. b, Kaplan–Meier plot for one-year graft survival with two-sided log-rank test.

    3. Extended Data Fig. 3 Machine perfusion parameters during NMP.

      a, Hepatic artery flow during NMP. b, Portal vein flow during NMP. c, Perfusate pH during NMP. d, Bile production during NMP. ad, Data are mean ± s.d. of each time point. Actual values are shown in the table. n = 87. Source data

    4. Extended Data Fig. 4 Perfusate lactate levels during NMP.

      Scatter graph with trend line showing perfusate lactate levels at different time points during NMP for all transplanted livers. n = 94. Source data

    5. Extended Data Fig. 5 NMP device and circuit.

      a, OrganOx metra (generation 1). The NMP device used in the trial. b, OrganOx metra NMP circuit. The liver is perfused via the hepatic artery and portal vein. It drains via the inferior vena cava to a centrifugal pump through which the perfusate passes, via a heat exchanger/oxygenator, to a reservoir or directly into the hepatic artery. The perfusate in the reservoir drains under gravity into the portal vein.

    6. Extended Data Table 1 Detailed breakdown of reasons for discard of NMP livers
    7. Extended Data Table 2 Post-reperfusion syndrome analysis
    8. Extended Data Table 3 Extended primary outcome analysis
    9. Extended Data Table 4 Characteristics and perfusate analysis of livers included in NMP liver quality model development
    10. Extended Data Table 5 Adverse events analysis
    11. Extended Data Table 6 Detailed breakdown of adverse events in each trial arm

    Supplementary information

    1. Supplementary Information

      Clinical Trail Protocol. The full trial protocol for a multicentre randomised controlled trial to compare the efficacy of ex-vivo normothermic machine perfusion with static cold storage in human liver transplantation.

    2. Reporting Summary

    3. Supplementary Information

      Statistical Analysis Plan. A comprehensive description of the statistical methodology applied to the trial data.

    4. Supplementary Information

      Final Statistical Report. The full report from trial statisticians reporting trial outcomes available at 1 year following completion of recruitment.

    5. Supplementary Information

      Primary Non-Function Serious Adverse Event. Clinical trial source document submitted to the trial Data Monitoring Committee providing a narrative description of the events surrounding the transplantation of a normothermic machine perfused liver which resulted in primary non-function of the organ.

    6. Supplementary Information

      Device Error Serious Adverse Event. Clinical trial source document submitted to the trial Data Monitoring Committee providing a narrative description of the events surrounding the normothermic machine perfusion of a liver in which a device error led to the organ being discarded.

    Source data

    About this article

    Publication history

    Received

    Accepted

    Published

    DOI

    https://doi.org/10.1038/s41586-018-0047-9

    Comments

    By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.