Xenogeneic cross-circulation for extracorporeal recovery of injured human lungs

Abstract

Patients awaiting lung transplantation face high wait-list mortality, as injury precludes the use of most donor lungs. Although ex vivo lung perfusion (EVLP) is able to recover marginal quality donor lungs, extension of normothermic support beyond 6 h has been challenging. Here we demonstrate that acutely injured human lungs declined for transplantation, including a lung that failed to recover on EVLP, can be recovered by cross-circulation of whole blood between explanted human lungs and a Yorkshire swine. This xenogeneic platform provided explanted human lungs a supportive, physiologic milieu and systemic regulation that resulted in functional and histological recovery after 24 h of normothermic support. Our findings suggest that cross-circulation can serve as a complementary approach to clinical EVLP to recover injured donor lungs that could not otherwise be utilized for transplantation, as well as a translational research platform for immunomodulation and advanced organ bioengineering.

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Fig. 1: Maintenance of explanted human lungs using a xenogeneic cross-circulation platform.
Fig. 2: Human lung function over the course of 24 h of xenogeneic cross-circulation.
Fig. 3: Multiscale analyses of human lungs over the course of 24 h of xenogeneic cross-circulation.
Fig. 4: Endovascular integrity and immunologic response over the course of xenogeneic cross-circulation.
Fig. 5: Maintenance of pulmonary airways and alveolar–capillary barrier after 24 h of xenogeneic cross-circulation.

Data availability

The authors declare that all data supporting the findings of this study are available within the text, figures and Supplementary Information.

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Acknowledgements

The authors thank the following collaborators and supporters: Institute of Comparative Medicine veterinary staff, including A. Hubbard, S. Robertson, R. Ober, A. McLuckie, N. Herndon, D. Ordanes and A. Rivas for supporting animal studies; Weill Cornell Microscopy and Image Analysis Core Facility staff, including L. Cohen-Gould and J. P. Jimenez for transmission electron microscopy imaging services; Rockefeller University Electron Microscopy Resource Center staff, including K. Uyru and N. Soplop for scanning electron microscopy imaging services; Herbert Irving Comprehensive Cancer Center Molecular Pathology Shared Resources, including T. Wu, D. Sun and R. Chen for histology services; S. Chicotka, P. Liou, M. Foley, J. Diaz, M.S. Fultz, J. Adcock, N. Llore, E. Lopes, G. Pierre and I. Fedoriv for technical and analytical support; S. Pistilli, K. Fragoso and S. Halligan for administrative support. The authors gratefully acknowledge funding support from the National Institutes of Health (EB27062, HL007854, HL120046, HL134760), Mikati Foundation and Blavatnik Foundation (STAR grant).

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A.E.H., J.D.O., R.D., A.D.G., B.A.G., G.V.-N. and M.B. designed the study. A.E.H., J.D.O., M.R.P., Y.T., R.D., K.M.C., A.T., K.F., R.U., M.S., D.Q., J.W.S., N.L.C., J.T., J.K., Y.-W.C., A.R., B.A.G. and M.B. performed experiments. C.C.M. performed the blinded pathologic assessment. A.E.H., J.D.O., M.R.P., Y.T., K.M.C., A.T., M.S., J.A.R., E.C.R., D.Q. and H.-W.S. analyzed data. A.E.H., J.D.O., G.V.-N. and M.B. co-wrote the manuscript.

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Correspondence to Matthew Bacchetta or Gordana Vunjak-Novakovic.

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Extended data

Extended Data Fig. 1 Experimental setup and xenogeneic cross-circulation circuit parameters.

a, Schematic of xenogeneic cross-circulation with mean values of perfusion circuit parameters. To maintain pulmonary vein drainage, lungs were positioned approximately 10 cm higher than swine hosts (Δh). b, Immunosuppression regimen, including induction immunosuppression before cross-circulation and maintenance immunosuppression during cross-circulation. c, Experimental setup during xenogeneic cross-circulation procedure. d, Perfusion circuit connecting the vascular compartments of explanted human lungs and anesthetized swine host. e, Pulmonary artery and vein cannulas connecting explanted human lungs to the xenogeneic cross-circulation circuit. f, Swine host neck cannulation sites. Extracorporeal circuit parameters: g, Pressure. h, Flow. i, Temperature. All graphs represent data for human lungs (n = 5 independent experiments). All values represent mean ± standard deviation.

Extended Data Fig. 2 Multi-scale analyses of human lung 1.

a, Gross photography. b, Radiography. c, Bronchoscopy of left and right lung. d, PaO2/FiO2. e, Change in pO2p= |pPApPV|). f, Change in pCO2p= |pPApPV|). g, Lung weight. h, Dynamic compliance. i, Peak inspiratory pressure (PIP). j, Transpulmonary pressure gradient (TPG). k, Lactate. All graphs represent images and data for human lung 1 (n = 1 independent experiment). e-i, k, Data points represent a single value obtained at each time point. j, Data points represent mean ± standard deviation of all values obtained at each time point.

Extended Data Fig. 3 Multi-scale analyses of human lung 2.

a, Gross photography. b, Radiography. c, Bronchoscopy of left and right lung. d, PaO2/FiO2. e, Change in pO2p= |pPApPV|). f, Change in pCO2p= |pPApPV|). g, Lung weight. h, Dynamic compliance. i, Peak inspiratory pressure (PIP). j, Transpulmonary pressure gradient (TPG). k, Lactate. All graphs represent images and data for human lung 2 (n = 1 independent experiment). e-i, k, All data points represent a single value obtained at each time point. j, Data points represent mean ± standard deviation of all values obtained at each time point.

Extended Data Fig. 4 Multi-scale analyses of human lung 3.

a, Gross photography. b, Radiography. c, Bronchoscopy of left and right lung. d, PaO2/FiO2. e, Change in pO2p= |pPA – pPV|). f, Change in pCO2p= |pPApPV|). g, Lung weight. h, Dynamic compliance. i, Peak inspiratory pressure (PIP). j, Transpulmonary pressure gradient (TPG). k, Lactate. All graphs represent images and data for human lung 3 (n = 1 independent experiment). e-i, k, All data points represent a single value obtained at each time point. j, Data points represent mean ± standard deviation of all values obtained at each time point.

Extended Data Fig. 5 Multi-scale analyses of human lung 4.

a, Gross photography. b, Bronchoscopy. c, Histologic staining with hematoxylin and eosin. d, PaO2/FiO2. e, Change in pO2p= |pPApPV|). f, Change in pCO2p= |pPApPV|). g, Lung weight. h, Dynamic compliance. i, Peak inspiratory pressure (PIP). j, Transpulmonary pressure gradient (TPG). k, Lactate. All graphs represent images and data for human lung 4 (n = 1 independent experiment). d-k, All data points represent a single value obtained at each time point.

Extended Data Fig. 6 Multi-scale analyses of human lung 5.

a, Gross photography. b, Bronchoscopy. c, Histologic staining with hematoxylin and eosin. d, PaO2/FiO2. e, Change in pO2p= |pPApPV|). f, Change in pCO2p= |pPApPV|). g, Lung weight. h, Dynamic compliance. i, Peak inspiratory pressure (PIP). j, Transpulmonary pressure gradient (TPG). k, Lactate. All graphs represent images and data for human lung 5 (n = 1 independent experiment). d-k, All data points represent a single value obtained at each time point.

Extended Data Fig. 7 Histologic evaluation of human lung 1.

Micrographs of hematoxylin and eosin staining of upper and lower lobes. a, Lung parenchyma at low magnification. b, Lung parenchyma at high magnification. c, Small airways. d, Pulmonary vessels. e, Scanning electron micrographs of alveoli. f, Transmission electron micrographs of alveolar septa. Immunohistochemical staining of: g, HT2-280+ type II pneumocytes. h, Caveolin-1+ type I pneumocytes. i, CC10+ club cells and Mucin 5B+ goblet cells. j, α-tubulin+ ciliated cells. k, α-SMA+ submucosal glands. l, p63+ basal cells. m, CD31+ microvascular endothelial cells and ZO-3+ epithelial tight junctions. n, Vascular endothelial (VE)-Cadherin+ endothelial cells.

Extended Data Fig. 8 Histologic evaluation of human lung 2.

Micrographs of hematoxylin and eosin staining of upper and lower lobes: a, Lung parenchyma at low magnification. b, Lung parenchyma at high magnification. c, Small airways. d, Pulmonary vessels. e, Scanning electron micrographs of alveoli. f, Transmission electron micrographs of alveolar septa. Immunohistochemical staining of: g, HT2-280+ type II pneumocytes. h, Caveolin-1+ type I pneumocytes. i, CC10+ club cells and Mucin 5B+ goblet cells. j, α-tubulin+ ciliated cells. k, CD31+ microvascular endothelial cells and ZO-3+ epithelial tight junctions. l, Vascular endothelial (VE)-Cadherin+ endothelial cells.

Extended Data Fig. 9 Histologic evaluation of human lung 3.

Micrographs of hematoxylin and eosin staining of upper and lower lobes: a, Lung parenchyma at low magnification. b, Lung parenchyma at high magnification. c, Small airways. d, Pulmonary vessels. e, Scanning electron micrographs of alveoli. f, Transmission electron micrographs of alveolar septa. Immunohistochemical staining of: g, HT2-280+ type II pneumocytes. h, Caveolin-1+ type I pneumocytes. i, CC10+ club cells and Mucin 5B+ goblet cells. j, α-tubulin+ ciliated cells. k, CD31+ microvascular endothelial cells and ZO-3+ epithelial tight junctions. l, Vascular endothelial (VE)-Cadherin+ endothelial cells.

Extended Data Fig. 10 Envisioned applications of xenogeneic cross-circulation platform.

a, Clinical applications of human lungs recovered using xenogeneic cross-circulation. Injured human lungs can be recovered at organ recovery or transplant centers. Lungs recovered by cross-circulation could be transplanted into recipient patients awaiting transplantation. b, Research applications. Xenogeneic cross-circulation can be used as a physiologic bioreactor to maintain extracorporeal organs or grafts, enabling research and development of bioengineered constructs, advanced therapeutics, disease models, and investigation of cross-species immunological interactions. EVLP, ex vivo lung perfusion. XC, cross-circulation.

Supplementary information

Supplementary Information

Supplementary Figs. 1–5 and Supplementary Tables 1–14.

Reporting Summary

Supplementary Video 1

Evaluation of human lung recovery throughout 24 h xenogeneic cross-circulation.

Supplementary Video 2

Ventilation and recruitment of human lungs during 24 h of xenogeneic cross-circulation.

Supplementary Video 3

Live uptake of surfactant protein B by human lungs after 24 h of xenogeneic cross-circulation.

Supplementary Data 1

RNA sequencing raw data.

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Hozain, A.E., O’Neill, J.D., Pinezich, M.R. et al. Xenogeneic cross-circulation for extracorporeal recovery of injured human lungs. Nat Med 26, 1102–1113 (2020). https://doi.org/10.1038/s41591-020-0971-8

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