Prof. Dr. Nathanael Raschzok received a grant of € 1.85 million for the first three years from the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) for the Pilot, open, prospective, randomized, multicenter trial on expanding the donor pool by quality assessment of liver grafts declined for transplantation by normothermic ex vivo liver perfusion – ExTra. Co-applicants and/or significantly involved in the preparation of the study were Prof. Dr. Johann Pratschke, Prof. Dr. Igor M. Sauer, Prof. Dr. Dominik Modest, and Priv.-Doz. Dr. Simon Moosburner.

Liver transplantation in Germany is severely limited by a critical shortage of acceptable grafts and a high mortality rate on the waiting list. Furthermore, a significant number of organs are declined due to quality concerns. As demonstrated in pilot studies in the UK, Netherlands, Australia, and the United States, declined liver grafts can and should be used for transplantation after quality assessment by normothermic ex vivo liver machine perfusion (NMP).

The ExTra trial is a randomized controlled trial with a specific focus on patients with a model for end-stage liver disease (MELD) score ≤25 that are not eligible for (non)standard MELD exceptions. This cohort of patients faces an unacceptably long wait time for transplantation, which increases their mortality risk while on the waitlist. The ExTra trial aims to demonstrate that the time-to-transplant for these patients is shortened through the use of grafts that were initially declined for transplantation but fulfill specified quality criteria on normothermic ex vivo machine perfusion assessment. A total of 186 patients will be randomized in a 1:1 fashion to the experimental arm, which consists of a 12-month option to receive a liver graft that was declined by all German transplant centers but meets specified quality criteria, in addition to listing for liver transplantation through the standard allocation process. The control arm will consist of patients who are waitlisted for liver transplantation through the standard allocation process. Liver grafts that have been declined for transplantation must meet specific quality criteria. These include a maximum of 60% macrovesicular steatosis, no fibrosis greater than stage F3, and no cirrhosis. In line with previously published viability criteria for initially declined liver grafts, the decision to use or decline the graft will be made at least four hours after the start of perfusion.

The ExTra trial aims to show that by expanding the donor pool to include the ExTra option of non-transplantable organs, which appear to be usable after machine perfusion, patients without a high MELD score can be transplanted significantly faster. The ExTra trial is thus the first study worldwide in which this concept will be investigated in a randomized clinical trial. The study should make an important contribution to expanding the donor pool for liver transplants and thus ultimately help all patients on the waiting list for liver transplantation.

Our systematic review on "Thrombogenicity assessment of perfusable tissue engineered constructs" has been accepted for publication in Tissue Engineering, Part B, and is available online ahead of print.

Vascular surgery faces a critical demand for novel vascular grafts that are biocompatible and thromboresistant. This urgency particularly applies to bypass operations involving small caliber vessels. In the realm of tissue engineering, the development of fully vascularized organs holds great promise as a solution to organ shortage for transplantation. To achieve this, it is imperative to (re-)construct a biocompatible and non-thrombogenic vascular network within these organs. In this systematic review, we identify, classify and discuss basic principles and methods used to perform in vitro/ex vivo dynamic thrombogenicity testing of perfusable tissue engineered organs and tissues. We conducted a pre-registered systematic review of studies published in the last 23 years according to PRISMA-P Guidelines, comprising a systematic data extraction, in-depth analysis and risk of bias assessment of 116 included studies. We identified shaking (n=28), flow loop (n=17), ex vivo (arterio-venous shunt, n=33) and dynamic in vitro models (n=38) as main approaches for thrombogenicity assessment. This comprehensive review unveils a prevalent lack of standardization and serves as a valuable guide in the design of standardized experimental setups.

Authors are Luna M. Haderer, Yijun Zhou, Peter Tang, Assal Daneshgar, Brigitta Globke, Felix Krenzien, Anja Reutzel-Selke, Marie Weinhart, Johann Pratschke, Igor M. Sauer, Karl H. Hillebrandt, and Eriselda Keshi.

Our work on a “A new bicornuate model of rat uterus transplantation” has been accepted for publication in Acta Obstetricia et Gynecologica Scandinavica.

Uterus transplantation has revolutionized reproductive medicine for women with absolute uterine factor infertility, resulting in more than 40 reported successful live births worldwide to date. Small animal models are pivotal to refine this surgical and immunological challenging procedure aiming to enhance safety for both the mother and the child.
We established a syngeneic bicornuate uterus transplantation model in young female Lewis rats. All surgical procedures were conducted by an experienced and skilled microsurgeon who organized the learning process into multiple structured steps. Animals underwent meticulous preoperative preparation and postoperative care. Transplant success was monitored by sequential biopsies, monitoring graft viability and documenting histological changes long-term. Bicornuate uterus transplantation were successfully established achieving an over 70% graft survival rate with the passage of time. The bicornuate model demonstrated safety and feasibility, yielding outcomes comparable to the unicornuate model in terms of ischemia times and complications. Longitudinal biopsies were well-tolerated, enabling comprehensive monitoring throughout the study. Our novel bicornuate rat uterus transplantation model provides a distinctive opportunity for sequential biopsies at various intervals after transplantation and therefore comprehensive monitoring of graft health, viability, and identification of potential signs of rejection. Furthermore, this model allows for different interventions in each horn for comparative studies without interobserver differences contrary to the established unicornuate model. By closely replicating the clinical setting, this model stands as a valuable tool for ongoing research in the field of uterus transplantation, promoting further innovation and deeper insights into the intricacies of the uterus transplant procedure.

Authors are Dietrich Polenz, Igor Maximilian Sauer, Friederike Martin, Anja Reutzel-Selke, Muhammad Imtiaz Ashraf , Anja Schirmeier , Steffen Lippert, Kirsten Führer, Johann Pratschke, Stefan Günther Tullius, and Simon Moosburner.

The publication "miRNA as potential biomarkers after liver transplantation: A systematic review" is now available online in Transplantation Reviews. Authors are Pia F. Koch, Kristina Ludwig, Felix Krenzien, Karl H. Hillebrandt, Wenzel Schöning, Johann Pratschke, Nathanael Raschzok, Igor M. Sauer, and Simon Moosburner.

Early and accurate diagnosis of acute cellular rejection (ACR) and graft complications after liver transplantation is crucial for timely intervention and improved patient outcomes, but their diagnosis rely currently on invasive biopsy sampling, thus prompting the search for non-invasive Biomarkers. MicroRNA (miRNA) have emerged as promising biomarkers in various pathological conditions, and their potential utility in diagnosing acute cellular rejection after liver transplantation has gained significant interest.

This systematic review analyzes studies exploring miRNA as biomarkers for ACR and graft dysfunction in liver transplantation (PROSPERO ID CRD42023465278). The Cochrane Collaboration tool for assessing risk of bias was employed. Population data, identified miRNA and their dynamic regulation, as well as event prediction were compared. Data extraction and quality assessment were performed independently by two reviewers.

The results highlight the potential of miRNA as specific, non-invasive biomarkers for ACR and graft dysfunction following liver transplantation. However, further research is needed to validate these findings and establish standardized diagnostic panels to incorporate them into clinical practice and explore miRNA-based therapies in the future.

The publication "Moderate LMWH Anticoagulation Improves Success Rate of Hind Limb Allotransplantation in Mice" is now available online in Plastic & Reconstructive Surgery-Global Open. Authors are B. Kern, M.-I. Ashraf, A. Reutzel-Selke, J. Mengwasser, D. Polenz, E. Michaels, J. Pratschke, S.G. Tullius, Ch. Witzel, and I.M. Sauer.

The mouse hind limb model represents a powerful research tool in vascularized composite tissue allotransplantation, but its applicability is limited due to poor graft survival (62%–83%). Vascular thrombosis and massive hemorrhage are the major causes for these drop-outs. We hypothesize that because of better anticoagulation effect and lower risk of thrombocytopenia, application of low molecular weight heparin (LMWH) will minimize vascular complications and enhance graft and animal survival.

Fifty allogeneic hind limb transplantations were performed (C57BL/6 to DBA/2 mice) using five different anticoagulation protocols. Bleeding and thromboembolic events were recorded macroscopically by postoperative hemorrhage and livid discoloration of the graft, respectively. Graft perfusion and survival were monitored daily by capillary-refill-time of graft toes within 2–3 seconds. Vascular congestion and tissue necrosis were examined by histological evaluation of hematoxylin-eosin-stained tissue sections.

All transplantations were technically successful. Increase in thromboembolic events and a concomitant decrease in bleeding events were observed with the decreasing concentration of heparin in the perfusion solution. Although treatment of donor and recipient with low dose of LMWH could not reduce thromboembolic events, moderate dose effectively reduced these events. Compared with the poor outcome of graft perfusion with heparin alone, additional treatment of donor and recipient with low dose of LMWH improved graft and animal survival by 18%. Interestingly, animals treated with moderate dose of LMWH demonstrated 100% graft and animal survival.
Treatment of donor and recipient mice with a moderate dose of LMWH prevents vascular complications and improves the outcome of murine hind limb transplants.