Angiographic and gravametric studies of dog kidneys perfused with electrolyte, Dextran, or albumin solution are presented to demonstrate the possibility of extending organ preservation for transplantation without loss of function. Findings include a reduction in flow and weight gain with the nonprotein solutions and maintenance of flow with albumin solution. Gross changes of the perfused kidneys are also described

Dienst, Stanley G.

Krieg, Michael A.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 17 Number 3 Article 2 9-1969 Initial Studies of Isolated Kidney Perfusion Stanley G. Dienst Michael A. Krieg Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Dienst, Stanley G. and Krieg, Michael A. (1969) "Initial Studies of Isolated Kidney Perfusion," Henry Ford Hospital Medical Journal : Vol. 17 : No. 3 , 165-170. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol17/iss3/2 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 17, No. 3, 1969 Initial Studies of Isolated Kidney Perfusion Stanley G. Dienst, M.D. and Michael A. Krieg, M.D.* Angiographic and gravametric studies of dog kidneys perfused with electrolyte, Dextran, or albumin .solution are presented lo demonstrate the possibility of ex-tending organ preservation for transplantation without loss of function. Findings inchuie a reduction in flow and weight gain with the nonprotein solutions and maintenance of flow with albumin solutiim. Gross changes of the perfused kidneys are also described. The objective of isolated kidney perfusion is to extend the period dur-ing which normal renal function can be preserved between excising and re-implanting the kidney. In studies to-ward this objective, the dog has be-come the standard experimental ani-mal. It has now been shown that, without any perfusion, dog kidneys can be preserved—with subsequent ?ood function on reimplantation—by leparinization and rapid surface cool-•ngfor up to 12 hours.' This 12-hour "base line" should be significantly ex-•cnded by the addition of perfusion '0 a kidney preservation system. Feemster and Lillehei- were able to preserve dog kidneys for 24 hours by ^"ig hyperbaria and perfusing with ^itran in a balanced salt solution. Belzer-' preserved dog kidneys for 72 ™urs, with sufficient function to allow ^mediate contralateral nephrectomy, • "sing filtered cryoprecipitated plas-^»at 8= to 10̂  C. Humphries,' pre-1 of Vascular Surgery, Department I Surgery . Work was sponsored in part by The '̂ ^raw Foundation serving dog kidneys with diluted homo-golous blood, has achieved the pres-ervation of one kidney for five days (or 110 hours) with enough function to maintain the animal after delayed contralateral nephrectomy. These stud-ies are a measure of the success that has been achieved and also show the diversity of procedures that have been applied. In initiating further studies of iso-lated kidney perfusion, it was first necessary to determine the most suit-able composition of the perfusate. Essentially, the choice lay between electrolyte glucose solution and a pro-tein solution, such as filtered homogo-lous plasma or a commercial albumin solution. For the protein colloid, com-mercially concentrated human albu-min was first chosen because of its availability and the absence of anti-body containing globulin fractions. Cyroprecipitated dog plasma filtered through Millipore filters after Bci/er has been used for subsequent studies. Procedure: Angiographic Studies. Dog kidneys weighing near 40 gm were excised and 165 Dienst and Krieg flushed free of blood with A"' to 8' C heparinized Ringer's lactate solution. The renal artery was cannulated and the kidney placed in chipped ice. Slow perfusion was begun from a height of one meter (76 mm Hg) with ice cold saline, saline with 6% clinical Dex-tran. or saline plus 6 gm/100 ml of concentrated human albumin.* Angio-grams were taken using x-ray magnifi-cation techniques and an ice cold solution of 50% Conray in saline— also under one meter of hydrostatic pressure. Isogravametric Studies: Dog kidneys were prepared as above and placed in an insulated chamber on a pan balance. They were perfused with the same solutions over a period of three to four hours. Arterial and venous perfusion tubings were disconnected momentarily at each weighing. Weight changes and rates of Mow were plotted against time. Gross Clianges; All kidneys were hemisected. Changes were noted, par-ticularly in the medullary portion, and representative gross sections were pho-iDgraphed. Results Figure 1 shows the angiographic ap-pearance of a controlled kidney with-out perfusion after 3i^. hours. The only differences noted between this and angiograms taken immediately af-ter excision is a blurring of the smaller \es-el iMillmes ,iiul ;i deereascil tillme of the medullary portion. In the kidney perfused with saline, the perfusion rate has fallen over three hours from eight to less than 2 ml/min. The weight i:ain of these kidneys is 10% or more and they are grt>ssly edematous. It was • .Mhumisol found that placing the kidney in a hyperbaric chamber at three atmo-spheres of oxygen allowed saline per-fusion to five hours with the rate of flow falling to 3 ml/min. Weight gain of these kidneys was generally less. However, angiographic appearances were similar. The angiogram of the saline perfused kidney at atmospheric pressure (Fig 1) demonstrates the marked slowing of the dye (15 sec-onds). Later films at 45 seconds show only a few additional secondar\ and tertiary branches filling. In Figure 2, the vascular pattern resulting from perfusing with Dextrar and albumin solution are compared In the Dextran perfused kidney, the cortex is well perfused, but the medul-lary portion does not fill. The vessel outlines have become appreciabh blurred and the flow rate has fallerl to less than 3 ml/min. The tinc-rcticular angiographic pattern witli homogeneous filling of both coru medulla was consistently obtaincii the albumin solution. There is som.'| edema of the outer cortex of the al-bumin perfused kidney from prolongecj exposure to the hypotonic ice The flow rate through the albumin per-fusion was controlled at 7 to 8 ml/mi' | but readily increased to 14 ml at •' hours. Weight gain by albumin p" fused kidneys was less than 29f. Weight changes of the colloid ar the saline perfused kidney are ccr--ii pared on a single kidney in Diagram With albumin perfusion, there is * j weight gain. Immediately after staif^ saline, there is a progressive ga'"' 10 to 15% per hour over the i ' hours measured and an associateî  duction in flow. Restarting the albu-'HI slopped the increase in weight but''*! 166 Initial Studies of Isolated Kidney Perfusion Figure 1 Angiograms of dog kidneys after 3','i' hours at 0 to 40° C. The kidney on the left has not been perfused after initial flushing with Ringer's lactate. The kidney on the right was perfused with saline at 6 mm Hg pressure. Figure 2 jj'°8rams of dog kidneys perfused for 3'/2 hours at 0 to 40° •^Albumisol in saline (right). C with Dextran in saline (left) 167 Dienst and Krieg CANINE KIDNEY PERFUSION FLOW ml / m i n T — I — I — I — I — r O 10 iO 30 «0 50 r—r 10 20 30 40 T I M E Diagram I This shows the weight and flow rate changes of a dog kidney perfused consecutively with albumin solution, saline, and then returning to albumin. Flow during the first period of albumin perfusion is limited to 3.0 ml/min. Flow rates during the saline perfusion and tht final albumin perfusion represent maximum rates at the constant pressure of 50 mm Hg. not reduce it toward normal and did not re-establish flow. Gro.<;s Changes: Hemisection of the saline perfused kidneys showed an homogenous white translucent appear-ance through both the inner and outer medulla. The normal architecture in this region was abolished. This was true to a lesser extent of those kidneys perfused with Dextran in saline. The albumin perfused kidneys, on the other hand, showed the normal striated pat-tern of collecting tubules converging toward the pyramids. There were few gross changes in the cortices of the kidneys studied Discussion Obstruction of the vascular bed hâ  been the dominant problem in organ preservation work. It is recognized a> the cause of immediate failure when autotransplanting the perfused kidne) The obstruction is considered secon-dary to the macroaggregation of nor-mally soluble proteins in the perfusing plasma and to swelling of capillar) endothelial cells. The problem of obstructing aggre-gates, though not entirely clarified. ha> found a partial solution in the of Belzer's' cryoprecipitated plasm̂  This process removes a portion 168 Initial Studies of Isolated Kidney Perfusion the lipoproteins from the plasma. VV ithout cryoprecipitation, these lipo-proteins form large macromolecules or aL'jregates presumably as a result of trauma in the pump and oxygenator. These microemboli have been shown to k> ê in the capillary bed of perfused organs and in the case of kidney are concentrated in peritubular capillaries. It is interesting to note that in the preparation of this plasma the primary clotting factor (X) is removed. This may be also a significant factor in pre-venting vascular obstruction by block-ing initial clotting reactions. Current interest is focused on the role of the endothelial cell in either "swelling" or "contracting" to produce capillary obstruction. This work has been given impetus by the increased availability of the electron microscope. The swelling of these cells, as well as various degrees of dissolution of mitochondrial cristae resulting from perfusion, have been demonstrated. Though these changes have been docu-mented, specific etiological factors have not been identified. Colloid osmolality of the perfusing solution may well be a factor in pre-venting or partially controlling endo-thelial swelling. It may be significant in the first hours, whereas alterations such ^ anoxia, acidosis, substrate and imino depletion may be prominent 'ster in the course of preservation. These studies were designed to corn-Pare kidney perfusion, using isotonic êlectrolyte solution alone, to perfusion *ilh Dextran or protein colloid added '0 the electrolyte solution. The perfu-sion time was kept short and tempera-tures low enough to minimize cellular anoxic changes. Therefore, differences in perfusion would be due primarily to the effect of colloid oncotic pressure. Intermittent or pulsatile flow were not used for this study. The measures would have allowed for longer perfu-sion at higher flows. These adjuncts were deleted to accentuate the angio-graphic and flow differences. The results show a progressive ob-struction to flow through the vascular bed when noncolloid solutions were used for perfusion; and lesser obstruc-tion when Dextran was used. No ob-struction to flow was produced at 314 hours with 6% albumin solution. The relative importance of endothelial cell swelling, interstitial edema and cellular parenchymal swelling cannot be dif-ferentiated by this type of study. Grossly, most of the changes occur in the medullary portion of the kidney. The usual hypertonicity of cells in the inner medulla make this region the most prone to swelling when the rate of metabolism is acutely reduced and filtration slowed. In the case of saline perfusion, this is probably accentuated by the presence of noncolloid fluid in the peritubular capillaries. The use of albumin or cryoprecipitated plasma for perfusion will minimize the problem of early vascular bed obstruction. Longer perfusion will depend on the close regulation of metabolic factors such as oxygen and substrate supply, control of pH, the establishment of extracellu-lar-intracellular amino acid balance, and the provision of soluble respiratory enzymes. 169 Dienst and Krieg REFERENCES 1. Collins. G.M.; Shugarman, M.B.; and Terasaki, P.I.: NIH Progress Report. Jun 1969. 2. Feemstcr, J.H.. and Lillehei, R.C: Hypothermic, hyperbaric pulsatile perfusion for pri -ervation of the canine kidney, unpublished, 1968. 3. Belzer, F.O., et al: Etiology of rising perfusion pressure in isolated organ perfusion, Ann Surg 168:382-91, Sept 1968. 4. Humphries, A.L., ct al: Successful five-day kidney preservation. Invest Urol 5:609-18, May 1968. 170 

Initial Studies of Isolated Kidney Perfusion

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Initial Studies of Isolated Kidney Perfusion

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