Total parenteral nutrition in ex vivo lung perfusion: Addressing metabolism improves both inflammation and oxygenation

Abstract

Ex vivo lung perfusion (EVLP) protocols generally limit metabolic supplementation to insulin and glucose. We sought to determine whether the addition of total parenteral nutrition (TPN) would improve lung function in EVLP. Ten porcine lungs were perfused using EVLP for 24 hours and supplemented with insulin and glucose. In the treatment group (n = 5), the perfusate was also supplemented with a continuous infusion of TPN containing lipids, amino acids, essential vitamins, and cofactors. Physiologic parameters and perfusate electrolytes were continuously evaluated. Perfusate lactate, lipid and branch chain amino acid (BCAA) concentrations were also analyzed to elucidate how substrates were being utilized over time. Lungs in the TPN group exhibited significantly better oxygenation. Perfusate sodium was more stable in the TPN group. In the control group, free fatty acids (FFA) were quickly depleted, reaching negligible levels early in the perfusion. Alternatively, BCAA in the control group rose continually over the perfusion demonstrating a shift toward proteolysis for energy substrate. In the TPN group, both FFA and BCAA concentrations remained stable at in vivo levels after initial stabilization. TNF‐α concentrations were lower in the TPN group. The addition of TPN in EVLP allows for better electrolyte composition, decreased inflammation, and improved graft performance.

Successful 3-day lung preservation using a cyclic normothermic ex vivo lung perfusion strategy

“…This is in accordance to previous work which has been performed that showed that addressing metabolism through EVLP perfusate modification may improve donor lung quality. 26 , 27 , 28 , 29 Taken together with our findings, we believe that strategies that further promote metabolic recovery during the intermittent EVLP periods may prove to enhance our currently proposed protocol, which may lead to an extension of preservation periods significantly beyond 3 days.…”

Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support

“…The status of micronutrients and trace elements during ESOP and its association with inflammation and oxidative stress and outcomes of ex-situ organ preservation and transplantation has been almost unexplored so far. In a porcine model of extended ESLP for 24 hours, Buchko et al showed that continuous supplementation of the perfusate with the total parenteral solutions that also contain micronutrients, lead to lower inflammation, and improved graft function compared to the controls, however, the specific effects of the micronutrients/trace elements had not been explored (135). Also, to our best knowledge, there is no data available on the potential alterations in the levels of micronutrients and trace elements during ESHP, and implications of their decline, or supplementation on the preservation of the donated heart during ESHP, or the outcomes of transplantation.…”

The Impact of Nutritional Supplementation on Donor Kidneys During Oxygenated Ex Vivo Subnormothermic Preservation

“…After perfusing the lungs for 24 h, they found that TPN improved early graft function with substantial increase in oxygenation. 11 However, TPN creates the need for additional monitoring, costs, and complexity of the ex vivo perfusion system, complicating its clinical use.…”