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A United States Army Medical Department continuing 

education program.

Organ perfusion with 

J.Wesley alexander, M.D.

Associate professor of Surgery,

University of Cincinnati now 

relating to organ preservation.

We have had no 

experience whatever with 

organ preservation other than the bells er 

life instrumentation unit.

We've had no experience with the waters or 

the Gambro units for instance.

So my limits will be directed 

only to the use of the bells or unit.

Can I see the first slide?

The Belzer unit is basically consists 

of a pumping mechanism in which 

oxygenated plasma goes through a membrane 

auction leader into a reservoir and then 

it's pumped by an arterial pump through a heat 

exchanger back in through 

a pulse dampener into 

tubes into these two chambers 

in which the arterial cannula is 

attached.

Then the venus effluent 

passes through the chamber down in this 

collecting system here and back into 

venus reservoir and subsequently 

continuous re circuiting this material.

Now,

for the most part,

human plasma is used in this preservation apparatus 

and most of the preservation apparatuses are 

basically similar.

This particular instrument has uh 

a gas inflow for oxygen and carbon dioxide 

for regulation of ph and oxygen tension.

It has a temperature monitor with 

a thermometer probe which fits underneath the kidney 

and it has a 

regulation for pulse 

frequency and also a regulation for 

pressure.

Next slide 

this shows the front of the unit again,

which indicates a few of the alarm 

systems,

portable aspects of it.

It has a built in battery so that it can be transported.

I think this is relatively useful and 

transported from one area to the hospital to another,

particularly if you're preservation laboratory is 

not within the operating room itself.

The top part of the unit ah 

is shown here.

This is the arterial line coming 

in and through the back here from the heat 

exchanger.

It divides through a pulse dampener into the two 

limbs and so that the kidneys can be 

individually per fused.

And it also has the advantage of being able 

to evaluate the flow of each 

kidney individually.

One of the advantages of the bells.

Our unit is that multiple vessels 

can be individually.

Kanye waited.

This is a rather rube Goldberg type of apparatus.

Ordinarily we only have two but occasionally 

three renal arteries are found of sufficient size 

that they need to be a nest and most for 

survival of the kidney.

And we did use this kidney.

The double renal arteries can 

be handled in several ways.

It can either be attached together and implanted 

as one office by sliding down the 

opposing sides the two vessels and suturing that 

together to make a new bifurcation or they 

can be implanted individually.

Have had a considerable experience with either type of 

implant and feel that probably it is 

best to implant them individually 

because of the if you don't get a 

perfect 

fit at this bifurcation,

you will build up deposits on it over a 

period of time,

which can lead to secondary hypertensive changes.

Mhm.

Now I mentioned before about the use 

of Ventolin mean or Reggie teen for 

injection into a kidney at the time of 

profusion very often will see very low 

perfusion rates initially this is a set 

of pig experiments which shows the 

relative value of it.

I'm afraid the color doesn't show terribly well,

but this is a cyanotic kidney.

five minutes after it was placed on 

profusion And with extremely 

low perfusion rates of about five 

ml per minute,

you can begin to see slight opening 

up of some of these peripheral arc article 

vessels.

This is the mate to that kidney which has been 

injected With 10 mg 

of fentaNYL.

Amina Reggie teen showing a marked 

difference in the clearing of these 

darkened areas,

which really reflects blood being trapped 

in the outer cortical surface 

At 15 minutes.

This is the non injected kidney which is beginning to 

clear a little bit and still has very low 

perfusion rates.

And this is the injected kidney now,

which shows complete the clearing of the 

cortex and much better profusion rates.

Generally.

It takes about 15 to 

25 minutes for the profusion to 

become maximal in these kidneys that are 

injected with regifting again.

This is the same slot I showed before to 

indicate the degree to which the 

reggaeton injected kidneys attains 

almost normal perfusion values 

over a period of time.

Now we have also used this technique of 

injection of kidneys during 

perfusion with Reggie team to help us determine 

whether or not a initial low flow 

rate is related more 

to cata cola mean induced visa 

spasm,

which we think is correctable and these kidneys are 

usable or whether it is related 

to Visa spasm and induced 

from ischemic injury.

The skeptic injury that type 

of Visa spasm we feel is not 

correctable in these kidneys should generally 

not be used 

Because of this.

We have the situation where we'll often start out 

with the kidney on perfusion,

which will have an initial flow rate of sometimes 

20 to 50 ml per minute 

if after the injection of 15 mg of rigidity 

in these flow rates come up to 80 to 100 ccs per 

minute.

This is a usable kidney.

If the flow rates remain relatively low at 50 to 

80 mL per minute and we feel it is 

generally not a usable kidney.

The flow rates on profusion or particular 

health,

but in addition,

you must use other methods of 

evaluation.

one is that the the rate at 

which the block or 

are spasm can be broken with the use of 

Ventolin mean I forgot to mention another technique 

we use is to take the initial pressure up 

2 80 millimeters systolic pressure 

for no longer than about an hour and if the 

combination of these two does not result in 

satisfactory flow rates is 60 millimeters from 

mercury that being 80/80 

or 100 millimeters per minute.

These kidneys are not and we feel are not 

usable or should not be used.

Another subjective criterion that we have used,

which we feel may reflect the outer 

particle flow is the 

bounce to the kidney.

The kidneys will have a pulse,

it'll bounce and those who have relatively good out of particle 

flow and non possible 

profusion even sometimes with reasonably 

high profusion rates when they 

have less of an outer particle flow,

which we relate to the incidents of acute renal 

failure in the postoperative period.

Other evaluations have been used,

which we have not looked at in our laboratory,

we are now looking at trying 

to evaluate out of particle and inter 

particle differential flow rates with the use of 

thermography,

which looks like a very promising technique.

But there are many variables in the technique which need to 

be modified before it reaches the general use.

Other things that people have used our lactate 

production,

LDH production changing Ph and the 

release of Renan.

We have particularly been impressed that in the systemic kidneys 

there is a marked release of Renan And sometimes a 

secondary lowering the flow rate after about 

12 to 16 or 18 

hours because of the 

production of angiotensin during the 

profusion.

Whether or not this can be corrected with the appropriate 

drug therapy remains to be seen.

I would like to make a couple more 

practical comments about the use of the Belzer 

machine.

It seems to be a a very good machine 

but one which has a potential number of 

problems.

We've had problems of the connectors becoming 

disconnected and losing all the profuse it on the floor,

the rocker arm becoming disconnected and the bag 

filled with plasma.

And we've had at least four kidneys 

sets of kidneys which we have.

Now.

I had airport fusion of these 

kidneys which we feel is not in the best interest of the 

kidney.

Ah some of these however,

and I would like to emphasize that some of these,

even though they have been refused with air can be 

salvaged.

And if we get good flow rates upon 

reinstitution of plasma as a 

profuse it.

We have used three kidneys which have 

successfully supported the patient's life 

afterwards.

If we do not have good flow rates.

We have not used them 

for this reason and the reasons of 

problems with the machine.

We always have a technician stay with the machine 

wherever there are whenever there 

is kidneys on perfusion.

Sometimes this means a rather prolonged period of time,

but someone should check the state of the kidneys 

at least once an hour.

There are several advantages of kidney profusion,

which I would like to point out one is that it 

allows the the 

evaluation of the kidney on 

profusion,

which the non 

pulse,

it'll profusion techniques do not.

That is the mere flush outs and cold storage.

I do not think you can 

you can eliminate marginal kidneys 

by the use of flushing techniques and you 

certainly can.

Those with the bells are 

machine.

Another advantage is that if there is a problem with the donor 

like suspected sepsis and you want to wait 

cultures or if you want to get 

hepatitis associated intelligence or do 

particularly and prolong the evaluation 

of a particular recipient that allows 

additional time.

This two weeks ago we had 

Five donors to come in within a period of about 

72 hours and we're able to 

use all but two of these kidneys.

One of the kidneys was shipped to another center and 

the other kidney was discarded 

because it had relatively low flow rates but all 

of the rest were successfully used.

Some of them were on perfusion.

We had at one time five kidneys on perfusion.

I'm sorry,

six kidneys on perfusion at one time 

Using two bills or units 

to blood group types and both in law 

and and we feel that 

we would not have been able to 

successfully utilized all of these had we not had the 

capability of profusion.

It also another particular advantage in 

buying time is it allows proper evaluation of 

cross matches and we have had in the 

past year,

a considerable amount of difficulty because we have 

not now gotten down to a relatively 

hardcore of individuals,

nearly all of whom have circulating antibodies 

or who have had a previous transplantation.

Ah about 

10 months ago We had a run in which we had 

seven out of 12 

transplants and developed a 

accelerated our hyper acute type of 

rejection.

And then looking back to try and determine what the problem 

was.

We were able to find that the tissue typing 

laboratory had arbitrarily decided that they would 

type only five past syrah on each 

individual.

Because of this,

we went back and in subsequent transplants 

have typed every serum.

There has been available on a 

particular potential recipient and have been 

able to find an incident Of 

additional positive cross match is 

in uh in those in that group of patients of 

about 40-50% 

by typing all of this here.

In other words,

it appears that they will have circulating 

levels of antibody which will wax and wane 

and many times they will have a 

sub detectable 

levels of circulating antibodies.

His compatibility antigens.

This allows then time for not only initial 

testing but time for retesting of all 

available syrah on any potential 

recipients that we have settled on.

Some of the disadvantages of using profuse 

it plasma for profuse it 

is that you cannot always rule out the presence of 

H.

L.

A antibodies.

We feel fairly strongly and I think that the doctor 

light is certainly going to go into this in much more detail.

So I won't but we feel fairly strongly 

that each of the plasma donors for 

profuse it for transplantation should be 

screened for H.

L.

A antibodies.

In addition we feel that there should be screened for high 

titles and called him a glutinous because you can't have 

called him gluten antibody induced neurological damage 

to kidneys as well.

There is some evidence that other 

potential areas of 

damaged during perfusion may occur,

such as toxins related to inadequate 

sterilization or inadequate 

storage length of storage when ethylene oxide is 

used to and sterilized some of the materials.

But that should be relatively 

infrequent.

And also there's some indication that anti 

endothelial antibody may play a role.

But we have not investigated this and 

in more recent transplants.

And since that rash of accelerated rejections has 

occurred we have done what we feel 

is to eliminate the problem at the present 

time.

Organ perfusion with 

J.

Wesley alexander,

M.

D.

Associate professor of Surgery,

University of Cincinnati was 

produced through the mobile facilities of the television division,

Academy of Health Sciences,

United States Army,

Fort Sam Houston texas.