Pharmacologic targeting of renal ischemia-reperfusion injury using a normothermic machine perfusion platform

Ahmer M Hameed,David B Lu,Chow H P’Ng,Ray Miraziz,Nicole Byrne,Negar Talaei Zanjani,Kedar Ghimire,Daniel Meijles,Lawrence Yuen,Yi Vee Chew,Suat Dervish,Henry C Pleass,Heather Burns,Ross Matthews,Greg O’Grady,Wayne J Hawthorne,Natasha M Rogers,Sohel Julovi

doi:10.1038/s41598-020-63687-0

Abstract

Normothermic machine perfusion (NMP) is an emerging modality for kidney preservation prior to transplantation. NMP may allow directed pharmacomodulation of renal ischemia-reperfusion injury (IRI) without the need for systemic donor/recipient therapies. Three proven anti-IRI agents not in widespread clinical use, CD47-blocking antibody (αCD47Ab), soluble complement receptor 1 (sCR1), and recombinant thrombomodulin (rTM), were compared in a murine model of kidney IRI. The most effective agent was then utilized in a custom NMP circuit for the treatment of isolated porcine kidneys, ascertaining the impact of the drug on perfusion and IRI-related parameters. αCD47Ab conferred the greatest protection against IRI in mice after 24 hours. αCD47Ab was therefore chosen as the candidate agent for addition to the NMP circuit. CD47 receptor binding was demonstrated by immunofluorescence. Renal perfusion/flow improved with CD47 blockade, with a corresponding reduction in oxidative stress and histologic damage compared to untreated NMP kidneys. Tubular and glomerular functional parameters were not significantly impacted by αCD47Ab treatment during NMP. In a murine renal IRI model, αCD47Ab was confirmed as a superior anti-IRI agent compared to therapies targeting other pathways. NMP enabled effective, direct delivery of this drug to porcine kidneys, although further efficacy needs to be proven in the transplantation setting.

Highlights

Normothermic machine perfusion (NMP) is an emerging modality for kidney preservation prior to transplantation
This study provides the first direct in vivo comparison of three potent anti-ischemia-reperfusion injury (IRI) agents, αCD47Ab, soluble complement receptor 1 (sCR1), and recombinant thrombomodulin (rTM), in a murine model of severe renal IRI
We show that αCD47Ab alone provides the greatest level of protection that is not substantially increased by combination with sCR1

Summary

Introduction

Normothermic machine perfusion (NMP) is an emerging modality for kidney preservation prior to transplantation. Three proven anti-IRI agents not in widespread clinical use, CD47-blocking antibody (αCD47Ab), soluble complement receptor 1 (sCR1), and recombinant thrombomodulin (rTM), were compared in a murine model of kidney IRI. Short-term transplantation outcomes, including delayed graft function (DGF), are inferior in DCD kidneys in comparison to kidneys from brain-dead (DBD) donors with no significant comorbidities[6] This increased susceptibility to ischemia-reperfusion injury (IRI) and DGF can translate into poorer long-term graft survival[8]. Most pharmacotherapeutics shown to ameliorate renal IRI have been unable to bridge the ‘valley of death’ (translational gap) to the clinic This is at least partly attributable to the inherent difficulties and ethical considerations associated with the systemic use of such therapies in donors or recipients[14,15]. Because IRI is characterized by the activation of multiple intersecting pathways[28,29], it is plausible that synergistic anti-IRI effects may be derived by delivering two or more of these agents together

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