making more organs available for successful transplantation · (pgd) affects 15-20% of the lung...
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Timely objective assessment of donor organs during
normothermic perfusion:
Making more organs available for
successful transplantation
MyCartis Wouter Laroy, Chief Scientific Officer – [email protected]
Toon Venneman and Els Decoster
Newcastle University & Newcastle Upon Tyne Hospitals
Andrew J Fisher, Professor of Respiratory Transplant Medicine & Dean of Clinical Medicine, Faculty of
Medical Sciences, Newcastle University and Academic Director and Honorary Consultant Physician,
Institute of transplantation, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust
Anders Andreasson, Morvern Morrison and Catriona Charlton
MyCartis has made great progress in the development of a fast (<30min) immunoassay to
objectively assess the fitness of a donor organ during perfusion as well as help predict the post-
transplant survival. This is the first assay that meets the demanding analytical performance criteria
required in this emerging field and is ideally suited for repeated testing during the course of an
organ perfusion process. These assay characteristics are made possible through a combination of
high quality DMAT® features as well as unique Evalution® platform concepts.
When implemented, the transplant team would get timely insight on the organ’s
fitness for transplantation and gain confidence in the outcome of this life-saving
procedure.
MyCartis has now set up with a specialized transplant center to run its first pre-clinical tests in the real
environment. As a first model case, donor lungs undergoing perfusion are objectively assessed for
their inflammation status using an ultra-fast and reliable IL-1β assay, a choice based on the findings
of Prof. Dr. Andrew Fisher and team (Newcastle University) who demonstrated that this biomarker
can be predictive for organ fitness as well as subsequent recipient survival. Together with its fast
turnaround time, Evalution®’s specific cartridge form factor allows for repeated testing of the organ,
allowing the transplant team to decide on the right timing for transplantation. The same unique
model assay concept can be easily applied to other biomarkers as well as to other organs, enabling
multiplex organ perfusion panel testing.
The perfusion procedure and companion test has the potential of making
available for transplant 30% more organs from those initially deemed unsuitable
ones and could therefore have a serious positive effect on waiting list size and
mortality.
The market potential of perfusion is growing at a double digit CAGR and expands from lungs into
heart, liver, kidney and other solid organs.
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Contents 1. Introduction ..................................................................................................................................................... 3
1.1. The clinical need for organ perfusion .................................................................................................... 3
1.2. Objective fit-for-purpose testing during Ex-vivo Lung Perfusion (EVLP) ........................................... 5
2. The DMAT® technology ................................................................................................................................. 6
2.1. The DMAT® technology explained ......................................................................................................... 6
2.2. Connection the dots: Organ perfusion testing meets DMAT® .......................................................... 8
3. The IL-1β test for the objective assessment of donor lung quality and readiness during EVLP ........ 9
3.1. Assay setup ................................................................................................................................................. 9
3.2. Analytical sensitivity and specificity ..................................................................................................... 10
3.3. Analytical accuracy and precision ..................................................................................................... 12
3.4. Perfusion sample testing ......................................................................................................................... 12
3.4.1. Precision ................................................................................................................................................ 12
3.4.2. Matrix interference ............................................................................................................................. 13
3.4.3. Technology comparison .................................................................................................................... 14
3.5. Repeated testing during perfusion ...................................................................................................... 15
4. Conclusions and Future directions ............................................................................................................ 17
5. Bibliography .................................................................................................................................................. 18
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Facts
In 2016, 135,860 solid organ transplants (kidney, liver, heart, lung, pancreas and small
bowel) were reported globally, an increase of >7% versus 2015
This covers <10% of the global need for organs
There is a shortage of donor organ supplies. Actually, only 3 in 1000 people die in a
way that currently allows for organ donation. On the other hand, one organ donor can
save 8 lives
Of the organs that become available, only 20-25% (lungs and hearts) to 80% (livers) are
actually used for transplantation
In 2015 and 2016 the US saw over 30,000 transplants per year. Yet, every 10 minutes,
someone is added to the transplant waiting list
Over 25% of patients in need of an organ die while being on the waiting list or are
removed from it. In the US alone, 20 people die each day while waiting for a transplant
1. Introduction
1.1. The clinical need for organ perfusion
Each day, tens of thousands of patients are waiting for that one call that says a match is found and an
organ is available for transplantation. A call that could transform or save their life. However, the Global
Observatory of Donation and Transplantation (GODT) reports that, despite yearly growing transplantation
numbers, organ waiting lists remain growing at an even faster pace (Figure 1). Clearly, there is a shortage
of suitable donor organs for transplantation, as the demand is larger than the availability. As a result,
people stay on a waiting list for longer times with a reduced quality of life, or they die while waiting. This
represents a huge burden for the patient, for his or her direct environment, for the healthcare system and
for the overall community.
According to multiple reports, it is not only the quantity of available donor organs that is the problem, but
also their quality. There are clear problems during organ recovery, storage and transport and these have
a proven effect on transplantation success (e.g. Primary Graft Dysfunction, Acute Rejection).
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Figure 1 – The waiting list growth largely exceeds available donor and transplantation numbers
Europe and global: http://www.transplant-observatory.org/ - US: https://optn.transplant.hrsa.gov/
Sadly, the gap between the number of patients on an organ waiting list and the number of available
and usable organs continues to widen. The shortage of fit-for-purpose donor organs has been globally
recognized as the major limiting factor to organ transplantation (Girlanda, 2016).
To grow the number of available donors, several initiatives have been taken to convince more people
to support the “gift of life” after death, and certain countries have decided to step away from the
consent-based or “opt-in” system and use a presumed consent or “opt-out” system instead. However, it
seems like these actions alone have not dramatically increased the number of donor organs available
or at least not to a level able to halt the waiting list growth.
Improved organ procurement and transplantation procedures (Cantu, 2017) have certainly led to
improved success in treating critically ill patients. It is well recognized that the right preservation solutions
and techniques between procurement and transplantation, actions that can take place 100s or even
1000s of kilometers apart, determine donor organ quality (Salehi, 2018). Reports do indicate a direct link
between organ quality and survival after transplantation. The current clinical gold standard for
preservation of solid organs is still static cold storage (SCS), despite the knowledge that prolonged SCS
increases the risk of early graft dysfunction. Moreover, ischemia occurs in the absence of sufficient
oxygen and glucose supply to the organ.
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
WAITING LIST (US)
DONORS RECOVERED (US)
TRANSPLANTS PERFORMED (US)
DONORS RECOVERED (EUROPE)
TRANSPLANTS PERFORMED (EUROPE)
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The major challenge in organ preservation is to maintain or regain the viability and function of the organ
in the absence of a blood supply or physiological stimulation. More recently, there has been a trend
towards the use of normothermic or warm machine perfusion systems (Van Raemdonck, 2018; Akateh,
2018) to enhance the functional preservation of solid organs like livers (Nasralla, 2018), lungs (Figure 2)
(Slama, 2017; Andreasson A. , 2017; Van Raemdonck, Ex-vivo lung perfusion, 2015), hearts (Messer, 2015)
and kidneys (Hosgood, 2018; DiRito, 2018). Re-conditioning of solid donor organs by ex-vivo machine
perfusion is becoming increasingly established and is making its move from research to clinical
application, in small as well as large transplant centers (Fisher, 2016; Rosso, 2018; Salehi, 2018).
Figure 2 – A typical Ex-vivo Lung Perfusion (EVLP) setup
1.2. Objective fit-for-purpose testing during Ex-vivo Lung Perfusion (EVLP)
For many patients, lung transplantation is the only effective treatment available for end-stage lung
disease. Of all the donor lungs coming available, about 80% are deemed unsuitable for transplantation
because of clinical impression of sub-optimal quality. Furthermore, severe primary graft dysfunction
(PGD) affects 15-20% of the lung transplant recipients, carrying a high morbidity and mortality risk.
To improve the outcome for patients in need of a donor lung, the use of the pool of donor lungs that
become available needs to be optimized. EVLP has been described as a promising tool to do so (Hsin,
2018; Pan, 2018). Next to the advantageous biological reasons mentioned above, the perfusion fluid is
also an ideal solution to use for the objective assessment of organ quality through measurement of
biomarkers of organ fitness or for PGD prediction. Hence, the continuous or repeated measurement of
those biomarkers during perfusion could help identify more donor organs that are fit for successful
transplantation.
Multiple studies have been conducted to identify biomarkers for different endpoints. Biomarkers to assess
the inflammatory status of the organ (Andreasson A. , 2017), tissue damage markers or PGD prediction
markers (Hashimoto, 2018; Hamilton, 2017) could all add to the target of identifying good organs.
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To allow such biomarkers to get successfully applied, they need to be measured rapidly at multiple
timepoints during perfusion. Not only the timing but also the time to get the result is of critical importance
as the window of opportunity for transplantation is small and hence the transplant team needs to make
a decision on the spot. For the same reason, samples cannot be sent to the central lab and thus
measurements must be done at the site where perfusion occurs. Easy workflows are therefore a must. The
ideal test would need to cover:
• Simultaneous measurement of multiple biomarkers (multiplex technology)
• Timely output (less than 30 minutes between sample taking and result)
• Easy workflow (as little as possible sample work-up)
• Repeated measurements at different timepoints during perfusion
• Demanding analytical specifications (sensitive, specific and robust)
2. The DMAT® technology
2.1. The DMAT® technology explained
Designed to combine accurate detection of clinically relevant biomarkers with fast, robust and
reproducible methods of testing, the Evalution® platform with its DMAT® (Dynamic Multi-Analyte
Technology) technology inside is well positioned to become an important next generation solution in the
immunoassay market (Faclonnet, 2015).
Evalution® is MyCartis’ multiplex analysis platform. Evalution® integrates into a single instrument all the
functions of incubation, washing and optical readout for seamless operation of sophisticated assay
protocols. In one platform, Evalution® combines an extended set of high-end technological features:
• A multiplexing platform requiring small sample volumes
o Tens of biomarkers can be measured from minute amounts of clinical sample. A
theoretical multiplex level of 150 analytes per channel can be reached.
• Fast and easy assays
o Reagents and samples are brought in close contact in the microfluidic channel, fully
eliminating the dependence on diffusion as a driver for assay turnaround time.
Therefore, only short incubation times with no or limited need for washing steps are
required. Evalution® offers an integrated assay workflow where all reactions occur on
board of the instrument, reducing user-induced variation.
• Assays can be assessed at end-point as well as in real time
o Reaction kinetics can be measured, allowing the qualitative next to quantitative
assessment of immune responses through the measurement of affinity or avidity. This can
be done directly from a clinical sample without the need for pre-fractionation.
o Binding reactions can be followed, generating a binding profile which can be used as
a quantitative measure. Such approach allows for ultra-fast turnaround times (minutes)
for biomarker assays that typically take hours.
• Highly flexible cartridge setup
o The 16 channels in the assay cartridge are individually controlled, opening new
opportunities in (multiplex) random access or time course patient assessment.
• High performance assays
o Calibration curve stability
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▪ Stability has been demonstrated for >1 month, obliviating the need for daily
calibration
o Sensitivity:
▪ Typically, single digit to sub-pg/ml analytical sensitivities can be reached in
complex clinical matrices
o Dynamic range:
▪ When using classical workflows with end-point readout, a biomarker dynamic
range of 4-5 logs can be covered, while with more advanced workflows this
number can be exceeded
o Precision:
▪ Intra-assay (replicates on the same cartridge) and inter-assay (replicates on
different cartridges) of <5%CV or <10%CV can be reached after limited
development efforts, when using good quality reagents
o Agreement with other technologies:
▪ Good agreement and clinical concordance with competing technologies and
platforms (ELISA, Luminex, Phadia, MSD…) has been extensively demonstrated
The DMAT® technology on board of the Evalution® platform is built around three major components:
• The encoded multifunctional microparticles
• A disposable microfluidic cartridge
• Software to control the assays and to evaluate the output
The platform’s proprietary encoded microparticles drive the system’s multiplexing capability. By
encoding each microparticle with a physical binary code, the optical system of the instrument is able to
precisely and uniquely identify each microparticle. With 1024 unique digital codes available a maximum
multiplexing capability of 150-plex per channel can be achieved from a single reporter dye. Once the
appropriate capture biomolecules have been covalently attached to the surface of the microparticles,
these functionalized microparticles are loaded into the microfluidic channels of the cartridge. Each code
is associated with a specific assay, which can be combined in multiple populations within the cartridge
channel for multiplexing.
The Evalution® cartridge is a disposable consumable, which has 16 individually actuated microfluidic
channels capable of accepting and processing from 1 to 16 samples concurrently or sequentially. Fast
biological reactions using small sample volumes, are made possible thanks to a specific reaction-limited
binding environment, i.e. diffusion dependence is taken out. Microparticles are retained within the fluidic
channels at the detection zone behind a filter wall where they form a planar layer and precisely located
targets for the optical system, to interrogate the reactions on each individual microparticle in real time.
As such, each microparticle represents an individual reportable reaction or assay, and jointly they create
one assay environment with different (multiplex) and identical (replicates) assays in one single run.
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Figure 3 – The Evalution® platform with DMAT technology inside
The Evalution® platform can accommodate one 16-channel cartridge (top-left). Within each channel a
multiplex analysis can be performed in real-time (right). Microparticles (bottom left) with different codes have
different immunoassays built on top and are imaged for decoding and identification (birght-field) and
quantification (fluorescence).
2.2. Connection the dots: Organ perfusion testing meets DMAT®
Most classical immunoassay technologies and platforms cannot comply to the steep requirements for
EVLP testing. The Evalution® platform with the DMAT® technology inside now provides the necessary
specifications to allow objective testing during organ perfusion:
• Simultaneous measurement of multiple biomarkers (multiplex technology)
o DMAT is a multiplex platform that can measure tens of biomarkers simultaneously
• Timely output (less than 30 minutes between sample taking and result)
o Binding reaction in DMAT do not rely on diffusion and are therefore fast
• Easy workflow (as little as possible sample work-up)
o DMAT needs no or short washes and allows simultaneous incubation of samples and
reagents, largely reducing sample/reagent processing times
• Repeated measurements at different timepoints during perfusion
o DMAT’s cartridge with 16 individually actuated channels allows straightforward
repeated testing
• Demanding analytical specifications (sensitive, specific and robust)
o DMAT can reach clinically relevant analytical specifications
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This study describes a multiplex but yet single biomarker assay for the assessment of the inflammatory
status of a donor lung under perfusion (Andreasson A. , 2017): a robust and sensitive IL-1β assay that
provides results within 30 minutes using a technology that allows for repeated testing. Starting from this
assay concept and using the same assay principals, additional biomarkers can be added to create a
comprehensive testing panel for perfusion testing.
3. The IL-1β test for the objective assessment of donor lung quality and readiness during EVLP
3.1. Assay setup
The DMAT® technology allows for multiplex analysis, through the use of microparticle populations with
different binary codes. To each different code, different molecules are coupled. Next to measuring
multiple specific biomarkers simultaneously, such feature also provides the opportunity to add internal
controls to the assay. Here, a four-plex assay was developed for the specific and reliable quantitation of
IL-1β in lung perfusion samples (Figure 4). To the assay-specific microparticle population, three control
populations were added:
• CODE 1 : anti-hIL-1β
o For the specific capture of IL-1β in samples
• CODE 2 : recombinant hIL-1β
o A positive reagent control
• CODE 3 : Uncoupled
o A negative assay control
• CODE 4 : Mouse Anti-hIL-8
o A negative assay control
o Amongst others, a control for potential Heterophilic Anti-Mouse Antibody (HAMA)
interference
For this assay, a so-called “co-flow” workflow setup was chosen. Such workflow is made possible thanks
to two DMAT® -specific features: (1) the specific binding regime in the microfluidic channel of the assay
cartridge, where binding occurs independent of diffusion, and (2) the binding reaction that occurs under
continuous flow, where assay components are constantly replenished. Next to the advantage of fast
reactions, this also allows for easy workflows where liquid handling steps are reduced to a minimum.
Prior to incubation, the sample (calibrator, QC or perfusate sample) is premixed with the anti-hIL-1β
detection antibody and immediately loaded on the cartridge where the flow over the particles is
induced. After sample incubation under continuous flow and a short and single wash step, the result is
immediately read, processed and provided to the user. A batch-specific pre-loaded calibration curve
allows for immediate conversion of fluorescence values into actual biomarker concentrations and the
in-channel control values confirm the validity of the result.
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Figure 4 - Assay setup and workflow
3.2. Analytical sensitivity and specificity
Six calibration curves are generated over a time period of 3 weeks (Figure 5). One calibration series
consists of STEEN solution spiked with 12 different concentrations of recombinant IL-1β. Each calibration
series is then fitted using a non-linear 4-parameter logistic (4PL) regression model with a weighing factor
of 1/Y². From this, an accuracy & precision profile is generated. For precision, an acceptance level for
the coefficient of variation (CV) of 15% is used in the linear range of the curve and 20% near the limit of
quantitation (LOQ). For accuracy, a ≤15% deviation of the measured or observed concentration from
the expected value (O/E) is accepted in the linear range of the curve and ≤20% near the LOQ.
The lowest calibrator for which precision and accuracy criteria are met contains 5 pg/ml IL-1β. For the
next calibrator (2 pg/ml), this is no longer the case. Hence, the lower limit of quantitation (LLOQ) lays
between 2 and 5 pg/ml. At the highest calibrator concentration level tested (10 ng/ml), acceptance
criteria for precision and accuracy are met and therefore the upper limit of quantitation (ULOQ) is at
least 10 ng/ml. Within the context of this assay, the assay dynamic range between LLOQ and ULOQ is
expected to suffice to test perfusion samples. The robust behavior of the calibration curve over 3 weeks
also demonstrates system stability and indicates that future use of company-provided calibration curves
is feasible.
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Figure 5 - Calibration curve precision, accuracy and quantification range
To determine the limit of detection (LOD) of this assay, 22 blank samples (STEEN solution) are measured.
The average signal supplemented with three times the standard deviation (SD) on these measurements
is back-calculated using the calibration curve. Doing so, an LOD of 2.7 pg/ml was estimated.
The presence of other cytokines in perfusion fluids was illustrated before. Hence, a specificity study is
performed where cross-reactivity with cytokines with shared common ancestry and structural similarity is
tested (Figure 6). To solutions with no or spiked IL-1β content, high concentrations of other cytokines were
added and the effect on the specific signal assessed. No cross-reactivity could be observed, hence this
assay should be considered highly specific for IL-1β.
Figure 6 – The assay specifically measures IL-1β
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3.3. Analytical accuracy and precision
Three independent run validation quality control (QC) samples were included in all 22 assay runs (one
run includes 16 channels in a cartridge) performed over three weeks. A high (1000 pg/ml), mid (100
pg/ml) and low (10 pg/ml) QC sample was prepared and stored frozen in single-use aliquots. From these,
the inter-assay precision as well as the accuracy over 3 weeks and at different concentrations can be
assessed.
For the high-, mid- and low-QC, inter-assay precision and accuracy (Figure 7) are well within acceptance
criteria (same as in 3.2), illustrating a very stable assay and system performance.
Figure 7 – Run validation control accuracy over 3 weeks (n=22) illustrates stable assay performance
3.4. Perfusion sample testing
Lung perfusions were performed using the STEEN solution (Prof. Dr. Andrew Fisher, Newcastle upon Tyne)
and samples were taken at different timepoints and frozen. IL-1β was measured later using the MSD
cytokine assay (V-PLEX Plus Proinflammatory Panel 1 (human) Kit from MesoScale Discovery). Here, 15
random samples from that series, taken at different timepoints, were used for evaluation of the IL-1β assay
on the Evalution® platform.
3.4.1. Precision
On day one, 15 perfusion samples were measured in duplicate. On day two, 9 of these were measured
again in duplicate.
All samples with a quantifiable concentration above LOD showed an intra-day %CV of ≤15%. For all
tested samples covering the full range of IL-1β concentrations measured so far in perfusion fluid, an inter-
day %CV of ≤12% is obtained. Both results fall well within typically accepted acceptance criterium (≤15%)
for this type of assay.
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Figure 8 – Intra- and inter-assay precision
3.4.2. Matrix interference
Three lung perfusion samples with confirmed IL-1β content were serially diluted in STEEN solution to assess
linearity of dilution for this assay and to identify potential matrix effects. Dilution linearity is achieved if the
back-calculated and dilution-corrected concentrations of the different dilutions don’t deviate more
than 20% from the undiluted concentration. For the 3 samples and for all tested dilutions with a value
above LOD, a percent recovery between 93% - 107% was obtained (Figure 9), well within the typical
acceptance range.
Alternatively, linearity of dilution is assessed by linear correlation coefficient (R2) calculation. For all
samples, an R2 of 0.999 was obtained, even when including the non-diluted sample (Figure 9).
Matrix interference can also be assessed using a spike-recovery experiment. Here, a high (1000 pg/mL)
or a low amount (10 pg/mL) of recombinant IL-1β is spiked into four different perfusion samples with
confirmed levels of endogenous IL-1β. The value of the non-spiked lung perfusion sample was subtracted
from the value of the high and low spiked lung perfusion sample. This results in a ‘recovered value’ from
which the % recovery is determined. Where the non-spiked sample had endogenous levels below LOD,
no value was subtracted. The calculated recovery of the spiked material indicates if the expected value
can be measured accurately, without the interference of the matrix it is spiked in. For all spiked lung
perfusion samples a % recovery between 84% – 102% is obtained (Figure 10) which is well within the
acceptance criterium for a good spike/recovery (100 ±20%).
These combined results clearly demonstrate that no matrix interference is observed when analyzing
perfusion samples (STEEN solution) and that perfusion samples can be tested without prior sample dilution.
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Figure 9 – Matrix interference
Figure 10 – Spike & Recovery
3.4.3. Technology comparison
The 15 samples were analyzed in duplicate using the Evalution® method. At the time of that
measurement, MSD results were blinded to the MyCartis operators.
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The data indicates that both methods generate similar results above the Evalution® LOD (2.7
pg/ml)(Figure 11). This is confirmed by a good overall linear correlation coefficient (R²) of 0.894. The only
technology discrepancy is found for one sample for which a value of 9.4 pg/mL is measured with the
Evalution® technology (and a %CV of 6% between the duplicate analysis) and a value of 24 pg/mL is
measured with the MSD method. If this sample is removed from the correlation plot, an R² of 0.977 is
obtained. At this moment, it is unclear what causes the discrepancy in results of this sample. At the low
end of the concentration range, Evalution® seems to still reliably separate samples, whereas MSD seems
to have reached the limit of detection.
Figure 11 – Technology comparison
3.5. Repeated testing during perfusion
As illustrated above, the DMAT® technology is unique in its ability to measure challenging biomarkers with
the right analytical and technical specifications. The fact that robust cytokine readouts can be achieved
within less than 30 minutes with little to no sample workup is unique.
Next to the analytical performance, the cartridge design is ideally suited for repeated testing during
perfusion. Each cartridge contains 16 channels that can be individually actuated (Figure 12). Upon start
of perfusion, such cartridge can be loaded in the Evalution® platform, where it then resides until the end
of the perfusion process (i.e. the decision point for transplantation or rejection). At specific timepoints,
samples can be taken from the perfusion circulation and immediately loaded and analyzed in one of
the channels. This can be repeated until satisfactory values are obtained and a decision is taken to
accept or reject the organ.
To prove that the assay format is stable when stored in the platform and repeatedly used, a cartridge
was loaded in the platform and quality control (QC) samples as well as a real perfusion sample were
loaded and analyzed at different timepoints without intermediate unloading and storage of the
cartridge (Figure 13). Clearly, no deterioration of signal could be observed.
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Figure 12 – Multiplex interval testing during EVLP
Figure 13 – Repeated testing during EVLP is stable
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4. Conclusions and Future directions In this study, a highly performant Evalution® IL-1β assay is described for the timely assessment of
inflammation in donor lungs during perfusion. The assay doesn’t only meet the analytical requirements
but is also practically applicable in a transplant perfusion laboratory while perfusion is ongoing,
generating real-time data on donor organ suitability for transplant. Such information should help the
transplant surgeon and team on the use of an organ, the timing of the surgery and give them confidence
in a positive outcome for the recipient.
This assay can be considered as a benchmark assay for objective testing during organ perfusion. Indeed,
the same assay principle can be applied to other biomarkers in order to build a panel of analytes that
can provide more relevant information on inflammation, tissue damage, risk for primary graft dysfunction
or any other process related to organ fitness. Multiple biomarker selection programs are currently ongoing
in public as well as private labs and this on perfusion fluids from different solid organs like lung, heart, liver
or kidney. Organ-specific panels can be developed as well as general ones for common processes.
Despite a better overall awareness of the importance of organ donation and the implementation of
improved procurement, storage and transplantation conditions, waiting lists for donor transplantation
continue to grow. According to key opinion leaders in the field, the perfusion procedure and a
companion test have the potential of making available for transplant 30% more organs from the initially
rejected ones and could therefore have a serious positive effect on waiting list size and mortality.
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