Patent Publication Number: US-2021161126-A1

Title: Devices and Methods to Improve and Assess Viability of Human Livers

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
     This application is a divisional application of U.S. patent application Ser. No. 15/125,918, filed Sep. 13, 2016, which is a 371 National Phase Entry of International Patent Application No. PCT/US2015/020336 filed on Mar. 13, 2015 which claims benefit under 35 U.S.C. § 119(e) of U.S. Provisional Application No. 61/952,461 filed on Mar. 13, 2014, the contents of both of which are incorporated herein by reference in their entireties. 
    
    
     GOVERNMENT SUPPORT 
     This invention was made with Government support under grant numbers DK080942 and DK096075 awarded by the National Institutes of Health and under grant number W81XWH-09-0001 awarded by the Army. The Government has certain rights in the invention. 
    
    
     TECHNICAL FIELD 
     The present invention relates generally to organ preservation and organ perfusion systems. 
     BACKGROUND 
     Over 30,000 lives in the US are claimed by end-stage liver disease every year. Transplantation is currently the only established treatment, but the critical shortage of donor organs necessitates that more than 60% of wait-listed candidates will not be treated this year. As they become too ill to tolerate the procedure, the majority go on to lose this singular opportunity for recovery. 
     Alternatives to whole organ transplantation, such as bridge-to-transplantation bioartificial assist devices, cell transplantation and tissue engineered liver substitutes, are all dependent on a reliable, abundant and affordable source of viable human hepatocytes (the major functional cells in the liver). Since all healthy donor organs are used for transplantation, only suboptimal livers remain for cell isolation purposes. The cells from these livers are inadequate and of insufficient quality to meet the continuous needs of cell-based treatments. 
     The current gold standard of preservation “static cold storage” merely comprises flushing the organs of blood and transporting them on ice. Static cold storage offers no means of providing the organs with the treatments they need or evaluating their viability prior to transplantation. It is a deleterious process that slowly deprives the organ of oxygen and nutrients, and can therefore be tolerated only by the healthiest donor organs for a finite period of time. As a direct consequence thousands of donor livers are disqualified because of largely-reversible pathologies or the lack of objective data regarding their viability. Without a novel methodology to recover their utility, an invaluable resource is being wasted. 
     SUMMARY 
     Provided herein are organ perfusion systems that can operate at room temperature. The organ perfusion systems described herein can prevent or decrease ischemic damage in an organ, thus having the potential to preventing thousands of donor organs from being disqualified for transplantation. The organ perfusion systems described herein can also increase the recovery of cells from damaged organs. 
     The invention is based on, inter alia, the discovery that the organ perfusion systems described herein can be used at room temperature to effectively maintain liver function with minimal injury and sustain or improve various hepatobiliary parameters post ischemia. The organ perfusion systems described herein do not require a temperature controller or any means for controlling the temperature. 
     In one aspect, the technology described herein relates to an organ perfusion system operating at room temperature, the system comprising (a) a first container configured to encase an organ removed from a subject and store a perfusion fluid, whereby the organ is at least partially immersed in the perfusion fluid; (b) a fluidic circuit system having a first end connected to the perfusion fluid stored in the first container and a second end connected to the organ, the fluidic circuit system configured to draw the perfusion fluid through the first end and perfuse the organ with the perfusion fluid. 
     In some embodiments, the organ perfusion system does not comprise a cleaning device for cleaning the perfusion fluid. In some embodiments, the cleaning device is a dialyzer, filter, or scrubber. 
     In some embodiments, the organ perfusion system is portable. 
     In some embodiments, the fluidic circuit system comprises a pressure sensor configured to measure the pressure of the perfusion fluid flowing towards the organ. 
     In some embodiments, the fluidic circuit system comprises a pump configured to control the pressure of the perfusion fluid as a function of the measurements of the pressure sensor. 
     In some embodiments, the fluidic circuit system comprises an oxygenator configured to increase oxygen level in the perfusion fluid flowing towards the organ. 
     In some embodiments, the fluidic circuit system comprises a bubble-removing device configured to remove bubbles from the perfusion fluid flowing towards the organ. 
     In some embodiments, the bubble-removing device is a bubble trap or a bubble filter. 
     In some embodiments, the organ is selected from the group consisting of liver, pancreas, kidney, spleen, heart, lung, and a vascular composite tissue that can be cannulated for perfusion. 
     In some embodiments, the organ comprises a portal vein and an artery, and the fluidic circuit system comprises (a) a first fluidic circuit connected to the portal vein and configured to flow a first perfusion fluid through the portal vein and (b) a second fluidic circuit connected to the artery and configured to flow a second perfusion fluid through the artery. 
     In some embodiments, the organ is liver. 
     In some embodiments, the first fluidic circuit is independently controlled from the second fluidic circuit. 
     In some embodiments, the first fluidic circuit is not independently controlled from the second fluidic circuit. 
     In some embodiments, the first fluidic circuit comprises a first pressure sensor configured to measure the pressure of the first perfusion fluid flowing towards the organ. 
     In some embodiments, the first fluidic circuit comprises a first pump configured to control the pressure of the first perfusion fluid as a function of the measurements of the first pressure sensor. 
     In some embodiments, the pressure of the first perfusion fluid is in the range of 1-10 mmHg. 
     In some embodiments, the first fluidic circuit comprises a first oxygenator configured to increase a first oxygen level in the first perfusion fluid flowing towards the organ. 
     In some embodiments, the first fluidic circuit comprises a first bubble-removing device configured to remove bubbles from the first perfusion fluid flowing towards the organ. 
     In some embodiments, the second fluidic circuit comprises a second pressure sensor configured to measure the pressure of the second perfusion fluid flowing towards the organ. 
     In some embodiments, the second fluidic circuit comprises a second pump configured to control the pressure of the second perfusion fluid as a function of the measurements of the second pressure sensor. 
     In some embodiments, the pressure of the second perfusion fluid is in the range of 20-120 mmHg. 
     In some embodiments, the second fluidic circuit comprises a second oxygenator configured to increase a second oxygen level in the second perfusion fluid flowing towards the organ. 
     In some embodiments, the second fluidic circuit comprises a bubble-removing device configured to remove bubbles from the second perfusion fluid flowing towards the organ. 
     In some embodiments, the oxygenator is coupled to an oxygen container. 
     In some embodiments, the perfusion fluid is a rich and chemically-defined medium. 
     In some embodiments, the perfusion fluid comprises Williams&#39; medium E. 
     In some embodiments, the perfusion fluid further comprises insulin, one or more antibiotics, hydrocortisone, or any combinations thereof 
     In some embodiments, the perfusion fluid does not comprise red blood cells. 
     In some embodiments, the organ perfusion system further comprises a second container connected to the organ and configured to collect a product produced by the organ. 
     In some embodiments, the product is bile produced by the liver. 
     In some embodiments, the pump is at least partially immersed in the perfusion fluid stored in the first container. 
     In some embodiments, the first container is gas permeable. 
     In some embodiments, the subject is mammalian. In some embodiments, the subject is a human. 
     In some embodiments, the organ perfusion system further comprises a power supply module for supplying power to the organ perfusion system. In some embodiments, the power supply module is a battery. 
     Methods are also disclosed herein for preserving an organ, preventing ischemic damage in an organ, or recovering an ischemically damaged organ, the methods comprising connecting the organ to the organ perfusion systems described herein. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIGS. 1A-1B  show machine perfusion system operating at room temperature. Schematic representation ( FIG. 1A ) and actual photo ( FIG. 1B ) of a liver in the system. 
         FIGS. 2A-2F  is a set of graphs showing perfusion and metabolic dynamics. Development of arterial and portal flow ( FIG. 2A ) and hepatic arterial (HAR) and portal venous resistance (PVR) ( FIG. 2B ) during room-temperature machine perfusion. ( FIG. 2C ) Perfusate sodium, potassium and chloride concentrations during room-temperature machine perfusion. ( FIG. 2D ) Oxygen uptake rate (OUR) and partial oxygen pressure in the inflow and outflow perfusate. ( FIG. 2E ) pH of the inflow perfusate. ( FIG. 2F ) Lactate concentration in the perfusate during room-temperature machine perfusion. Shaded areas represent normal electrolyte ranges in blood. Data presented as median and interquartile range. 
         FIGS. 3A-3D  is a set of graphs showing hepatic function and injury. Urea production as a biochemical marker of clearance ( FIG. 3A ), albumin as a synthetic marker ( FIG. 3B ) and alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) as markers of injury ( FIG. 3C ) and representative hematoxylin and eosin photomicrographs of liver biopsies of the seven perfused livers, before and after perfusion ( FIG. 3D ). Data presented as median and interquartile range. 
         FIGS. 4A-4C  show experimental results related to adenosine triphosphate (ATP). Scatterplot of tissue ATP content at the end of cold storage (preperfusion) correlated to relative warm ischemic time ( FIG. 4A ), tissue ATP content per hour of perfusion ( FIG. 4B ) and ATP content at the end of perfusion correlated to alanine aminotransferase (ALT) release ( FIG. 4C ). Data presented as median and interquartile range. *Significantly higher than baseline. 
         FIGS. 5A-5D  is a set of graphs showing biliary parameters. Bile flow measured for every hour of perfusion ( FIG. 5A ), the concentration of bile salts and phospholipids in the bile ( FIG. 5B ), as well as the bile salt to phospholipid ratio ( FIG. 5C ) and the bicarbonate concentration and pH of bile during perfusion ( FIG. 5D ). Data presented as median and interquartile range. 
         FIG. 6  is a graph showing tissue ATP trends for individual grafts. Solid lines represent liver grafts that have a final ATP content of &gt;200 pmol/mg protein and dashed lines (excluding mean) those that stay below 200 pmol/mg protein. 
         FIG. 7  is an illustration of an organ perfusion system  700  in accordance with some embodiments of the invention. 
         FIG. 8  is an illustration of an organ perfusion system  800  in accordance with some embodiments of the invention. 
         FIG. 9  is an illustration of an organ perfusion system  700   a  in accordance with some embodiments of the invention. 
     
    
    
     DETAILED DESCRIPTION 
     The invention discloses organ perfusion systems that do not require temperature controllers. The invention is based on, inter alia, the discovery that the organ perfusion systems described herein can be used at room temperature to effectively maintain liver function with minimal injury and sustain or improve various hepatobiliary parameters post ischemia. In some embodiments, the organ perfusion systems described herein do not require cleaning devices for cleaning the perfusion fluid. Non-limiting examples of cleaning devices include dialyzers, filters, and scrubbers. By eliminating temperature controllers and/or cleaning devices in the perfusion systems, these systems can be simplified and miniaturized. In some embodiments, the organ perfusion systems can be portable. 
     The organ perfusion systems described herein are different from the systems described in WO2011/002926 and WO2011/140241. For example, the perfusion system in WO2011/002926 requires a temperature controller in the form of a heat exchanger. Additionally, the perfusion system in WO2011/002926 requires a dialyzer. The perfusion system in WO2011/140241 also requires a temperature controller as the organ needs to be cooled and stored at a predefined sub-zero temperature. 
     The organ perfusion systems described herein can be used on a variety of organs including, but not limited to, liver, pancreas, kidney, spleen, heart, and lung. The organ perfusion systems described herein can be used on any vascular composite tissues that can be cannulated for perfusion, including limbs, face, abdominal wall, among others. The systems and methods described herein provide a valuable solution to the problem of organ shortage for transplantation. 
     One aspect of the invention relates to an organ perfusion system as shown in  FIG. 7 , the perfusion system  700  comprising a container  710  for encasing an organ  712  and storing a perfusion fluid, and a fluidic circuit system  730  connected to the organ  712  for perfusing the organ  712  with the perfusion fluid. The organ  712  can be at least partially immersed in the perfusion fluid. In some embodiments, the organ  712  can be fully immersed in the perfusion fluid. The organ perfusion system  700  does not comprise a temperature controller and/or a dialyzer. 
     The container  710  can be any container capable of holding the organ  712  and the perfusion fluid. In some embodiments, the container  710  can be a plastic bag. In some embodiments, the container  710  can be a bowl. In some embodiments, the container  710  can comprise polyolefin/polyamide co-extruded plastic (PL-2442). 
     In some embodiments, the container  710  can be a closed system without exposure to air. The container  710  can function as a bubble trap. Any bubbles will float to the top and can be removed with a syringe or a valve (e.g., luer-lock stopcock). 
     In some embodiments, the container  710  can have a water-tight zip that opens a flap at the top of the container to allow the organ  712  to be placed in the container  710 . The container  710  can be of any shape, depending on how the components fit inside the container  710 . For example, the top view of the container  710  can be circular, square, or rectangular. In some embodiments, the container  710  can have a stiff outer ring that determines the shape of the container  710 . The height of the outer ring can be determined by the size and/or composition of the tubes that carry the perfusion fluid in the fluidic circuit system  730 . In some embodiments, the tubes can be oxygen-permeable, functioning as an oxygenator. In some embodiments, the tubes can be comprised of silicon or the same material as the container  710  is made of. 
     The fluidic circuit system  730  can have a first end  720  connected to the perfusion fluid stored in the container  710  and a second end  722  connected to the organ  712  through a blood vessel of the organ  712 . In some embodiments, the second end  722  is connected to the blood vessel of the organ  712  using valved quick disconnects. The fluidic circuit system  730  can thus draw the perfusion fluid stored in the container  710 , flow the perfusion fluid through one or more components, and perfuse the organ  712  with the perfusion fluid. After passing through the organ  712 , the perfusion fluid enters the container  710 . The fluidic circuit system  730  can comprise one or more components configured to optimize one or more conditions (e.g., pressure, flow rate, oxygen level, or number of bubbles) of the perfusion fluid flowing into the organ  712 . In some embodiments, the fluidic circuit system  730  can comprise a pump  732 , an oxygenator  734 , a pressure sensor  738 , and optionally a bubble-removing device  736 . It should be noted that some oxygenators have bubble-removing capabilities, so a separate bubble-removing device may not be necessary. 
     The pump  732  is configured to draw the perfusion fluid from the container  710  and control the pressure and/or flow rate of the perfusion fluid flowing towards the organ  712 . Various types of pump can be used in the perfusion system  700 . Preferably, the pump does not contaminate the perfusion fluid. In some embodiments, the pump  732  can be at least partially immersed in the perfusion fluid stored in the container  710 . In some embodiments, the pump  732  can be fully immersed in the perfusion fluid stored in the container  710 . 
     The oxygenator  734  is configured to increase the oxygen level in the perfusion fluid flowing towards the organ  712 . In some embodiments, the oxygenator  734  can increase the oxygen levels by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90% as compared to the oxygen level in the perfusion fluid when the oxygenator is not used. In some embodiments, the oxygenator  734  can be coupled to an oxygen container containing oxygen. In some embodiments, the oxygen container can contain at least about 70% oxygen by volume, at least about 80% oxygen by volume, at least 90% oxygen by volume, or at least 95% oxygen by volume. For example, the oxygen container can contain about 95% oxygen and 5% carbon dioxide. The oxygen container can be connected to the outer ring, either sitting in a pocket within the ring if it is large enough, or attached outside to the ring. The ring is sealed from top to bottom, but on the opposite end of the oxygenator (across the device) there is a small release hole for the oxygen to escape. In some embodiments, the oxygenator  734  can be at least partially immersed in the perfusion fluid stored in the container  710 . In some embodiments, the oxygenator  734  can be fully immersed in the perfusion fluid stored in the container  710 . 
     In some embodiments, the oxygenator  734  can comprise the same microfibers as dialyzers (e.g., Gambro), with the potting compound/glue forming the seat in which the organ  712  sits. 
     The bubble-removing device  736  is configured to remove one or more bubbles from the perfusion fluid flowing towards the organ  712 . As used herein, the term “bubble-removing device” means broadly any air removal technology or device. Examples of bubble-removing devices include, but are not limited to, bubble traps and bubble filters. In some embodiments, the bubble-removing device  736  can be at least partially immersed in the perfusion fluid stored in the container  710 . In some embodiments, the bubble-removing device  736  can be fully immersed in the perfusion fluid stored in the container  710 . 
     The pressure sensor  738  is configured to measure the pressure of the perfusion fluid flowing towards the organ  712 . The pump  732  can control the pressure of the perfusion fluid as a function of the measurements of the pressure sensor  738 . In some embodiments, the pressure sensor  738  can be at least partially immersed in the perfusion fluid stored in the container  710 . In some embodiments, the pressure sensor  738  can be fully immersed in the perfusion fluid stored in the container  710 . 
     While  FIG. 7  shows that the pump  732 , oxygenator  734 , bubble-removing device  736 , and pressure sensor  738  are outside the container  710 , in some embodiments, however, at least one of these components is encased by the container  710 . 
     In some embodiments, a control unit (not depicted) can be coupled to at least one of the pump  732 , oxygenator  734 , bubble-removing device  736 , and pressure sensor  738 . The control unit can monitor operating parameters (e.g., pressure, flow rate, oxygen levels, electrolyte levels, and the like) and/or organ function and viability indicators (e.g., production of albumin, bile, urea, nitrogen oxide, and the like) via one or more sample ports (not depicted). The sample ports can permit a catheter or syringe to retrieve a sample for measurements. For example, the control unit can control the operation of the pump  732 . The control unit can also receive input from, e.g., the one or more pressure sensors. The control unit can include a user interface for displaying one or more parameters and indicators and/or allowing a user to alter one or more parameters. 
     Additionally or alternatively, the control unit can include storage means for storing one or more parameters and indicators and/or communication means for communicating one or more parameters and indicators with another system (e.g., a personal computer, a cellular phone, a personal digital assistant, and the like). In some embodiments, the control unit includes an audible and/or visual alarm to alert users when one or more parameters or indicators exceeds a threshold. 
     In some embodiments, the perfusion system  700  can further comprise a container (not shown) connected to the organ  712  to collect a product produced by the organ  712 . The product can be a waste product or a metabolic product. For example, liver produces bile, and kidney produces urine. In some embodiments, the container for collecting the product can be a vacutainer tube. 
     While  FIG. 7  shows that the pump, oxygenator, bubble-removing device, and pressure sensor are connected in a specific order in the fluid pathway, variations of this order are contemplated as long as the functions of these components can be properly executed for their intended purposes. For example, the pressure sensor can be placed before the bubble-removing device in the fluid pathway. 
     Some organs may comprise at least two types of blood vessel. For example, some organs such as liver comprise a portal vein and an artery. In some embodiments, a fluidic circuit system can comprise two or more fluidic circuits, each of which can be connected to each type of blood vessel.  FIG. 8  is an illustration of an organ perfusion system  800  in accordance with some embodiments of the invention, wherein the organ comprises at least two types of blood vessel. The system  800  can comprise a first container  810  configured to encase an organ  812  and store a perfusion fluid, a fluidic circuit system  820  connected to the organ  812  and configured to perfuse the perfusion fluid through the organ  812 . 
     In some embodiments, the at least two types of blood vessel are portal vein and artery. The fluidic circuit system  820  can comprise a first fluidic circuit  830  connected to the portal vein of the organ  812  and configured to flow a first perfusion fluid through the portal vein, and a second fluidic circuit  840  connected to the artery of the organ  812  and configured to flow a second perfusion fluid through the artery. In some embodiments, the first perfusion fluid and the second perfusion fluid are both drawn from the perfusion fluid stored in the first container  810 . 
     The first fluidic circuit  830  and second fluidic circuit  840  can share a common fluidic pathway. In some embodiments, the fluidic circuit system  820  uses a single pump to draw the perfusion fluid from the first container  812 , and the perfusion fluid is then split into the first fluidic circuit  830  and second fluidic circuit  840 . In some embodiments, the first fluidic circuit  830  and second fluidic circuit  840  can share one oxygenator, one bubble-removing device, and/or a pressure sensor. 
     In some embodiments, the first fluidic circuit  830  is independently controlled from the second fluidic circuit  840 . In some of these embodiments, the first fluidic circuit  830  can comprise a first pump  832  and the second fluidic circuit  840  can comprise a second pump  842 . The first pump  832  and second pump  842  can each independently control the pressure and/or flow rate of the perfusion fluid in the circuits. The first fluidic circuit  830  can also comprise a first oxygenator  834 , a first pressure sensor  838 , and optionally a first bubble-removing device  836  that are fluidicly coupled with each other. Similarly, the second fluidic circuit  840  can also comprise a second oxygenator  844 , a second pressure sensor  848 , and optionally a second bubble-removing device  846 , and that are fluidicly coupled with each other. It should be noted that in the embodiments of the first fluidic circuit  830  independently controlled from the second fluidic circuit  840 , the two fluidic circuits can each have its own control unit or share one control unit. 
     The pumps  832  and  842  are configured to draw the perfusion fluid from the first container  810  and control the pressure and/or flow rate of the perfusion fluid flowing towards the organ  812 . 
     In some embodiments, the pump  832  controls the pressure of the first perfusion fluid flowing towards to the organ  812  to be in the range of 1-20 mmHg. In some embodiments, the pump  832  controls the pressure of the first perfusion fluid flowing towards to the organ  812  to be in the range of 1-15 mmHg. In some embodiments, the pump  832  controls the pressure of the first perfusion fluid flowing towards to the organ  812  to be in the range of 1-10 mmHg. In some embodiments, the pump  832  controls the pressure of the first perfusion fluid flowing towards to the organ  812  to be in the range of 4-7 mmHg. 
     In some embodiments, the pump  832  controls the flow rate of the first perfusion fluid flowing towards to the organ  812  to be in the range of 200-1500 mL/min. In some embodiments, the pump  832  controls the flow rate of the first perfusion fluid flowing towards to the organ  812  to be in the range of 200-1200 mL/min. In some embodiments, the pump  832  controls the flow rate of the first perfusion fluid flowing towards to the organ  812  to be in the range of 200-1000 mL/min. In some embodiments, the pump  832  controls the flow rate of the first perfusion fluid flowing towards to the organ  812  to be in the range of 200-800 mL/min. 
     In some embodiments, the pump  842  controls the pressure of the second perfusion fluid flowing towards to the organ  812  to be in the range of 10-150 mmHg. In some embodiments, the pump  842  controls the pressure of the second perfusion fluid flowing towards to the organ  812  to be in the range of 20-150 mmHg. In some embodiments, the pump  842  controls the pressure of the second perfusion fluid flowing towards to the organ  812  to be in the range of 20-120 mmHg. In some embodiments, the pump  842  controls the pressure of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-120 mmHg. In some embodiments, the pump  842  controls the pressure of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-80 mmHg. 
     In some embodiments, the pump  832  controls the flow rate of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-500 mL/min. In some embodiments, the pump  832  controls the flow rate of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-400 mL/min. In some embodiments, the pump  832  controls the flow rate of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-300 mL/min. In some embodiments, the pump  832  controls the flow rate of the second perfusion fluid flowing towards to the organ  812  to be in the range of 50-200 mL/min. 
     In some embodiments of the organ perfusion systems described herein, the perfusion system can further comprise a power supply module. In some embodiments, the power supply module is a battery. 
     One aspect of the invention relates to an organ perfusion system as shown in  FIG. 9 , the perfusion system  700   a  comprising a container  710  for encasing an organ  712  and storing a perfusion fluid  710   a,  and a fluidic circuit system  730  connected to the organ  712  for perfusing the organ  712  with the perfusion fluid  710   a.  In some embodiments, the organ  712  can be at least partially immersed in the perfusion fluid  710   a.  In some embodiments, the fluidic circuit system  730  can comprise a pump  732 , an oxygenator  734 , a pressure sensor  738 , and optionally a bubble-removing device  736 . In some embodiments, the pump  732  can be at least partially immersed in the perfusion fluid  710   a  stored in the container  710 . In some embodiments, the oxygenator  734  can be at least partially immersed in the perfusion fluid  710   a  stored in the container  710 . In some embodiments, the bubble-removing device  736  can be at least partially immersed in the perfusion fluid  710   a  stored in the container  710 . In some embodiments, the pressure sensor  738  can be at least partially immersed in the perfusion fluid  710   a  stored in the container  710 . The organ perfusion system  700   a  does not comprise a temperature controller and/or a dialyzer. 
     In some embodiments of the organ perfusion systems described herein, the container for encasing the organ is gas permeable. In some of these embodiments, the oxygenator is not connected to the fluidic circuit, but rather the container for encasing the organ resides in a box that gets oxygenated. 
     In some embodiments, the perfusion fluid which can be used in the systems and methods as disclosed herein is a rich and chemically-defined medium. As used herein, the term “rich”, when used to describe a medium, refers to a medium containing nutrients, amino acids, vitamins, antioxidants and the like. As used herein, the term “chemically-defined medium” means that all of the chemical components in the medium are known. 
     In some embodiments, the perfusion fluid comprises a base solution which is Williams&#39; Medium E solution (available from Sigma-Aldrich Corp. of St. Louis, Mo.). In some embodiments, the perfusion fluid does not comprise erythrocytes. In some embodiments, the perfusion fluid can comprise one or more antioxidants such as bucillamine. See Farin Amersi, et al, “Bucillamine, a thiol antioxidant, prevents transplantation-associate reperfusion injury,” 99(13) Proc. Nat&#39;l Acad. Sci. 8915-20 (2002). In some embodiments, the perfusion fluid can comprise one or more anti-inflammatory agents such as hydrocortisone. In some embodiments, the perfusion fluid can comprise one or more vasodilators such as alpha-adrenoceptor antagonists (“alpha-blockers”), endothelin receptor antagonists (“ERAs”), angiotensin converting enzyme inhibitors (“ACE inhibitors”), and the like. In some embodiments, the perfusion fluid can comprise one or more amino acids such as L-argenine, L-glutamine, and the like. In some embodiments, the perfusion fluid can comprise one or more buffers such as phosphate buffered saline (“PBS”), Krebs-Ringer buffer (“KRB”) (available from Sigma Aldrich, Inc. of St. Louis, Mo.), and the like. In some embodiments, the perfusion fluid can comprise one or more inorganic salts such as sodium chloride, calcium chloride, potassium chloride, and the like. In some embodiments, the perfusion fluid can comprise one or more substrates for metabolism such as glucose and other carbohydrates, lactate, fatty acids, other energy sources, vitamins, and the like. In some embodiments, the perfusion fluid can comprise one or more hormones such as insulin. In some embodiments, the perfusion fluid can comprise one or more antibiotics such as penicillin and/or streptomycin. In some embodiments, the perfusion fluid can comprise plasma. The one or more anticoagulants can include heparin. In some embodiments, the perfusion fluid can comprise one or more agents for maintaining oncotic pressure such as albumin, polyethylene glycol, and the like. 
     In some embodiments, the perfusion fluid can comprise varying levels of insulin, e.g., about 1 μg/L, or about 2 μg/L, or about 3 μg/L, or about 4 μg/L, or about 5 μg/L, or more than about 5 μg/L. 
     In some embodiments, the perfusion fluid can comprise varying levels of glucagon, for example, in the range of about 0-20 ng/L, or about 10-30 ng/L or about 20-50 ng/L, for example, about 5 ng/L, or about 10 ng/L, or about 15 ng/L, or about 20 ng/L, or about 50 ng/L or more than about 50 ng/L of glucagon. 
     In some embodiments, the perfusion fluid comprises one or more of the following: Williams Medium E (# W1878, Sigma), 5 U/L insulin (Humulin, Eli Lily, Indianapolis, Ind.), 40,000 U/L penicillin, 40 mg/L streptomycin sulfate (Gibco, Invitrogen, Grand Island, N.Y.), 10 mg/L hydrocortisone (Solu-Cortef, Pharmacia &amp; Upjohn, Kalamazoo, Mich.). 
     In some embodiments, the perfusion fluid can include a solution of osmolality ranging from about 100 mOsm to about 500 mOsm, one or more antioxidants, one or more anti-inflammatory agents, one or more vasodilators, one or more amino acids, one or more buffers, one or more inorganic salts, one or more substrates for metabolism, and one or more agents to maintain oncotic pressure between about 15 to about 45 mm Hg. 
     In some embodiments, the perfusion fluid can comprise decellularization agents, for example, one or more agents selected from the group consisting of detergents, vasodilators, buffers, inorganic salts, and enzymes. Non-limiting examples of inorganic salts include calcium chloride, cupric sulfate, ferric nitrate, magnesium chloride, magnesium sulfate, potassium chloride, sodium bicarbonate, sodium chloride, sodium chloride, and zinc sulfate. 
     The organ perfusion systems described herein can be used in a variety of applications including, but not limited to, organ preservation, prevention of an organ from ischemic damage, recovery of an ischemically damaged organ, organ rehabilitation, and recovery of cells from damaged organs. In some embodiments, the organ perfusion systems described herein can be used to perfuse decellularized scaffolds on which one or more cells are engrafted. In some embodiments, cell isolation can be performed after an organ is perfused with the systems described herein. 
     In some embodiments, the organ can be donated by a donor subject and transplanted into a recipient subject. In some embodiments, the organ can be isolated from a subject for rehabilitation using the systems described herein. The organ is then transplanted back to the same subject once it is determined to be functional. In some embodiments, the subject is a mammal. In some embodiments, the subject is a human. 
     In some embodiments, the organ can be stored below room temperature prior to perfusion. Prior to connecting the organ to the organ perfusion systems described herein, the organ can be flushed with a solution such as a NaCl solution. For example, the donor liver can be flushed with 2L of cold 0.9% NaCl solution through the portal vein and 1L through the artery. 
     In some embodiments, an organ can be perfused from about several hours to about 14 days. In some embodiments, an organ can be perfused for between about 4 days and about 7 days. In some embodiments, an organ can be perfused for at least 1 hour, or at least about 2, or 3, or 4, or 5, or 6, or 7, or 8, or 9, or 10 or 11, or 12 hours, or about 24 or about 36 hours, or about 48 hours, or about 3 days or more than 3 days. 
     The viability or transplant-worthiness of the organ can be assessed using methods known in the art, e.g., see WO 2011/140241, the contents of which are incorporated herein by reference in their entirety. 
     In some embodiments, the method of organ perfusion with a perfusion fluid as disclosed herein permits one to maintain or extend the viability and storage time of cells, tissues, and organs beyond current limits. In some embodiments, the method of perfusing an organ or tissue with a perfusion fluid as disclosed herein is at least about 20% reliable, or about 30% reliable, or about 40% reliable, or about 50% reliable, or about 60% reliable, or about 70% reliable, or about 80% reliable, or about 90% reliable, or about 100% reliable, in that, after perfusing a perfusion fluid (with or without subsequent steps of metabolic suppression via chemical or environmental means) the organ reaches the required threshold of viability for transplantability, or a reaches the required threshold of viability for cell viability for cell harvesting. 
     In some embodiments, the method of perfusing an organ or tissue with a perfusion fluid as disclosed herein prevents ischemic damage in the organ by about 10%, or by about 20%, or by about 30%, or by about 40%, or by about 50%, or by about 60%, or by about 70%, or by about 80%, or by about 90%, or by about 100% as compared to an organ, or tissue which has not been perfused with the perfusion fluid as disclosed herein. 
     In another embodiment, the amount of ischemic damage to an organ or tissue is decreased upon perfusion with the perfusion fluid according to the methods as disclosed herein by about at least 10%, or at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90%, greater than 90% as compared to an organ which has not undergone perfusion with the perfusion fluid as disclosed herein. Stated another way, in some embodiments, an organ or tissue which has undergone perfusion with the perfusion fluid according to the methods as disclosed herein has at least about 10% more viable cells than an organ or tissue which has not undergone the perfusion with the perfusion fluid, or about 20% more viable cells, or about 30% more viable cells, or about 40% more viable cells, or about 50% more viable cells, or about 60% more viable cells, or about 70% more viable cells, or about 80% more viable cells, or about 90% more viable cells, or about 100% more viable cells, or about 200% more viable cells, or about 1000% more viable cells, or more than 1000% more viable cells as compared to an organ or tissue which has not undergone the perfusion with the perfusion fluid as disclosed herein. 
     It should be understood that this invention is not limited to the particular methodology, protocols, and reagents, etc., disclosed herein and as such may vary. The terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention, which is defined solely by the claims. 
     As used herein and in the claims, the singular forms include the plural reference and vice versa unless the context clearly indicates otherwise. Other than in the operating examples, or where otherwise indicated, all numbers expressing quantities of ingredients or reaction conditions used herein should be understood as modified in all instances by the term “about.” 
     Although any known methods, devices, and materials may be used in the practice or testing of the invention, the methods, devices, and materials in this regard are disclosed herein. 
     Some embodiments of the invention are listed in the following numbered paragraphs:
     1. An organ perfusion system operating at room temperature, the system comprising a first container configured to encase an organ removed from a subject and store a perfusion fluid, whereby the organ is at least partially immersed in the perfusion fluid; a fluidic circuit system having a first end connected to the perfusion fluid stored in the first container and a second end connected to the organ, the fluidic circuit system configured to draw the perfusion fluid through the first end and perfuse the organ with the perfusion fluid, and wherein the organ perfusion system does not comprise a temperature controller.   2. The organ perfusion system of paragraph 1, wherein the organ perfusion system does not comprise a cleaning device for cleaning the perfusion fluid.   3. The organ perfusion system of paragraph 2, wherein the cleaning device is a dialyzer, filter, or scrubber.   4. The organ perfusion system of any one of paragraphs 1-3, wherein the organ perfusion system is portable.   5. The organ perfusion system of any one of paragraphs 1-4, wherein the fluidic circuit system comprises a pressure sensor configured to measure the pressure of the perfusion fluid flowing towards the organ.   6. The organ perfusion system of any one of paragraphs 1-5, wherein the fluidic circuit system comprises a pump configured to control the pressure of the perfusion fluid as a function of the measurements of the pressure sensor.   7. The organ perfusion system of any one of paragraphs 1-6, wherein the fluidic circuit system comprises an oxygenator configured to increase oxygen level in the perfusion fluid flowing towards the organ.   8. The organ perfusion system of any one of paragraphs 1-7, wherein the fluidic circuit system comprises a bubble-removing device configured to remove bubbles from the perfusion fluid flowing towards the organ.   9. The organ perfusion system of paragraph 8, wherein the bubble-removing device is a bubble trap or a bubble filter.   10. The organ perfusion system of any one of paragraphs 1-9, wherein the organ is selected from the group consisting of liver, pancreas, kidney, spleen, heart, lung, and a vascular composite tissue that can be cannulated for perfusion.   11. The organ perfusion system of any one of paragraphs 1-9, wherein the organ comprises a portal vein and an artery, and wherein the fluidic circuit system comprises (a) a first fluidic circuit connected to the portal vein and configured to flow a first perfusion fluid through the portal vein and (b) a second fluidic circuit connected to the artery and configured to flow a second perfusion fluid through the artery.   12. The organ perfusion system of paragraph 11, wherein the organ is liver.   13. The organ perfusion system of paragraph 11 or 12, wherein the first fluidic circuit is independently controlled from the second fluidic circuit.   14. The organ perfusion system of paragraph 11 or 12, wherein the first fluidic circuit is not independently controlled from the second fluidic circuit.   15. The organ perfusion system of any one of paragraphs 11-14, wherein the first fluidic circuit comprises a first pressure sensor configured to measure the pressure of the first perfusion fluid flowing towards the organ.   16. The organ perfusion system of paragraph 15, wherein the first fluidic circuit comprises a first pump configured to control the pressure of the first perfusion fluid as a function of the measurements of the first pressure sensor.   17. The organ perfusion system of paragraph 16, wherein the pressure of the first perfusion fluid is in the range of 1-10 mmHg.   18. The organ perfusion system of any one of paragraphs 11-17, wherein the first fluidic circuit comprises a first oxygenator configured to increase a first oxygen level in the first perfusion fluid flowing towards the organ.   19. The organ perfusion system of any one of paragraphs 11-18, wherein the first fluidic circuit comprises a first bubble-removing device configured to remove bubbles from the first perfusion fluid flowing towards the organ.   20. The organ perfusion system of any one of paragraphs 11-19, wherein the second fluidic circuit comprises a second pressure sensor configured to measure the pressure of the second perfusion fluid flowing towards the organ.   21. The organ perfusion system of paragraph 20, wherein the second fluidic circuit comprises a second pump configured to control the pressure of the second perfusion fluid as a function of the measurements of the second pressure sensor.   22. The organ perfusion system of paragraph 21, wherein the pressure of the second perfusion fluid is in the range of 20-120 mmHg.   23. The organ perfusion system of any one of paragraphs 11-22, wherein the second fluidic circuit comprises a second oxygenator configured to increase a second oxygen level in the second perfusion fluid flowing towards the organ.   24. The organ perfusion system of any one of paragraphs 11-23, wherein the second fluidic circuit comprises a bubble-removing device configured to remove bubbles from the second perfusion fluid flowing towards the organ.   25. The organ perfusion system of paragraph 7, 18, or 23, wherein the oxygenator is coupled to an oxygen container.   26. The organ perfusion system of any one of paragraphs 1-25, wherein the perfusion fluid is a rich and defined medium.   27. The organ perfusion system of paragraph 26, wherein the perfusion fluid comprises Williams&#39; medium E.   28. The organ perfusion system of paragraph 27, wherein the perfusion fluid further comprises insulin, one or more antibiotics, hydrocortisone, or any combinations thereof   29. The organ perfusion system of any one of paragraphs 1-28, wherein the perfusion fluid does not comprise red blood cells.   30. The organ perfusion system of any one of paragraphs 1-29, further comprising a second container connected to the organ and configured to collect a product produced by the organ.   31. The organ perfusion system of paragraph 30, wherein the product is bile produced by the liver.   32. The organ perfusion system of paragraph 6, wherein the pump is at least partially immersed in the perfusion fluid stored in the first container.   33. The organ perfusion system of any one of paragraphs 1-32, wherein the first container is gas permeable.   34. The organ perfusion system of any one of paragraphs 1-33, wherein the subject is mammalian.   35. The organ perfusion system of paragraph 34, wherein the subject is human.   36. The organ perfusion system of any one of paragraphs 1-35, further comprising a power supply module for supplying power to the organ perfusion system.   37. The organ perfusion system of paragraph 36, wherein the power supply module is a battery.   38. A method of preserving an organ, the method comprising connecting the organ to an organ perfusion system of any one of paragraphs 1-37 to perfuse the organ.   39. A method of preventing ischemic damage in an organ, the method comprising connecting the organ to an organ perfusion system of any one of paragraphs 1-37 to perfuse the organ.   40. A method of recovering an ischemically damaged organ, the method comprising connecting the organ to an organ perfusion system of any one of paragraphs 1-37 to perfuse the organ.   

     Definitions 
     Unless stated otherwise, or implicit from context, the following terms and phrases include the meanings provided below. Unless explicitly stated otherwise, or apparent from context, the terms and phrases below do not exclude the meaning that the term or phrase has acquired in the art to which it pertains. The definitions are provided to aid in describing particular embodiments, and are not intended to limit the claimed invention, because the scope of the invention is limited only by the claims. Further, unless otherwise required by context, singular terms shall include pluralities and plural terms shall include the singular. 
     As used herein the term “comprising” or “comprises” is used in reference to compositions, methods, and respective component(s) thereof, that are useful to an embodiment, yet open to the inclusion of unspecified elements, whether useful or not. 
     As used herein the term “consisting essentially of” refers to those elements required for a given embodiment. The term permits the presence of elements that do not materially affect the basic and novel or functional characteristic(s) of that embodiment of the invention. 
     As used herein, the term “portable” refers to a device that can be held by a person of ordinary strength in one or two hands, without the need for any special carriers. A portable device can be configured to be used outside of a laboratory setting. In certain embodiments, a portable device is, e.g., battery powered. 
     The term “organ” as used herein refers to a structure of bodily tissue in a subject, e.g., a mammalian subject such as a human, wherein the tissue structure as a whole is specialized to perform a particular bodily function. Organs which are perfused within the meaning of the present invention include for example, but without limitation, heart, lung, kidney, pancreas, liver, spleen. In some embodiments, the term “organ” also encompasses decellularized and recellularized organs, as well as engineered and artificial organs and tissues, including engineered organs (e.g., tissue engineered constructs), engineered organs comprising a bioscaffold, tissues, organ slices and partial organs. In some embodiments, the organ can be a vascular composite tissue that can be cannulated for perfusion, including limbs, face, abdominal wall, among others. 
     The term “viability” as used herein refers to the state of an organ&#39;s survival capability, e.g., capable of survival after transplantation into a recipient. Viability can be used as a measure of the entire organ&#39;s survival or a part of the organ, or the viability of cells within the organ. 
     The term “reliability” as used herein refers to the extent to which a measure, procedure or instrument yields the same result on repeated trials. Stated another way, reliability as used herein refers how well a particular assessment method provides consistent results, regardless of who uses the method or when it is used. 
     The term “marginal organ” or “damaged organ” as used herein shall be understood to indicate an organ that is in less than ideal condition for transplantation, such that the expected probability of transplant success is reduced. Examples of damaged organs include, but are not limited to, organs that suffer warm ischemia for more than 30 minutes, organs that suffer cold ischemia for more than 12 hours, moderate or highly steatotic livers (e.g., livers with greater than 30% fat), fibrotic livers, cirrhotic livers, livers from patients afflicted with hepatitis C or HIV, and the like. 
     The term “transplantation” refers to the method of transferring of an organ, or other bodily tissue from its site of origin in one subject to a recipient site in the same or a different subject, whether or not autologous, homologous or heterologous and whether or not it is performed directly or subsequently to further processing or preservation of the tissue or organ. 
     The term “room temperature” as used herein shall be understood to mean a temperature between about 15° C. and about 25° C. For example, “room temperature” includes, but is not limited to, temperatures between about 18° C. and about 23° C., temperature between about 19° C. and about 21° C., temperatures between about 24° C. and about 25° C., temperatures between about 20° C. and about 21° C., and the like. 
     The term “perfusion” as used herein refers to the flowing of fluid through the tissue or organ. Stated in anther way, perfusion or to “perfuse” refers to supplying an organ, tissue with a fluid by circulating it through blood vessels or other natural channels. 
     The term “perfusate” or “perfusion fluid” as used herein shall be understood to be any fluid capable of improving or maintaining the vitality of a cell, tissue, organ (including decellularized and recellularized organs), bioscaffold, and the like. Improving or maintaining vitality can include one or more of the following: maintenance of appropriate osmotic pressure, maintenance of appropriate oncotic pressure, maintenance of appropriate temperature, inhibition of decay, inhibition of microbial growth, and the like. 
     The terms “increased”, “increase”, “enhance” or “improve” are all used herein to generally mean an increase by a statically significant amount; for the avoidance of any doubt, the terms “increased”, “increase”, “enhance” or “improve” means an increase of at least 10% as compared to a reference level, for example an increase of at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% increase or any increase between 10-100% as compared to a reference level, or at least about a 2-fold, or at least about a 3-fold, or at least about a 4-fold, or at least about a 5-fold or at least about a 10-fold increase, or any increase between 2-fold and 10-fold or greater as compared to a reference level. 
     The terms “lower”, “reduce”, “reduction” or “decrease” are all used herein generally to mean a decrease by a statistically significant amount. However, for avoidance of doubt, “lower”, “reduce”, “reduction” or “decrease” means a decrease by at least 10% as compared to a reference level, for example a decrease by at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% decrease (i.e. absent level as compared to a reference sample), or any decrease between 10-100% as compared to a reference level. 
     The term “statistically significant” or “significantly” refers to statistical significance and generally means a two standard deviation (2SD) or more. 
     A “subject” shall be understood to include any animal including, but not limited to, humans, primates, swine, cows, sheep, and rats. 
     The singular terms “a,” “an,” and “the” include plural referents unless context clearly indicates otherwise. Similarly, the word “or” is intended to include “and” unless the context clearly indicates otherwise. 
     Other than in the operating examples, or where otherwise indicated, all numbers expressing quantities of ingredients or reaction conditions used herein should be understood as modified in all instances by the term “about.” The term “about” when used in connection with percentages may mean ±1% of the value being referred to. For example, about 100 means from 99 to 101. 
     Although methods and materials similar or equivalent to those disclosed herein can be used in the practice or testing of this disclosure, suitable methods and materials are described below. The term “comprises” means “includes.” The abbreviation, “e.g.” is derived from the Latin exempli gratia, and is used herein to indicate a non-limiting example. Thus, the abbreviation “e.g.” is synonymous with the term “for example.” 
     Although preferred embodiments have been depicted and described in detail herein, it will be apparent to those skilled in the relevant art that various modifications, additions, substitutions, and the like can be made without departing from the spirit of the invention and these are therefore considered to be within the scope of the invention as defined in the claims which follow. Further, to the extent not already indicated, it will be understood by those of ordinary skill in the art that any one of the various embodiments herein described and illustrated can be further modified to incorporate features shown in any of the other embodiments disclosed herein. 
     All patents and other publications; including literature references, issued patents, published patent applications, and co-pending patent applications; cited throughout this application are expressly incorporated herein by reference for the purpose of describing and disclosing, for example, the methodologies described in such publications that might be used in connection with the technology disclosed herein. These publications are provided solely for their disclosure prior to the filing date of the present application. Nothing in this regard should be construed as an admission that the inventors are not entitled to antedate such disclosure by virtue of prior invention or for any other reason. All statements as to the date or representation as to the contents of these documents is based on the information available to the applicants and does not constitute any admission as to the correctness of the dates or contents of these documents. 
     The description of embodiments of the disclosure is not intended to be exhaustive or to limit the disclosure to the precise form disclosed. While specific embodiments of, and examples for, the disclosure are disclosed herein for illustrative purposes, various equivalent modifications are possible within the scope of the disclosure, as those skilled in the relevant art will recognize. For example, while method steps or functions are presented in a given order, alternative embodiments may perform functions in a different order, or functions may be performed substantially concurrently. The teachings of the disclosure provided herein can be applied to other procedures or methods as appropriate. The various embodiments disclosed herein can be combined to provide further embodiments. Aspects of the disclosure can be modified, if necessary, to employ the compositions, functions and concepts of the above references and application to provide yet further embodiments of the disclosure. 
     Specific elements of any of the foregoing embodiments can be combined or substituted for elements in other embodiments. Furthermore, while advantages associated with certain embodiments of the disclosure have been described in the context of these embodiments, other embodiments may also exhibit such advantages, and not all embodiments need necessarily exhibit such advantages to fall within the scope of the disclosure. 
     EXAMPLES 
     The following examples illustrate some embodiments and aspects of the invention. It will be apparent to those skilled in the relevant art that various modifications, additions, substitutions, and the like can be performed without altering the spirit or scope of the invention, and such modifications and variations are encompassed within the scope of the invention as defined in the claims which follow. The technology disclosed herein is further illustrated by the following examples which in no way should be construed as being further limiting. 
     Example 1: Room-Temperature Machine Perfusion for Ex Vivo Preservation and Recovery of the Human Liver for Transplantation 
     To determine the feasibility in human livers, the effect of 3 hours of oxygenated room-temperature machine perfusion (21° C.) on seven livers discarded for transplantation was assessed. Biochemical and microscopic assessment revealed minimal injury sustained during perfusion. Improved oxygen uptake (1.30 [1.11-1.94] to 6.74 [4.15-8.16] mL O 2 /min kg liver), lactate levels (4.04 [3.70-5.99] to 2.29 [1.20-3.43] mmol/L) and adenosine triphosphate content (45.0 [70.6-87.5] pmol/mg preperfusion to 167.5 [151.5-237.2] pmol/mg after perfusion) were observed. Liver function, reflected by urea, albumin and bile production, was seen during perfusion. Bile production increased and the composition of bile (bile salts/phospholipid ratio, pH and bicarbonate concentration) became more favorable. In conclusion, ex vivo room-temperature machine perfusion effectively maintains liver function with minimal injury and sustains or improves various hepatobiliary parameters post ischemia. 
     Preserving the viability of the donor liver is essential for successful transplantation. While advances in preservation solutions and immunosuppression have resulted in excellent outcomes following liver transplantation using standard criteria donors [ 1 ], transplantation using marginal grafts remains problematic [ 2 ,  3 ]. Donation after circulatory death (DCD) livers with increased warm ischemic time (WIT), in particular, present a challenge as the incidence of primary nonfunction and biliary complications are increased [ 4 ]. The increasing use of marginal livers to expand the donor pool demands more sophisticated preservation modalities to prevent or treat the underlying deficiency of these livers. 
     While conventional static cold storage merely slows the deterioration of the donor liver, ex vivo machine perfusion techniques may be useful in sustaining organ viability, improving it or preconditioning the liver for reperfusion. Preclinical studies using hypothermic machine perfusion (HMP) at 0-4° C. have shown impressive benefits for preservation [ 5 - 8 ]. The first clinical series from 2010 employing HMP in livers donated after brain death (DBD) showed promising initial results and was a large step forward in bringing perfusion techniques to clinical transplantation [ 9 ], and a more recent trial showed that HMP of DCD livers produced similar results to unperfused DBD livers [ 10 ]. In contrast, normothermic machine perfusion (NMP) at ±37° C. offers the environment for a fully functional metabolism, which supports the reestablishment of homeostasis and other recovery processes, including an increase in adenosine triphosphate (ATP) content [ 11 ]. Additionally, maintaining a metabolically functional organ opens the opportunity of viability testing to assess liver function during perfusion and improve donor liver selection and allocation [ 12 ,  13 ]. Recently, the feasibility of NMP has been shown in sustaining discarded human DCD livers [ 14 ]. 
     Materials and Methods 
     Procurement and Back-Table Preparation 
     Donor livers were obtained from the New England Organ Bank (NEOB) with consent for research from the family after being turned down for clinical transplantation. Extubation of donors after circulatory death was performed by the primary service, which was also responsible for declaration of death 5 min after circulatory cessation. The procurement procedure did not begin until after declaration of death. Standard procurement technique includes an in situ flush with University of Wisconsin (UW) solution, intra-abdominal cooling with ice and an additional back-table UW flush. The gallbladder was incised, aspirated of bile and irrigated with saline. The common bile duct was flushed with UW solution. The relative WIT for DCD livers is defined as the time between extubation and in situ cold flushing, whereas absolute WIT begins after circulatory cessation and ends at in situ cold flushing. Donor livers were transported in sterile bags cooled on ice. On arrival at the center and during the priming of the machine perfusion system the donor liver was prepared for connection to the system. The portal vein and hepatic branches of the celiac trunk and/or superior mesenteric artery were dissected free. The portal vein was cannulated distally with a section of tubing (Masterflex 24 L/S; Cole Palmer, Vernon Hills, Ill.). The aortic segment was opened and the celiac trunk was cannulated at the origin with a vessel cannula (Medtronic, Minneapolis, Minn.). Other branches of the celiac trunk were tied using 0 silk sutures. The cystic duct was ligated and the gallbladder flushed of residual bile. The common bile duct was cannulated with a vessel cannula, which was then connected to a section of tubing to allow bile collection. All cannulae were secured using 0 silk sutures. 
     Ex Vivo Room-Temperature Machine Perfusion 
     The room-temperature perfusion system consisted of two independent circulations for portal and arterial perfusion, each including a roller pump (Masterflex L/S; Cole Palmer), hollow-fiber oxygenator (Affinity NT; Medtronic) and a bubble trap (Radnoti, Monrovia, Calif.) ( FIG. 1 ). Sensors allowed for continuous measurement of pressure on the inflow vessels. The livers were perfused with phenol-red Williams&#39; medium E (Sigma-Aldrich, St. Louis, Mo.), supplemented with insulin (5 U/L Humulin R; Eli Lilly &amp; Co, Indianapolis, Ind.), penicillin/streptomycin (40 000 U/L/40 000 μg/L) (Gibco/Invitrogen, Camarillo, Calif.) and 10 mg/L hydrocortisone (Solu-Cortef, Pharmacia &amp; Upjohn, Kalamazoo, Mich.). The complete composition can be found in Table 3. Additional sodium bicarbonate (8.4%) was added to correct a drop in pH after introducing the liver to the system. The solution was oxygenated and buffered with a carbogen mixture of 95% O 2 /5% CO 2 , achieving maximum partial oxygen pressure of &gt;700 mmHg and undepleted oxygen outflow (&gt;200 mmHg). 
     Immediately before connection to the machine perfusion system the donor liver was flushed with 2 L of cold 0.9% NaCl solution through the portal vein and 1 L through the artery. Prior to and following machine perfusion the liver was weighed. The liver was gradually warmed to room temperature (21° C.) over the first hour of perfusion. Donor livers were all perfused for 3 h, a duration chosen following our animal studies that demonstrate full reconstitution of tissue ATP content before 3 h of perfusion [18]. Flow was regulated manually to achieve a target pressure of 4-7 mmHg over the portal vein and 50-80 mmHg on the artery. Resistance was calculated throughout perfusion as the quotient of pressure and flow. 
     Hepatocellular and Biliary Function and Injury 
     Perfusate samples were taken frequently in the first half hour and every half hour thereafter. To assess tissue damage, alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) were analyzed. ALT was analyzed using an infinity liquid stable reagent (Cellomics/Thermo Electron, Pittsburgh, Pa.). LDH activity was quantified using a colorimetric assay based on the conversion on NAD+to NADH (BioVision, Inc., Milpitas, Calif.). Urea and albumin production were measured to assess metabolic and synthetic function. Urea was assayed enzymatically (Cell Biolabs, San Diego, Calif.), and albumin was detected using a Bromocresol Green-based assay (QuantiChrom; BioAssay Systems, Hayward, Calif.). Samples were drawn from the portal venous and arterial inflow and from the caval outflow for half-hourly blood gas analysis (BGA) (Rapidpoint 500; Siemens, Norwood, Mass.). BGA included electrolyte (Na + , K + , Ca 2+  and Cl − ), lactate and glucose concentrations, and acid/base physiology (pH, pO 2 , pCO 2 , HCO 3−  and base excess). Oxygen uptake rate (OUR) was calculated by subtracting the oxygen outflow from the combined inflow through the portal vein and hepatic artery (OUR=(pvO 2IN +haO 2IN )−O 2OUT ). The oxygen concentration in each was derived using Henry&#39;s law, C dO2 =a O2 ×P O2 , where C dO2  is the concentration of dissolved oxygen, a O2  is the solubility coefficient for oxygen (0.00314 mL O 2 /mmHg O 2 /dL) and P O2  is the partial oxygen pressure. pvO 2IN /haO 2IN  and O 2OUT  were calculated by multiplying the O 2  concentration by the flow rate, and finally OUR was divided by the weight of the liver. 
     Wedge biopsies were taken for analysis of tissue ATP content. Prior to homogenization of the tissue, biopsies were pulverized in liquid nitrogen. Pulverized tissue was subsequently analyzed for ATP content using a luminescence-based cell viability assay (BioVision). ATP content was normalized to protein content, measured spectrophotometrically after the reaction with Coomassie dye. 
     Bile was collected throughout and quantified at 1-h intervals. Alkaline phosphatase (ALP) was measured fluorometrically in the perfusate as a marker of biliary and hepatocellular injury (BioVision). Phospholipids (lecithin, lysolecithin, sphingomyelin) were analyzed in bile using the choline oxidase-DAOS method and measured calorimetrically (Wako Diagnostics, Richmond, Va.). Total bile acids in bile were measured colorimetrically using a commercially available enzymatic kit (BioQuant, San Diego, Calif.). Bile samples were collected under mineral oil to prevent atmospheric equilibration and allow evaluation of bicarbonate and pH of the bile sample. 
     Histology 
     Liver parenchyma biopsies were fixed in 10% formalin and transferred to 70% ethylalcohol until processing for light microscopy. After paraffin embedding, samples were sectioned and stained with hematoxylin and eosin (H&amp;E). Samples were assessed by a blinded transplantation pathologist (RNS). 
     Statistical Analysis 
     Data were analyzed using Prism 5.0a for Mac OS X (GraphPad software, Inc., La Jolla, Calif.). Data were analyzed for normality using the Kolmogorov-Smirnov normality test. After confirming normality (a=0.05), repeated measures analysis of variance with Tukey&#39;s posttests were used to analyze time-course parameters. Correlation between two continuous variables was analyzed by simple linear regression, using a t-test to determine whether the regression coefficient differed from 0. Statistical difference between high and low ATP groups was analyzed using a Mann-Whitney U-test for total perfusate release. Results are presented as median (upper-lower quartile). A p-value &lt;0.05 was considered significant. 
     Results 
     Donor and Preservation Parameters 
     Seven consecutively perfused discarded human livers were included in this study, five of which were DCD, with an average relative WIT of 28 (23-34) min (Table 1). Livers were discarded on the basis of prolonged WIT, donor age &gt;45 years in DCD donors, high macrovesicular steatosis and inability to allocate. As minimal dissection of the vasculature was performed on procurement, an average of 70 (63-87) min was needed to prepare the liver for perfusion, resulting in a mean cold ischemic time of 685 (473-871) min. 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 Donor and graft characteristics 
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                   
                 1 
                 2 
                 3 
                 4 
                 5 
                 6 
                 7 
               
               
                   
               
               
                 Donation type 
                 DCD 
                 DCD 
                 DCD 
                 DCD 
                 DBD 
                 DBD 
                 DCD 
               
               
                 (DCD/DED) 
                   
                   
                   
                   
                   
                   
                   
               
               
                 Primary reason 
                 WIT &gt; 30 min 
                 DCD and 
                 DCD and  
                 DCD and  
                 Donor age 
                 Steatosis 
                 DCD and 
               
               
                 for discard 
                   
                 preoperative 
                 donor age 
                 donor age 
                   
                   
                 donor age 
               
               
                   
                   
                 LFTs 
                   
                   
                   
                   
                   
               
               
                 Gender 
                 Male 
                 Male 
                 Male 
                 Female 
                 Male 
                 Male 
                 Male 
               
               
                 Age (years) 
                 50 
                 25 
                 50 
                 62 
                 75 
                 24 
                 51 
               
               
                 BMI 
                 24.6 
                 26.7 
                 25.8 
                 30.18 
                 26 
                 52.9 
                 26.5 
               
               
                 Cause of death 
                 Anoxia 
                 Anoxia 
                 Head trauma 
                 Resp. failure 
                 Head trauma 
                 Anoxia 
                 Anoxia 
               
               
                 Mechanism of  
                 Cardiovascular 
                 Asphyxiation 
                 Blunt injury 
                 Natural causes 
                 Blunt injury 
                 Cardiovascular 
                 Cardiovascular 
               
               
                 death 
                   
                   
                   
                   
                   
                   
                   
               
               
                 Ischemia (min) 
                   
                   
                   
                   
                   
                   
                   
               
               
                 Relative WIT 
                 54 
                 23 
                 28 
                 34 
                 N/A 
                 N/A 
                 20 
               
               
                 Absolute WIT 
                 10 
                 11 
                 10 
                 18 
                 N/A 
                 N/A 
                 11 
               
               
                 CIT 
                 1157 
                 1002 
                 296 
                 740 
                 685 
                 420 
                 525 
               
               
                 Macrosteatosis (%) 
                 &lt;10 
                 &lt;10 
                 &lt;10 
                 &lt;10 
                 20-30 
                 80 
                 &lt;10 
               
               
                   
               
               
                 CIT, cold ischemia time; DCD, donation after circulatory death; DBD, donation after brain death, LFTs, liver function tests; WIT, warm ishemia time 
               
            
           
         
       
     
     Perfusion and metabolic parameters during room-temperature machine perfusion 
     Once connected to the perfusion system the donor livers warmed up gradually, reaching ambient room air temperature of 20.8±1.0° C. after approximately 60 min. Pressures of 5.8 (4.8-6.2) mmHg on the portal vein and 56 (47-61) mmHg on the artery were maintained by adjusting the flow rates, resulting in an average flow rate of 767 (683-833) mL/min and 206 (195-311) mL/min, respectively ( FIG. 2A ). Portal resistance was constant throughout perfusion, while the arterial resistance increased in the first 30 min and began to decrease ( FIG. 2B ). No significant weight change (−0.89 [−5.3 to 2.1]) was observed between the beginning and end of perfusion (p=0.9). Sodium and chloride ion concentrations were in the normal range after 90 and 30 min, respectively, and ended at 137.5 (135.2-143.6) mmol/L and 103.7 (101.2-106.5) mmol/L, while the potassium ion concentration increased initially from a baseline of 5.36 to 12.8 (11.7-13.0) mmol/L and subsequently decreased slightly, and then remained steady and ended at 10.7 (7.25-12.7) mmol/L ( FIG. 2C ). 
     Oxygen uptake was immediate and continued to increase during the first 2 h and plateaued thereafter (1.30 [1.11-1.94] to 6.74 [4.15-8.16] mL O 2 /min per kg liver; p&lt;0.0001) ( FIG. 2D ). Partial oxygen outflow pressure did not fall below 200 mmHg. In all cases, an initial drop in pH was observed after 15 min, but overall pH returned to within the normal reference range by the second hour ( FIG. 2E ). Bicarbonate levels increased from 25.4 (24.75-26.04) to 37.0 (33.3-39.5) mmol/L. Glucose increased during the first 90 min and plateaued (final of 341.3 [270.5-490.5] mg/dL). Lactate levels decreased to near normal levels (2.29 [1.20-3.43] mmol/L) after peaking at 30 min (4.04 [3.70-5.99] mmol/L) ( FIG. 2F ). 
     Liver function and injury during room-temperature machine perfusion 
     Urea production from amino acids in the hepatic urea cycle was constant and totaled 33.12 (27.01-36.79) μg/mL per kg liver at the end of perfusion ( FIG. 3A ). Total albumin secreted into the perfusate was 142.2 (107.5-175.0) mg/dL per kg liver, with a peak output in the first 30 min, followed by a moderate rate of secretion thereafter (189.7 [151.8-293.4] mg/kg per liver per h) ( FIG. 3B ). ALT, LDH and ALP were measured as markers of hepatic and biliary injury ( FIG. 3C ). Substantial ALT release was limited to the first 20 min of perfusion and did not increase significantly thereafter, ending at 1062.1 (750.61-1062.4) U/L. Similarly, only a moderate increase in LDH and ALP was observed. ALP increased mildly during perfusion and most steeply to 2.46 (0.78-4.2) U/L in the first hour. 
     Histology 
     Liver biopsies stained with H&amp;E did not show any difference between preperfusion and postperfusion histology ( FIG. 3D ). Notably, normal hepatocyte morphology was preserved and no evidence of injury to the sinusoidal endothelium was seen after room-temperature machine perfusion. Preperfusion biopsies were consistent with donor characteristics including mild to severe steatosis in livers 5 and 6. 
     Liver Energy Status (ATP) 
     Tissue ATP content at the end of cold storage correlated negatively with relative WIT (p=0.0045, r 2 =0.83;  FIG. 4A ). ATP increased significantly from 45.0 (38.6-87.5) to 167.5 (116.3-237.2) pmol/mg protein ( FIG. 4B ). By the end of machine perfusion, a 3.7-fold increase in ATP was observed overall (p=0.022). ATP content was correlated to various noninvasive, donor or real-time parameters to determine whether these could be used as surrogates for invasive ATP analysis. ATP recovery was variable between livers ( FIG. 6 ); the tissue ATP content increased to &gt;200 pmol/mg in three of the seven donor livers (Table 2). These livers had significantly higher oxygen uptake (p=0.009) than the other donor livers. Additionally, mean LDH, ALP, ALT, lactate and relative WIT were lower in these high ATP livers compared with the low ATP livers, although this difference was not statistically significant. ATP at the end of perfusion correlated negatively with final ALT values (p=0.02, r 2 =0.68;  FIG. 4C ). 
     
       
         
           
               
             
               
                 TABLE 2 
               
             
            
               
                   
               
               
                 Comparison between high and low recovered ATP grafts 
               
            
           
           
               
               
               
               
            
               
                   
                 High ATP* 
                 Low ATP* 
                   
               
               
                   
                 (n = 3) 
                 (n = 4) 
                 p-value 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 Donor age (years) 
                 51 
                 (38-63) 
                 50 
                 (44-53) 
                 0.59 
               
               
                 Oxygen uptake (mL/kg liver) 
                 1204 
                 (1129-1282)* 
                 564.5 
                 (404-760)* 
                 0.009 
               
               
                 Mean arterial resistance (mmHgmin/mL) 
                 0.42 
                 (0.29-0.44) 
                 0.26 
                 (0.21-0.31) 
                 0.63 
               
               
                 Mean portal resistance (×10 −3  mmHgmin/mL) 
                 5.7 
                 (5.4-7.5) 
                 8.2 
                 (6.9-9.9) 
                 0.86 
               
               
                 Peak lactate (mmol/L) 
                 3.95 
                 (3.70-4.00) 
                 6.10 
                 (5.06-6.66) 
                 0.4 
               
               
                 ALT release (U/L) 
                 604.7 
                 (443.2-979.2) 
                 1194.9 
                 (1020.7-1330.9) 
                 0.62 
               
               
                 ALP release (U/L) 
                 1.32 
                 (1.25-5.16) 
                 5.12 
                 (3.38-7.18) 
                 0.86 
               
               
                 LDH release (U/L) 
                 190.0 
                 (173.3-535.0) 
                 660 
                 (526.7-1018) 
                 0.4 
               
               
                 Urea output (μg/mL per kg liver) 
                 33.12 
                 (31.2-47.5) 
                 29.3 
                 (23.7-35.3) 
                 0.62 
               
               
                 Albumin output (mg/dL per kg liver) 
                 135.5 
                 (94.1-136.9) 
                 175.0 
                 (147.3-190.0) 
                 0.23 
               
               
                 Relative WIT (min) 
                 21 
                 (20-22) 
                 34 
                 (31-44) 
                 0.28 
               
               
                 CIT (h) 
                 11.4 
                 (10.1-14.1) 
                 9.7 
                 (6.5-14.1) 
                 0.86 
               
               
                   
               
               
                 ALP, alkaline phosphatase; ALT, alanine aminotransferase; ATP, adenosine triphosphate; CIT, cold ischemia time; LDH, lactate dehydrogenase; WIT, warm ischemia time. 
               
               
                 *High (&gt;200 pmol/mg protein) and low (&lt;200 pmol/mg protein) ATP content postperfusion: 
               
               
                 *AUC = area under the curve. 
               
            
           
         
       
     
     Biliary Function 
     Bile flow generally started within the first 30 min of perfusion. Total bile production in the first hour was 2.25 (0.9-2.5) mL, which increased to 3.9 (2.4-5.1) mL in the final hour ( FIG. 5A ). Absence of an enterohepatic circulation of bile salts resulted in a decrease in biliary bile salt concentration from the first hour ( FIG. 5B ). Total phospholipid concentration increased throughout perfusion, which resulted in a lower and less toxic bile salt to phospholipid ratio ( FIG. 5C ). The secretion of cytoprotective bicarbonate increased favorably, which also raised the pH from 6.9 early in perfusion to a more alkaline pH of 7.6 at the end of perfusion ( FIG. 5D ). 
     Discussion 
     It is demonstrated herein that human livers can be supported ex vivo by room-temperature machine perfusion at room temperature. During this ex vivo period the liver is metabolically active, demonstrating synthetic and clearance function, while incurring minimal additional injury. Furthermore, this study shows that room-temperature machine perfusion can improve various functional and biochemical parameters after a period of extensive warm and cold ischemia, including a significant improvement in oxygen uptake, bile production and tissue ATP content. 
     Room-temperature machine perfusion likely operates through a number of cooperative mechanisms. Restoration of mitochondrial respiratory function and reversal of energy deficits have been shown to be pivotal in restoring liver viability [ 20 ,  21 ]. Mitochondria play a key role in ischemia/reperfusion injury through their role in reactive oxygen species formation and the induction of apoptosis [ 22 ,  23 ]. In this work, particular attention has been paid to improvement of the energy balance of the liver. Impairment of oxidative phosphorylation during warm hypoxia leads to a rapid dephosphorylation of ATP, which is only exacerbated during hypothermic preservation [ 18 ,  24 ]. As a result the ischemic liver is poorly prepared for warm reperfusion and the oxidative and inflammatory stress that follows. Improvement of mitochondrial condition, reflected here by augmentation of tissue ATP content, an increasing consumption of oxygen and decreasing lactate levels during room-temperature machine perfusion, may result in the improved tolerance to oxidative stress seen on reperfusion in animal studies [ 25 ]. Recovered levels of ATP appear to be a good indicator of mitochondrial respiratory function, as high ATP content at the end of room-temperature machine perfusion is correlated to higher oxygen uptake and lower lactate levels during perfusion. Moreover, the ability of the liver to recover ATP seems to depend on the severity of the injury sustained during ischemia. Livers with a poor recovery of ATP were subjected to a longer WIT and showed worse liver function tests (LFTs) during room-temperature machine perfusion. Conversely, clinical studies have shown that preimplantation ATP content correlates to liver failure [ 26 ] and postreperfusion ATP recovery to posttransplant function [ 27 ]. In various animal studies, it has been demonstrated that ATP content correlates to the number viable cells [ 28 ,  29 ] and it has been found that postperfusion ATP content is highly suggestive of outcome in transplant models [ 18 ,  30 ]. 
     Additional mechanisms of action may include the normalization of ion and metabolite balances through equilibration with the perfusion solution, which produces a more adequate environment for warm reperfusion. Microcirculatory obstructions, originating from either microthrombi or cellular edema, may be of underappreciated importance and prevent adequate tissue perfusion. Improving sinusoidal conductance prior to transplantation increases the rate of graft recovery [ 31 ]. 
     Discussions concerning the optimum phase during the ex vivo period for the application of machine perfusion are ongoing [ 32 ]. Various groups have considered long perfusion times, aiming to replace static cold preservation entirely and have shown success [ 33 - 35 ]. It has been shown in a porcine model that even a short period of cold preservation prior to warm perfusion has adverse effects on function and injury of the liver, suggesting that perfusion may benefit from immediate initiation on recovery [ 24 ,  36 ]. Warm perfusion that spans the transport period has been approached with rightful trepidation, namely considering the risk of equipment failure. Moreover, resource and personnel demands of long-term machine perfusion would make implementation of preservation-spanning perfusions arduous. However, new devices are gaining support and may play a role in the near future [ 37 ]. Postprocurement machine perfusion, particularly in the case of DCD livers, offers a recovery phase prior to cold preservation that may improve tolerance to extended cold ischemia [ 38 ]. It was previously shown that ATP can be recovered to baseline levels after 3 h of perfusion, a duration that is compatible with the logistics of transplantation [ 18 ]. Learning from clinical experience, various parameters in perfusion can be considered as indicators of liver function or injury and include standard LFTs, bile production and other hepatic synthetic functions [ 39 ,  40 ]. Detailed analyses of metabolism can be used to provide accurate criteria for liver viability. By applying dynamic discriminate analyses, Perk et al [ 12 ] have identified metabolites measured during perfusion that discriminate between warm ischemic and fresh livers with a very high specificity. Moreover, using easily measured metabolites like glucose, urea and lactate, indices for transplantation can be constructed that predict transplant success with equally high specificity [ 13 ]. 
     Although the importance of preserving and assessing hepatocellular viability is indisputable, progress toward expanding the current donor pool cannot occur without advances in biliary preservation. Bile duct complications remain a limiting factor in the use of DCD livers, with particularly high incidences of nonanastomotic biliary strictures [ 41 ]. With ischemia as the primary risk factor for biliary complications, room-temperature machine perfusion may provide an elegant solution, minimizing further injury and providing a platform for treatment. Additionally, bile salt toxicity has been proposed as a factor in bile duct injury. A compositional change in bile salt to phospholipid ratio has been associated with bile duct injury in clinical studies [ 42 ,  43 ]. Moreover, a shift to dominantly toxic, hydrophobic bile salts may play an important role [ 44 ]. It may prove beneficial to supplement the depletion of bile salts observed in this and other work with protective hydrophilic bile salts [ 45 ]. Room-temperature machine perfusion and other warm machine perfusion systems have already proven advantageous in reducing markers of biliary injury during preservation and restoring normal biliary physiology [ 14 ,  46 ]. In this work, machine perfusion&#39;s ability to rectify various compositional disturbances in bile is confirmed. Moreover, room-temperature machine perfusion results in a less toxic and more protective composition of bile through changes in bile salt, phospholipid and bicarbonate concentrations [ 47 ,  48 ]. 
     The precise constituents and setting for optimal machine perfusion of the liver remain uncertain. While simplicity and minimal risk have driven the development of hypothermic systems, NMP has sparked interest in the prospect of an ex vivo organ with close to normal physiology that opens up the opportunity for intervention, recovery and viability testing [ 14 ,  49 ]. The complexity and associated risk have delayed clinical implementation and have even veered groups away. In developing this room-temperature machine perfusion system, emphasis has been laid on simplicity while maintaining the goal of developing an effective system for liver recovery and assessment. With regard to efficacy, room-temperature machine perfusion has already shown excellent results in both hepatic and biliary preservation. 
     In this feasibility study, it has been demonstrated that room-temperature machine perfusion effectively supports the human liver ex vivo with minimal injury, stable if not improved metabolic activity, and normalized physiological disturbances postischemia. Moreover, room-temperature machine perfusion provides an environment for restoring the hepatic energy status, reflecting a recovery of mitochondrial function. This work is the first demonstration of the capacity of room-temperature machine perfusion to sustain human livers and supports previous experimental work that suggest a pivotal role of machine perfusion in expanding the use of currently discarded livers for transplantation. 
     
       
         
           
               
             
               
                 TABLE 3 
               
             
            
               
                   
               
               
                 Perfusate composition 
               
            
           
           
               
               
            
               
                   
                 g/L 
               
               
                   
                   
               
            
           
           
               
               
               
            
               
                   
                 Inorganic Salts 
                   
               
               
                   
                 Calcium Chloride 
                 0.2 
               
               
                   
                 Cupric Sulfate•5H 2 O 
                 0.0000001 
               
               
                   
                 Ferric Nitrate•9H 2 O 
                 0.0000001 
               
               
                   
                 Magnesium Chloride•4H 2 O 
                 0.0000001 
               
               
                   
                 Magnesium Sulfate (anhydrous) 
                 0.0977 
               
               
                   
                 Potassium Chloride 
                 0.4 
               
               
                   
                 Sodium Bicarbonate 
                 2.2 
               
               
                   
                 Sodium Chloride 
                 6.8 
               
               
                   
                 Sodium Phosphate Monobasic (anhydrous) 
                 0.122 
               
               
                   
                 Zinc Sulfate•7H 2 O 
                 0.0000002 
               
               
                   
                 Amino Acids 
               
               
                   
                 L-Alanine 
                 0.09 
               
               
                   
                 L-Arginine (free base) 
                 0.05 
               
               
                   
                 L-Asparagine•H 2 O 
                 0.02 
               
               
                   
                 L-Aspartic Acid 
                 0.03 
               
               
                   
                 L-Cysteine (free acid) 
                 0.04 
               
               
                   
                 L-Cystine 
                 0.02 
               
               
                   
                 L-Glutamic Acid 
                 0.0445 
               
               
                   
                 L-Glutamine 
                 0.292 
               
               
                   
                 Glycine 
                 0.05 
               
               
                   
                 L-Histidine (free base) 
                 0.015 
               
               
                   
                 L-Isoleucine 
                 0.05 
               
               
                   
                 L-Leucine 
                 0.075 
               
               
                   
                 L-Lysine•HCl 
                 0.08746 
               
               
                   
                 L-Methionine 
                 0.015 
               
               
                   
                 L-Phenylalanine 
                 0.025 
               
               
                   
                 L-Proline 
                 0.03 
               
               
                   
                 L-Serine 
                 0.01 
               
               
                   
                 L-Threonine 
                 0.04 
               
               
                   
                 L-Tryptophan 
                 0.01 
               
               
                   
                 L-Tyrosine•2Na•2H 2 O 
                 0.05045 
               
               
                   
                 L-Valine 
                 0.05 
               
               
                   
                 Vitamins 
               
               
                   
                 Ascorbic Acid•Na 
                 0.00227 
               
               
                   
                 D-Biotin 
                 0.0005 
               
               
                   
                 Calciferol 
                 0.0001 
               
               
                   
                 Choline Chloride 
                 0.0015 
               
               
                   
                 Folic Acid 
                 0.001 
               
               
                   
                 myo-Inositol 
                 0.002 
               
               
                   
                 Menadione (sodium bisulfite) 
                 0.00001 
               
               
                   
                 Niacinamide 
                 0.001 
               
               
                   
                 D-Pantothenic Acid (hemicalcium) 
                 0.001 
               
               
                   
                 Pyridoxal•HCl 
                 0.001 
               
               
                   
                 Retinol Acetate 
                 0.0001 
               
               
                   
                 Riboflavin 
                 0.0001 
               
               
                   
                 Thiamine•HCl 
                 0.001 
               
               
                   
                 DL-α-Tocopherol Phosphate•Na 
                 0.00001 
               
               
                   
                 Vitamin B12 
                 0.0002 
               
               
                   
                 Other 
               
               
                   
                 D-Glucose 
                 2 
               
               
                   
                 Glutathione (reduced) 
                 0.00005 
               
               
                   
                 Methyl Linoleate 
                 0.00003 
               
               
                   
                 Phenol Red•Na 
                 0.0107 
               
               
                   
                 Pyruvic Acid•Na 
                 0.025 
               
               
                   
                 Penicillin (U/L) 
                 40,000 
               
               
                   
                 Streptomycin 
                 0.04 
               
               
                   
                 Humulin R (U/l/hr) 
                 2 
               
               
                   
                 Hydrocortisone 
                 0.01 
               
               
                   
                 Sodium Bicarbonate (8.4%) 
                 30-50 mL 
               
               
                   
                   
               
            
           
         
       
     
     References for Example 1: 
     
         
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         22. Zhao K, Zhao G M, Wu D, et al. Cell-permeable peptide antioxidants targeted to inner mitochondrial membrane inhibit mitochondrial swelling, oxidative cell death, and reperfusion injury. J Biol Chem 2004; 279: 34682-34690. 
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         24. Reddy S P, Bhattacharjya S, Maniakin N, et al. Preservation of porcine non-heart-beating donor livers by sequential cold storage and warm perfusion. Transplantation 2004; 77: 1328-1332. 
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         26. Lanir A, Jenkins R L, Caldwell C, Lee R G, Khettry U, Clouse M E. Hepatic transplantation survival: Correlation with adenine nucleotide level in donor liver. Hepatology 1988; 8: 471-475. 
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         31. Minor T, Tolba R, Neumann S, Schulz S, Sitzia M. Fibrinolysis in organ procurement for transplantation after cardiocirculatory compromise. Thromb Haemost 2003; 90: 361-362. 32. Koetting M, Minor T. Donation after cardiac death: Dynamic graft reconditioning during or after ischemic preservation? Artif Organs 2011; 35: 565-571. 
         33. St Peter S D, Imber C J, Lopez I, Hughes D, Friend P J. Extended preservation of non-heart-beating donor livers with normothermic machine perfusion. Br J Surg 2002; 89: 609-616. 
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         43. Buis C I, Geuken E, Visser D S, et al. Altered bile composition after liver transplantation is associated with the development of nonanastomotic biliary strictures. J Hepatol 2009; 50: 69-79. 
         44. Hertl M, Harvey P R, Swanson P E, et al. Evidence of preservation injury to bile ducts by bile salts in the pig and its prevention by infusions of hydrophilic bile salts. Hepatology 1995; 21: 1130-1137. 
         45. Imber C J, St Peter S D, de Cenarruzabeitia I L, et al. Optimisation of bile production during normothermic preservation of porcine livers. Am J Transplant 2002; 2: 593-599. 
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     Example 2: Organ Preservation Bag 
     The preservation bag is comprised primarily of the same material used to produce Baxter saline bags (e.g. Sealed Air). 
     The perfusion is operated at room temperature, so no temperature control is needed. 
     The system is a closed system without air. In the event of bubbles, it functions as a bubble trap (any bubbles float). These can be siphoned off with a syringe and a rubber-stop or squeezing them out a valve (e.g. luer-lock stopcock). 
     From the top-view the design can be circular or square, depending on how the other components (e.g. oxygen tank, pumps) fit, thereby conferring stability on the bag. 
     From the side view, the bag is flimsy at the bottom and top because the bag is arced—this becomes more rigid when filled with perfusate. 
     The shape is determined by a stiff outer ring that has some height associated with it. 
     The height of the ring is determined primarily by the size and composition of the inner tubes that carry perfusate from the top of the device to the bottom. The tubes are oxygen-permeable, functioning as large-surface area oxygenators. 
     If the tubes are comprised of silicon tubing (or the same material the rest of the bag is made out of), which forms a holey floor of the organ chamber (top of the device) they could be large enough to enable flow to gravitate into the bottom chamber, minimizing the work needed to be done by the pumps to pull the fluid through. If the sizes of the holes need to be very small in order to minimize liver bed sores, the shape of the tubes can taper out, increasing in diameter, possibly even joining, at the bottom of the bag. 
     Alternatively, the oxygenator could comprise the same microfibers as dialyzers (e.g. Gambro), with the potting compound/glue forming the seat in which the liver sits. 
     The oxygen tank is connected to the outer ring, either sitting in a pocket within the ring if it is large enough, or attached outside to the ring. The ring is sealed from top to bottom, but on the opposite end of the oxygenator (across the device) there is a small release hole for the oxygen to escape. 
     There are two pumps (e.g. Quantex pumps) that suck perfusate from the bottom of the bag (and therefore, through the oxygenator-fibers/tubes, into the HA and PV. The pumps are preset to ensure the pressure out is within physiological range (up to 100 mmHg in the HA and 5 mmHg in the PV). They fit in the space afforded by the ring. 
     The PV and HA are hooked up to the pumps using valved quick disconnects. 
     The bile duct is cannulated (e.g. 14G Terumo catheter) and securely fasted to a large vacutainer tube (e.g. 50 ml) which is embedded with the space afforded by the ring. 
     There is a water-tight zip that opens a large flap at the top of the device to allow the liver to be immersed in the system. 
     The tubing to insert into the vasculature is attached to the zip flap to enable access when influx samples need to be procured and to measure pressure (e.g. Biopac system). 
     A similar attachment to the IVC is made to enable outflow measurements or a rubber stop is placed in the vicinity of the IVC for a catheter or syringe to be inserted into through the bag. 
     To use the preservation bag, the following protocol can be used: (1) At procurement, the liver is immediately pre-flushed with 1-2L of modified Williams Medium E35, using valved quick disconnects. (2) The liver is disconnected from the flush and placed into the organ preservation bag and snapped on to the pump quick disconnects. (3) The oxygen is turned on. (4) The pumps are initiated at low flow rates, ramped up slowly to optimal flow in the first 30 minutes of perfusion. (5) The bile tubing is inserted into a vacutainer. (6) Once the system is stable, the zip is closed and air removed. (7) Perfusion is evaluated using dynamic contrast enhanced ultrasound directly on the bag, and samples are taken from in- and outlets.