The ex vivio perfusion circuit was composed of a centrifugal pump (Rotaflow centrifugal pump), 2 hard shell reservoirs (Maquet, Hirrlingen, Germany), a leukocyte filter and a hollow-fiber dialyzer (NR16, Fresenius, Bad Homburg, Germany). The setup was similar to the OrganOx Metra that has recently been published in human clinical trials and has been described previously [46 (link),47 (link),48 (link)]. The hepatic artery pressure was set to 50–60 mm Hg, resulting in a flow of up to 400 mL/h. A second reservoir was used to regulate the portal vein pressure, which was intended to reach 2–4 mm Hg and a flow of 900–1400 mL/h. Porcine blood was obtained from the donor animal shortly before liver retrieval and erythrocytes were passed through leukocyte filters. For the perfusate, 1.5 L of Steen Solution (XVIVO Perfusion, Goteborg, Sweden) was mixed with the washed porcine erythrocytes (around 400 g) to achieve a final hematocrit of 15% with a hemoglobin level of 45 mg/dL. During the priming of the circuit, Heparin (10,000 international units (IU), Sandoz Canada, Quebec, QC, Canada), amino acid concentrate (Travasol 4.25%, 50 mL Bolus, Baxter, Hamilton, ON, Canada), sodium bicarbonate (20 mmol), calcium chloride (9.2 mmol/L) and antibiotics (Cefazolin—1 g, Pharmaceutical Partners of Canada, Richmond Hill, ON, Canada and Metronidazole—500 mg, Baxter, Mississauga, ON, Canada) were added. Additionally, amino acid concentrate (Travasol 4.25%, 8 mL/h, Baxter, Hamilton, ON, Canada), insulin (125 IU/h, NovoRapid, Novo Nordisk, Mississauga, ON, Canada), 2% taurocholic acid (7 mL/h, Sigma-Aldrich, St. Louis, MO, USA infused as a precursor for bile production) and prostaglandin E1 (500 μg/3 h, Pfizer, Kirkland, QC, Canada) were continuously administered during the perfusion. The surgical protocol for the donor liver retrieval and the liver transplantation has been described in more detail previously [24 (link),44 (link),45 (link)].
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