1. Liver Xenotransplantation Comprehensive Development Program
A. Joseph Tector MD PhD
Indiana University
School of Medicine
Clarian Transplant Institute

2. Need for Alternative Source of Organs
98,000 Americans are waiting for a solid organ transplant
46,000 have died waiting for a transplant since 2000

3. Xenotransplantation
Unlimited source of donor organs for all types of transplants
Potential to genetically engineer donor animals to eliminate immunological barriers

4. Problems with Xenotransplantation
Immunological barriers
Hyperacute rejection
Acute vascular rejection
Cellular rejection
Physiological barriers
Animal proteins may or may not work with human counterparts
Coagulation proteins

5. Problems with Xenotransplantation
Risks of zoonotic infection
Porcine Endogenous Retrovirus (PERV)
Finding an indication with immediate chance to benefit patient

6. The Case Against Cardiac and Renal Xenografts
Dialysis can be tolerated for years
Assist devices can bridge a patient for
12-18 months
Xenograft would need to function at least 6 months to be considered for a clinical trial

7. The Case for Liver Xenotransplantation
Temporary liver support is lacking
Liver xenograft could be used to bridge patients for a period of days and be a success

8. The Patient

9. The Solution

10. Three Weeks Following Pig Liver Perfusion Followed by Human Liver Transplant

11. Recipients with Liver Failure are Less Capable of Rejecting a Liver Xenograft

12. The Program

13. Genetic Engineering of Donor Pigs

14. Advantages of Genetic Engineering
Decrease response of the human immune system
Minimize zoonotic infectious risk
Eliminate physiologic incompatibilities

15. Nuclear Transfer Procedure
Enucleated
Oocyte
Fused dublet
Nucleated Oocyte
Dublet
Nuclear Donor
Somatic Cell
Activation
CLONE

16. Enucleation
1st polar body

17. Enucleation
1st polar body
Metaphase plate

18. Dublet Preparation
Nuclear donor
Enucleated oocyte or Cytoplast

19. Product of Genetic Engineering

20. Better Way to Make Pigs Bank fetal fibroblasts
Make genetic modifications on fibroblast from latest generation of donor pig
Eliminate expensive and time consuming breeding programs

21. Better Way to Make Pigs Eliminate need for large herds and big farms
New pig every 6 months instead of 2-3 years

22. Gal Knockout ConstructLH
PURO RH
SalI
BstXI
AscI
MluI

23. Human CD39/CD59 Construct

24. Human CD46/CD47 Construct

25. Next Steps in Donor Engineering
Introduce GTKO, CD/39/59, and CD46/47 constructs into fetal fibroblasts (1 month)
SCNT to produce pigs (5 months)
Transgenes to minimize risks of zoonotic infections
Transgenes to decrease cellular immunity

26. Xenograft Immunology Christopher Burlak PhD started July 1, 2008
PhD student working on non-gal xenoantigens
Surgical Resident studying T- cell xenoimmunology

27. Zoonotic Considerations
May Hired viral forecaster Dr. Nathan Wolfe DsC, UCLA School of Epidemiology, as a consultant to setup guidelines for monitoring xenograft recipients, their personal contacts, and health care workers
He is in the process of establishing an advisory board to provide guidance with regards to infectious risks

28. Operative Considerations in Pig to Human Liver Xenografts

29. Pig Liver in Situ

30. Human Cadaver

31. Suprahepatic Cava Anastamosis

32. Portal Venous and Hepatic Arterial Anastamoses

33. Next Steps We will transplant pig livers into brain-dead individuals
We should have GTKO pigs in early January
We could begin transplanting in late February or early March
If the GTKO pig livers function for 24 hours we could begin to use these organs as a bridge to transplant for clinical liver transplantation