Evaluation of the prospects for developing a next-generation perfusion solution for hypothermic oxygenated preservation of donor organs

Background. Ischemia-reperfusion injury remains a central challenge in clinical transplantology, determining outcomes particularly when using organs from expanded criteria donors and donors after circulatory death. Hypothermic oxygenated machine perfusion (HOPE) has established itself as an effective strategy for donor organ protection; however, existing preservation solutions (UW, HTK) were developed for static cold storage and are not optimized for oxygenated perfusion conditions. Current understanding of pathogenesis has revealed the key role of reverse electron transport in mitochondria and ferroptosis — mechanisms not addressed by classical solutions.

Aim. To analyze approaches to developing a next-generation universal perfusion solution (MITOPERF) optimized for protection against key mechanisms of ischemia-reperfusion injury: oxidative stress, mitochondrial reverse electron transport, ferroptosis, and inflammatory response.

Materials and methods. An experimental perfusion solution MITOPERF was developed, containing 18 pharmacologically active components with multitarget action: mitochondrial protectors, antioxidants, antiferroptotic agents, immunomodulators, and energy substrates. The study was performed on 36 male Wistar rats  (18 — liver model, 18 — kidney model). Animals were randomized into groups: Custodiol (control), MITOPERF, and modified Custodiol ex tempore (Custodiol-M). We modeled 30-minute warm ischemia (DCD conditions), 2-hour hypothermic oxygenated perfusion, and 60-minute normothermic reperfusion. Biochemical injury markers (ALT, AST, creatinine, lactate), ferroptosis markers (4-HNE, GPX4), functional parameters (bile production, glomerular filtration rate), and histological changes were evaluated.

Results. MITOPERF provided a 76% reduction in ALT (169±91 vs 694±247 U/L, p<0.05) and 64% reduction in creatinine (121±46 vs 334±97 μmol/L, p<0.05) compared to control. The ferroptosis marker 4-HNE concentration decreased more than 2-fold, GPX4 activity increased nearly 2-fold. Bile production in the MITOPERF group exceeded control by 2.4 times (0.74±0.24 vs 0.31±0.15 μL/min/g, p<0.05), glomerular filtration rate — by 3.2 times (0.76±0.29 vs 0.24±0.12 mL/min/g, p<0.05). Modified Custodiol-M showed intermediate protective effect (43–55% reduction in injury markers).

Conclusion. The experimental solution MITOPERF demonstrated proof of concept for effective protection of parenchymal organs from ischemia-reperfusion injury during hypothermic oxygenated preservation. Comparable protection of liver and kidney confirms action on universal pathogenetic mechanisms. Modified Custodiol ex tempore may be recommended for clinical implementation as an accessible alternative not requiring new drug registration.

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