Xenotransplantation

Pengantar

Xenotransplantation melibatkan transplantasi jaringan atau organ bukan manusia ke manusia

penerima Konsep ini dipelopori abad yang lalu, ketika transplantasi organ tubuh manusia
dianggap etis kontroversial.. Cangkokan dengan cepat ditolak, namun karena kekuatan tidak
diketahui kemudian diidentifikasi sebagai respon kekebalan tubuh.

. Ketertarikan di bidang xenotransplantation muncul kembali selama 1960-an, ketika kemajuan

besar dibuat olehbidang imunologi ginjal simpanse telah ditransplantasikan ke pasien dengan
gagal ginjal. 1 Pada tahun 1984, hati babon itu dipindahkan ke bayi baru lahir, Baby Fae, yang
telah menderitA sindrom hipoplasia jantung dan HIDUP 20 hari setelah operasi jantung. Hati
3
seekor babon ditransplantasikan ke pasien dengan kegagalan hati. sel pulau Babi dari
Langerhans telah disuntikkan ke pasien dengan tipe 1 diabetes mellitus . 4 kulit Babi yang telah
5
dicangkokkan ke pasien luka bakar, dan neuron sel babi ditransplantasikan ke pasien dengan
Parkinson (Parkinson) penyakit dan Huntington (Huntington) penyakit . 6

Selama kemajuan-kemajuan ini, beberapa kendala bagi keberhasilan xenotransplantation telah

diidentifikasi. (1) mencegah penolakan yang hiperakut, (2) mencegah penolakan vascular akut,
(3) memfasilitasi akomodasi kekebalan tubuh, (4) mendorong toleransi kekebalan tubuh, (5)
mencegah penularan virus dari xenografts menjadi manusia , dan (6) mengatasi isu-isu etika
seputar sumber hewan untuk xenografts dan pemilihan yang sesuai penerima (mengingat bahwa
xenotransplantation masih eksperimental). The purpose of this review is to identify the obstacles
and recent progress made in the field of xenotransplantation. Tujuan dari kajian ini adalah untuk
mengidentifikasi hambatan dan kemajuan yang baru-baru ini dibuat dalam bidang
xenotransplantation.

Dasar pemikiran dari xenotransplantation

. Motivasi untuk menggunakan sumber hewan untuk transplantasi organ atau jaringan didorong
oleh permintaan dan penawaran pasien yang membutuhkan transplantasi segera. Menurut
laporan saat ini yang paling dari Jaringan Serikat untuk Organ Sharing (UNOS), lebih dari
107.241 orang Amerika menunggu untuk transplantasi organ pada Mei 2010 tahun 2009, 28.464
pasien transplantasi, dan sekitar 40% dari calon terdaftar di daftar tunggu masih muda dari 50
tahun.

Mengingat kurangnya pasokan organ tubuh manusia untuk transplantasi, beberapa alternatif telah
diteliti dan diperdebatkan. alat-alat mekanis Implan telah dieksplorasi di bidang transplantasi
jantung. Baru-baru ini, penelitian telah meningkat di bidang transplantasi sel embrio di seluruh
spesies dan ginjal tumbuh dan sel-sel pankreas endokrin in situ. Organ dari babi telah menjadi
fokus dari banyak penelitian di xenotransplantation, sebagian karena penerimaan publik
membunuh babi dan persamaan fisiologis antara babi dan primata manusia dan bukan manusia.
Xenotransplantation organ dari simpanse dan babon telah dihindari, namun, karena masalah etis
dan takut penularan virus mematikan

Xenografts telah diusulkan sesuai untuk bayi yang secara fisik terlalu kecil untuk menampung
organ diambil dari orang dewasa atau donor pediatrik. Selain itu, organ dari sumber hewan bisa
dicangkokkan ke pasien yang saat ini dikecualikan dari daftar transplantasi organ manusia.
Akhirnya, sebagian besar pasien menganggap xenotransplantation sebagai jembatan diterima
transplantasi organ tubuh manusia dalam situasi yang mengancam kehidupan.

Sejarah prosedur

Alexis Carrel dikenal sebagai bapak pendiri transplantasi organ eksperimental karena karya
perintisnya dengan teknik vaskular.. Carrel dan Guthrie memberikan kontribusi besar terhadap
ilmu transplantasi 1904-1906. Mereka melakukan cangkokan vena autogenous, melakukan
peremajaan kaki pada anjing, dan mengembangkan teknik patch-graft terkenal pada pelebaran
pembuluh menyempit. Mereka juga melakukan transplantasi eksperimental heterotopic. larger
Bagian dari anjing kecil itu ditransplantasikan ke dalam leher anjing yang lebih besar. Mereka
mengembangkan teknik sosok untuk anastomosis donor dan penerima transplantasi ginjal untuk
mencegah pembentukan trombus.

Pada tahun 1906, jaboulay mentransplantasi ginjal dari kambing, domba, dan monyet pada
manusia. Upaya xenografting ginjal ini tidak berhasil. Pada tahun 1910, Unger mentransplantasi
ginjal bukan manusia pada orang sekarat karena gagal ginjal, yang menyebabkan kematian
sedikit lebih dari satu hari kemudian. Pada tahun 1932, Neuhof mentransplantasi ginjal domba ke
pasien dengan keracunan merkuri. Pasien hanya bertahan 9 hari. Pada tahun 1946, Demikhov
transplantasi hati heterotopic dan paru-paru, hewan bertahan selama 9 jam.

Kepentingan klinis dalam xenotransplants berkurang setelah serangkaian hasil mengecewakan

dan kesadaran bahwa kegagalan transplantasi disebabkan kekuatan yang tidak diketahui kuat
yang akhirnya akan diidentifikasi sebagai sistem kekebalan tubuh. Scientific interest did not
revive until the 1950s, following successful allografting of kidneys from identical twins.
Ketertarikan ilmiah tidak menghidupkan kembali sampai tahun 1950, mengikuti sukses
allografting ginjal dari kembar identik. Michon dan Hamburger berhasil melakukan transplantasi
ginjal terkait donor hidup di Paris pada tahun 1952, pada tahun 1954, Merrill dan Murray,
menggunakan imunosupresi tidak, melakukan transplantasi ginjal pertama antara kembar
monozigot

Munculnya terapi dialisis selama tahun 1940-an dan 1950-an dan ketersediaan luas dalam tahun
1970 akhirnya membuat dampak yang signifikan dan abadi pada transplantasi ginjal.
Hemodialisis didirikan jembatan untuk transplantasi dan secara signifikan memperluas populasi
pasien yang dapat manfaat dari transplantasi ginjal. Pasien dengan stadium akhir penyakit ginjal
memiliki 2 pilihan terapeutik: (1) dialisis dan / atau terapi atau (2) allograft (donor cadaver
terkait atau hidup).

Pada saat itu, pemahaman tentang immunobiology transplantasi dan obat imunosupresif baru saja
mulai berkembang. Pengetahuan tentang pengadaan organ dan pelestarian sangat terbatas, sangat
membatasi penggunaan klinis luas allografting. Selama ini, Starzl dan rekan (dan kelompok
lainnya) bereksperimen dengan xenotransplantation menggunakan simpanse atau babon.

Momentum xenotransplantation telah tergelincir pada 1990-an dengan penemuan retrovirus babi.
Kekhawatiran tentang risiko infeksi silang-spesies menghasilkan moratoriums pada uji klinis
pada xenotransplantation.

Definition Definisi
Xenotransplantation mengacu pada prosedur yang melibatkan transplantasi, implantasi, atau
infus ke penerima manusia baik (1) sel hidup, jaringan, atau organ dari sumber hewan bukan
manusia atau (2) cairan tubuh manusia, sel, jaringan, atau organ yang memiliki kontak ex vivo
dengan hidup sel-sel hewan bukan manusia, jaringan, atau organ. (US Food and Drug
Administration [FDA], 1999; FDA, 2001). (US Food and Drug Administration [FDA], 1999;
FDA, 2001).

produk xenotransplantation harus hidup, dan sirkulasi dan pengembalian darah pasien harus
terjadi melalui sel-sel bukan manusia hidup. Sebagai contoh, sel-sel kulit manusia tumbuh di luar
tubuh pada lapisan sel bukan manusia dan kemudian digunakan pada manusia untuk rekonstruksi
kulit juga dapat dianggap sebagai produk xenotransplantation.. Kategori prosedur yang terakhir
dimasukkan dalam definisi karena ilmuwan percaya bahwa potensi penularan penyakit menular
dengan prosedur seperti ini mungkin mirip dengan menanamkan sel-sel hewan hidup bukan
manusia, jaringan, atau organ langsung ke penerima manusia. . Produk xenotransplantation
termasuk mereka dari binatang transgenik atau nontransgenic dan produk komposit yang
mengandung produk xenotransplantation dalam kombinasi dengan obat atau perangkat Ini
mencakup, tetapi tidak terbatas pada, babi sel saraf janin, sel islet babi, sel chromaffin
adrenalinsapi , sumsum tulang babon, dan hati eksternal-membantu perangkat yang
menggunakan hati babi atau hepatosit babi. produk biologis Yg tdk hidup atau bahan dari hewan
bukan manusia, seperti katup jantung babi dan insulin babi, tidak diklasifikasikan sebagai produk
xenotransplantation untuk keperluan definisi ini.

produk xenotransplantation yang tunduk pada peraturan oleh FDA pada bagian 351 dari US
Public Health Service Act [42 USC 262] dan Federal Makanan, Obat dan Kosmetik Undang-
Undang [21 USC 321 et seq]. Sesuai dengan ketentuan hukum yang mengatur pengembangan
premarket, produk xenotransplantation ini dapat ditinjau dan disetujui FDA.

bergantung pada hubungan antara spesies donor dan penerima, xenotransplant dapat
digambarkan sebagai sesuai atau sumbangan. spesies sesuai adalah spesies dengan filogenetis
yang erat terkait. Kombinasi spesies termasuk mouse untuk tikus, babon untuk monyet
cynomolgus, atau, mungkin, primata non-manusia ke manusia. spesies sumbang, di sisi lain,
tidak berhubungan (misalnya, babi untuk mouse, babi ke manusia).
Sebuah penerima sesuai membutuhkan waktu beberapa hari untuk menolak organ, sedangkan
penerima sumbang mount sebuah respon, kekerasan hiperakut yang mengarah ke xenograft
kerugian dalam waktu beberapa menit sampai beberapa jam. Perbedaan waktu penolakan ini
berkaitan dengan ada atau tidak adanya antibodi alami preformed di pasang spesies sumbang
(dijelaskan dalam imunologi Hambatan xenotransplantation ).

Memilih Jenis Donor

Simpanse umumnya dianggap donor primata non-manusia terbaik dibandingkan dengan babon
atau monyet rhesus. Namun, ketersediaan mereka cepat berkurang pada tahun 1960, dan mereka
kemudian terdaftar sebagai spesies yang terancam punah. Akibatnya, para ilmuwan mencari
sumber hewan lain yang potensial untuk organ untuk xenotransplantation. Spesies seperti babon,
meskipun ada dalam jumlah yang lebih besar dibandingkan dengan simpanse, biaya yang buruk
di penangkaran, memiliki kehamilan yang panjang, dan memiliki beberapa keturunan.

BRMAC), setelah melakukan mendalam investigasi dalam masalah ini dan mengadakan dengar
pendapat publik, mencatat temuan dan keprihatinan tentang hal ini dalam register federal tanggal
Januari 2001. BRMAC menimbulkan kekhawatiran mengenai transmisi antarspesies dari agen
infeksi xenogeneic. Hal ini juga mencatat potensi untuk transmisi berikutnya agen infeksius
xenogeneic dari penerima untuk menutup kontak penerima, dan propagasi melalui populasi
manusia secara umum, sebagai tambahan dan risiko masalah kesehatan publik yang sudah
diakui.

Hal ini menyebabkan peneliti untuk mencari sumber hewan lain. Monyet tidak dianggap organ
donor diterima untuk alasan praktis dan etis. Selain menjadi tidak nyaman dekat dengan manusia
di tangga evolusi, mereka juga menghasilkan keturunan sedikit, lambat untuk dewasa, dan akan
sulit untuk belakang dalam kondisi steril diperlukan untuk meminimalkan kontaminasi oleh
patogen bersama.

Kebanyakan peneliti setuju bahwa babi memiliki potensi untuk menjadi kandidat utama untuk
donasi organ. Babi banyak, cepat untuk dewasa, berkembang biak dengan baik di penangkaran,
dan memiliki organ vital dalam ukuran kira-kira sebanding dengan manusia. Karena mereka
telah sering digunakan di pasar konsumen, penggunaannya dalam xenografting kurang
kemungkinan untuk memperoleh keberatan utama dari masyarakat. Karena manusia memiliki
kontak lama dan dekat dengan babi, penggunaannya untuk tujuan xenotransplantation diyakini
kecil kemungkinannya untuk memperkenalkan agen infeksi baru. Namun, penggunaan
xenografts babi dikaitkan dengan hambatan imunologi besar, sehingga penolakan hiperakut
(HAR) ketika dicangkokkan ke dalam primata bukan manusia atau penerima manusia.

Imunologi Hambatan xenotransplantation

Hiperakut penolakan

Transplanting solid organs from animal sources into humans results in rapid loss of the xenograft
because of hyperacute rejection. Transplantasi organ padat dari sumber hewan menjadi hasil
manusia dalam kerugian yang cepat dari xenograft karena penolakan hiperakut. In this dramatic
immunologic reaction, preformed antibodies circulating in human blood bind to the vascular
epithelium of the animal organ and trigger a cascade that quickly results in thrombosis of the
graft. Dalam reaksi imunologi dramatis, antibodi preformed beredar di mengikat darah manusia
ke epitel pembuluh darah organ hewan dan memicu kaskade yang cepat menghasilkan trombosis
dari korupsi tersebut.

Humans have preformed antibodies known as xenoreactive natural antibodies (XNAs), which are
directed against nonprimate species. Manusia memiliki preformed antibodi yang dikenal sebagai
antibodi alami xenoreactive (XNAs), yang ditujukan kepada spesies nonprimate. XNAs appear
in the early neonatal period following colonization of the large bowel by coliform bacteria.
XNAs muncul dalam periode neonatal awal setelah kolonisasi usus besar oleh bakteri coliform.
These antibodies primarily consist of immunoglobulin M but also probably include the
immunoglobulin G and immunoglobulin A classes. Antibodi ini terutama terdiri dari M
imunoglobulin tapi mungkin juga termasuk immunoglobulin G dan immunoglobulin A kelas.
Their binding is characterized by avidity and surprising uniformity. mengikat mereka ditandai
dengan keinginan besar dan keseragaman mengejutkan.
Most XNAs recognize carbohydrate moieties associated with bacterial cell walls. Kebanyakan
XNAs mengakui gugus karbohidrat yang terkait dengan dinding sel bakteri. Most human XNAs
are directed against terminal carbohydrate, Gal1, and 3a-GalbGlcNAC-R, in which a galactosyl
residue is linked to another galactosyl residue. Kebanyakan manusia XNAs diarahkan terhadap
karbohidrat terminal,, Gal1 dan 3a-GalbGlcNAC-R, di mana residu galactosyl terkait dengan
residu lain galactosyl. This process is controlled by an enzyme galactosyl transferase. Proses ini
dikontrol oleh enzim transferase galactosyl. Humans lack this enzyme, and the carbohydrate
epitope is therefore perceived as a foreign antigen and antibodies arise against it. Manusia
kekurangan enzim ini, dan epitop karbohidrat karena itu dianggap sebagai antigen asing dan
antibodi timbul menentangnya. This carbohydrate moiety is expressed on pig cells. Ini bagian
karbohidrat diungkapkan pada sel babi. Thus, humans have naturally occurring antibodies (ie,
XNAs) against pig cells. Dengan demikian, manusia memiliki antibodi alami (yaitu, XNAs)
terhadap sel babi.

XNAs recognize porcine glycoproteins of the integrin family. XNAs mengakui glikoprotein babi
dari keluarga integrin. Antibody binding initiates complement activation through the classic
pathway, triggering a number of effector mechanisms. Antibodi mengikat inisiat aktivasi
komplemen melalui jalur klasik, memicu sejumlah mekanisme efektor. These mechanisms may
include loss of heparan sulfate from endothelial cells (EC) mediated by C5a and xenoreactive
antibody, a change in endothelial cell shape mediated by C5b-7 or the membrane attack complex,
procoagulant changes mediated by the membrane-attack complex, and neutrophil adhesion
mediated by iC3b. 14 Mekanisme ini mungkin termasuk hilangnya sulfat heparan dari sel endotel
(EC) dimediasi oleh C5a dan antibodi xenoreactive, perubahan bentuk sel endotel dimediasi oleh
C5b-7 atau serangan kompleks membran, yang dimediasi oleh membran-serangan kompleks, dan
neutrofil procoagulant perubahan iC3b adhesi dimediasi oleh. 14

The immunologic cascades triggered during hyperacute rejection destroy very discordant
xenografts within minutes to hours. kaskade kekebalan itu memicu penolakan selama hiperakut
menghancurkan xenografts sangat sumbang dalam beberapa menit ke jam. This process is
characterized by immediate engorgement and discoloration of the organ. Proses ini ditandai
dengan pembengkakan segera dan perubahan warna organ. Under light microscopy, interstitial
hemorrhages and platelet microthrombi are evident. Di bawah mikroskop cahaya, perdarahan
interstitial dan microthrombi platelet yang jelas. Immunohistologically, dense deposition of
various immunoglobulins and multiple complement components is noted throughout the vascular
bed. Immunohistologically, pengendapan padat dari berbagai imunoglobulin dan beberapa
komponen pelengkap tercatat seluruh tempat tidur pembuluh darah. The anaphylatoxins C3a and
C5a generated in the process stimulate basophils and mast cells to release histamine, which, in
turn, results in platelet degranulation. Para anaphylatoxins C3A dan C5a dihasilkan dalam proses
merangsang basofil dan sel mast untuk melepaskan histamin, yang, pada gilirannya, hasil di
degranulation platelet.

Binding of histamine and serotonin to receptors on endothelial cells stimulate the expression of
platelet-activating factor and P-selectin. Pengikatan histamin dan serotonin pada reseptor pada
sel endotel merangsang ekspresi platelet-activating factor dan P-selectin. Platelet-activating
factor dramatically increases vascular permeability and endothelial cell contraction, resulting in
platelet and RBC sludging within the microcirculation. Platelet-activating factor secara dramatis
meningkatkan permeabilitas pembuluh darah dan kontraksi sel endotel, sehingga platelet dan
RBC sludging dalam mikrosirkulasi. This complex interplay of complement components,
platelets, and endothelial cells leads to platelet aggregation, coagulation, fibrin deposition, and
hemorrhage, typically culminating in thrombosis and ischemic necrosis within minutes of
engraftment. Ini saling melengkapi kompleks komponen, trombosit, dan sel endotel
menyebabkan platelet agregasi, koagulasi, deposisi fibrin, dan perdarahan, biasanya berpuncak
pada trombosis dan nekrosis iskemik dalam beberapa menit dari engraftment.

Acute vascular rejection Vascular akut penolakan

If the transplanted organ is not rejected within minutes to hours, a more delayed type of
immunologic response ultimately leads to thrombosis of the graft within hours to days. Jika
transplantasi organ tidak ditolak dalam beberapa menit ke jam, tipe yang lebih keterlambatan
tanggapan kekebalan pada akhirnya menyebabkan trombosis dari korupsi dalam beberapa jam ke
hari. This process known as delayed xenograft rejection or acute vascular rejection. Proses ini
dikenal sebagai penolakan xenograft tertunda atau penolakan vascular akut.
Under light microscopy, focal infarcts, interstitial hemorrhages, and widespread coagulation of
microvasculature are observed. Di bawah mikroskop cahaya, infark fokal, pendarahan
interstisial, dan koagulasi luas microvasculature diamati. DXR is characterized by progressive
infiltration of monocytes and natural killer cells (over several days), endothelial cell activation,
platelet and fibrin deposition, and cytokine expression. DXR ditandai dengan infiltrasi progresif
monosit dan sel-sel pembunuh alami (selama beberapa hari), aktivasi sel endotel, trombosit dan
deposisi fibrin, dan ekspresi sitokin. Only very small numbers of T cells are noted (~5%). Hanya
jumlah yang sangat kecil sel T tercatat (~ 5%). The role of macrophages and natural killer cells
in DXR has yet to be determined; however, neither XNAs nor T cells are essential for DXR in
complement-depleted rats. Peran makrofag dan sel-sel pembunuh alami dalam DXR belum
ditentukan, namun tidak XNAs atau sel T sangat penting untuk DXR dalam melengkapi-tikus
habis.

Although endothelial cell activation is believed to play a key role, factors that trigger it are not
well defined. Meskipun aktivasi sel endotel diyakini memainkan peran penting, faktor yang
memicu hal itu tidak didefinisikan dengan baik. Endothelial activation is type II in nature
because it involves gene induction and protein synthesis. aktivasi endotel adalah tipe II di alam
karena melibatkan induksi gen dan sintesis protein. This includes a shift to a procoagulant state,
secretion of chemokines such as membrane cofactor protein-1, and induction of leukocyte
adhesion molecules such as E-selectin, intercellular adhesion molecule-1, and vascular cell
adhesion molecule-1. Ini termasuk pergeseran ke keadaan procoagulant, sekresi kemokin seperti
protein kofaktor membran-1, dan induksi molekul adhesi leukosit seperti E-selectin, antar sel

Xenograft Mengatasi Penolakan

To devise therapeutically effective strategies to defeat HAR and DXR, a detailed understanding
and identification of complex inflammatory pathways and key events are indispensable. Untuk
merancang strategi terapi yang efektif untuk mengalahkan HAR dan DXR, pemahaman yang
rinci dan identifikasi jalur inflamasi yang kompleks dan peristiwa penting yang sangat
diperlukan. This involves in-depth study of both donor and recipient factors that play critical
roles in mounting and sustaining a rejection response. Ini melibatkan studi mendalam dari kedua
faktor donor dan penerima yang memainkan peran penting dalam pemasangan dan
mempertahankan respon penolakan. This section focuses on approaches proposed to circumvent
xenograft rejection. Bagian ini berfokus pada pendekatan yang diusulkan untuk menghindari
penolakan xenograft.

Donor-based strategies: Transgenic organs Donor berbasis strategi: organ transgenik

Genetically engineered pigs have been designed to downregulate expression of various

immunogenic substances. babi rekayasa genetik telah dirancang untuk downregulate ekspresi
berbagai zat imunogenik. Several groups have been successful at developing a breed of knockout
pigs that lack the 1,3 galactosyltransferase gene. Beberapa kelompok telah berhasil
mengembangkan keturunan babi KO yang kurang gen galactosyltransferase 1,3. This gene
ordinarily codes for an enzyme that is responsible for the expression of the immunogenic
Galalpha1,3Gal carbohydrate moiety on the vascular endothelium of pig organs. Gen ini
biasanya kode untuk enzim yang bertanggung jawab atas ekspresi Galalpha1 imunogenik, 3Gal
bagian karbohidrat pada endotelium vaskular organ babi. In 2005, pig hearts from alpha 1,3
15
galactosyltransferase knockout (GT-KO) pigs were transplanted into baboons. These grafts
survived 6 months. 16 Pada tahun 2005, babi hati dari alfa 1,3 KO galactosyltransferase (GT-KO)
babi ditransplantasikan ke babon. 15 ini cangkokan bertahan 6 bulan. 16

Others have bred pigs with increased expression of H-transferase (also known as 1,2
fucosyltransferase). Lain telah dibesarkan babi dengan ekspresi peningkatan H-transferase (juga
dikenal sebagai 1,2 fucosyltransferase). H-transferase is an enzyme that competes with alpha 1,3
galactosyltransferase, the substrate that is a precursor to the Galalpha1,3Gal moiety. H-
transferase adalah enzim yang bersaing dengan alpha 1,3 galactosyltransferase, substrat yang
merupakan awal dari bagian, Galalpha1 3Gal. The rationale is to decrease the amount of
17
Galalpha1,3Gal carbohydrate on pig vascular endothelium. Swine islet cells that express N-
acetylglucosaminyltransferase III (GnT-III) have been developed and have been recently
transplanted into monkeys. Alasannya adalah untuk mengurangi jumlah Galalpha1, 3Gal
17
karbohidrat pada endotelium vaskular babi. sel islet babi yang mengekspresikan N-
acetylglucosaminyltransferase III (GnT-III) telah dikembangkan dan telah baru-baru ini
dicangkokkan ke monyet.
Unlike other glycosyltransferases, GnT-III interrupts the biosynthesis of the Galalpha1,3Gal
xenoantigens by several mechanisms not fully understood, including interruption of carbohydrate
18
branching. Tidak seperti glycosyltransferases lain, GnT-III mengganggu biosintesis dari
Galalpha1, 3Gal xenoantigens melalui beberapa mekanisme tidak sepenuhnya dipahami,
termasuk gangguan karbohidrat percabangan. 18

Another variation of transgenic pigs has been developed to interfere with the mechanisms of
graft rejection. Variasi lain dari babi transgenik telah dikembangkan untuk mengganggu
mekanisme penolakan korupsi. For example, expression of human ecto-5'-nucleotidase (E5'N)
19
pig organs has protected grafts from natural killer cell–mediated lysis. Transgenic pigs have
also been bred to express glycoproteins that inhibit the human complement cascade. Sebagai
contoh, ekspresi manusia ecto--nucleotidase 5'(E5'N) organ babi telah melindungi cangkok dari
19
sel pembunuh alami yang dimediasi lisis. babi transgenik juga telah dibesarkan untuk
mengungkapkan glikoprotein yang menghambat manusia melengkapi kaskade. These include
CD55 (human decay accelerating factor [hDAF]), CD46 (membrane cofactor 1), and CD59
(protectin, which blocks the membrane attack complex from binding to cells). Ini termasuk
CD55 (pembusukan manusia mempercepat faktor [hDAF]), CD46 (kofaktor membran 1), dan
CD59 (protectin, yang menghambat kompleks serangan membran dari mengikat ke sel-sel).

Advances in genetic engineering have made double transgenic pig organs available. Kemajuan
dalam rekayasa genetik telah membuat organ babi transgenik ganda yang tersedia.
Xenotransplantation of double transgenic porcine skin to cynomolgus monkey survived 31 days.
Xenotransplantation kulit babi transgenik ganda monyet cynomolgus bertahan 31 hari. The skin
20
expressed both GnT-III and hDAF. Double transgenic pig kidneys with both human alpha-
galactosidase and alpha 1,2-fucosyltransferase have been shown to decrease Gal expression and
21
resist human serum–mediated lysis in ex vivo experiments. Others have engineered double
22
transgenic pig hearts expressing both hDAF and CD59. Kulit disajikan baik GnT-III dan
20
hDAF. Double ginjal babi transgenik dengan kedua galaktosidase-alpha manusia dan alpha
1,2-fucosyltransferase telah terbukti menurunkan ekspresi Gal dan menolak serum lisis-
21
dimediasi manusia dalam percobaan ex vivo. Yang lain rekayasa hati babi transgenik ganda
menyatakan baik hDAF dan CD59. 22
Triple transgenic pigs have recently become available. Triple babi transgenik baru-baru ini telah
tersedia. Hyperacute rejection was prevented in baboon recipients of orthotopically transplanted
23
swine livers that expressed hDAF, human CD59, and H-transferase. Japanese scientists
recently reported success with breeding alpha 1,3 galactosyltransferase knockout pigs that
express hDAF and Gnt-III. 24 Another variation of triple transgenic pigs has been bred to express
human CD59, human membrane cofactor protein, and hDAF. 25 Hiperakut penolakan itu dicegah
dalam babon penerima transplantasi hati babi orthotopically yang disajikan hDAF, CD59
23
manusia, dan H-transferase. ilmuwan Jepang baru-baru ini melaporkan keberhasilan dengan
alpha 1,3 penangkaran babi KO galactosyltransferase yang mengekspresikan hDAF dan Gnt-III.
24
Variasi lain babi transgenik triple telah dibesarkan untuk mengekspresikan CD59 manusia,
kofaktor protein membran manusia, dan hDAF. 25

Eksperimental xenotransplantation

. Beberapa eksperimen desain telah dikembangkan untuk xenotransplantation organ-organ ini

dimodifikasi secara genetikDalam model ex vivo, organ babi hasil transformasi genetik yang
diresapi dengan darah manusia atau serum untuk melihat apakah penolakan hiperakut terjadi.
organ babi Atau, dalam model mempertahankan hidup, rekayasa genetika telah dipindahkan ke
babon atau monyet menjalani terapi imunosupresif. Xenotransplantation dapat dilakukan
orthotopically sedemikian rupa sehingga organ asli akan dipindahkan dan organ transplantasi
menempati lokasi anatomi yang diinginkan.

Xenotransplantation organ dari babi transgenik untuk CD55 (hDAF) telah dipelajari secara
ekstensif selama lima tahun terakhir dengan hasil yang beragamPara peneliti baru-baru ini
menunjukkan bahwa semakin tinggi tingkat ekspresi CD55 dalam kelangsungan hidup babi
26
transgenik peningkatan cangkokan dalam babon yang telah mengalami xenotransplantation.
CD55 hati babi transgenik telah berhasil dicangkokkan orthotopically ke babon, dengan
27
kelangsungan hidup median 14,6 hari. Organ transgenik untuk CD55 juga tampaknya tahan
28
terhadap lisis seluler oleh serum manusia. Dalam model lain ex vivo melibatkan
xenotransplantation paru-paru babi transgenik ke babun, bagaimanapun, penolakan hiperakut
telah dilaporkan pada perfusi dari korupsi tersebut. 29
Many groups have prolonged survival of CD55 (hDAF) transgenic pig organs with infusion of
various agents or soluble antibodies. Banyak kelompok yang telah lama kelangsungan hidup
CD55 (hDAF) organ babi transgenik dengan infus berbagai agen atau antibodi larut. For
example, reduced myocardial damage has been reported in ex vivo experiments in which CD55
transgenic grafts were perfused with GPIIb/IIIa inhibitor tirofiban. 30 In other experiments, CD55
transgenic pig hearts have been transplanted into baboons that were also administered soluble
Gal-glycoconjugates to block baboon antibodies from binding to the Gal moiety on renal
endothelium. Sebagai contoh, mengurangi kerusakan miokard telah dilaporkan dalam percobaan
30
ex vivo di mana CD55 cangkok transgenik diperfusi dengan GPIIb / tirofiban IIIa inhibitor.
Dalam percobaan lain, CD55 hati babi transgenik telah dipindahkan ke babon yang juga
diberikan larut Gal-glycoconjugates untuk blok antibodi babon dari mengikat ke bagian Gal pada
31
endothelium ginjal. These grafts survived for 3 months. Anti–nonGal antibodies have been
32
suggested to be involved in the ultimate acute humeral xenograft rejection of the kidneys.
Other groups have attempted life-supporting xenotransplantation of transgenic CD55 pig kidneys
in baboons with infusion of soluble complement receptor type 1, TP 10. Cangkokan ini bertahan
selama 3 bulan. 31 -nonGal antibodi Anti telah diusulkan untuk terlibat dalam humerus xenograft
32
penolakan akut akhir dari ginjal. kelompok lain telah berusaha xenotransplantation pendukung
kehidupan babon CD55 ginjal babi transgenik dengan infus larut melengkapi reseptor tipe 1, TP
10. These grafts ultimately failed because of chronic deposition of complement in the
33
endothelium. Cangkok ini akhirnya gagal karena endapan kronis komplemen dalam
endothelium. 33

Recipient-based strategies Penerima berbasis strategi

Acute vascular rejection is thought to be triggered by antibodies to the xenograft and complete
activation of the complement cascade. Penolakan akut vaskular adalah pemikiran yang akan
dipicu oleh antibodi terhadap xenograft dan aktivasi komplemen lengkap kaskade.

In theory, the complement cascade can be interrupted therapeutically by using several inhibitory
agents. Secara teori, kaskade melengkapi dapat terganggu terapi dengan menggunakan agen
beberapa penghambatan. Such complement inhibitory molecules include cobra venom factor (to
deplete C3), soluble complement receptor type 1, anti-C5 antibodies, K76COOH, and FUT-125.
34 , 35
Toxicity associated with cobra venom factor is a major obstacle to its clinical use. Seperti
molekul hambat melengkapi termasuk kobra faktor racun (untuk C3 menguras), larut melengkapi
34 , 35
reseptor tipe 1,-C5 antibodi anti, K76COOH, dan Fut-125. Toksisitas terkait dengan faktor
racun kobra merupakan hambatan utama untuk menggunakan klinis. Moreover, recent studies
show the administration of cobra venom alone does not appear to prevent the deposition of C3
36
complement in grafts. The soluble complement receptor type 1 (TP10) does not appear to be
clearly effective in interrupting the complement cascade. Selain itu, studi terbaru menunjukkan
administrasi racun kobra saja tidak muncul untuk mencegah pengendapan komplemen C3 dalam
36
tandur. yang larut melengkapi reseptor tipe 1 (TP10) tidak tampak secara jelas efektif dalam
mengganggu komplemen kaskade. Deposition of complement was found in grafts of monkeys
that were transplanted with life-supporting hDAF transgenic pig kidneys and given cyclosporine,
33
mycophenolate, steroids, soluble glycoconjugates to Galalpha1,3Gal, and TP10. Deposisi
komplemen ditemukan di cangkok dari monyet yang dicangkok dengan pendukung kehidupan
transgenik ginjal babi hDAF dan diberikan siklosforin, mofetil, steroid, glycoconjugates larut
untuk Galalpha1, 3Gal, dan TP10. 33

Several immune-modulating therapies have been developed to prolong xenograft survival.

Beberapa terapi modulasi kekebalan telah dikembangkan untuk memperpanjang kelangsungan
hidup xenograft. Combinations of immunosuppressive agents, including cyclosporine A,
mycophenolate sodium, and steroids, have prolonged survival of hDAF porcine renal xenografts
37 , 38
in primates. Recently, soluble decay-accelerating factor has been used to prevent humeral
39
rejection. Kombinasi agen imunosupresif, termasuk siklosporin A, natrium mofetil, dan
37 , 38
steroid, telah lama kelangsungan hidup hDAF xenografts ginjal babi pada primata. Baru-
baru ini, faktor peluruhan-mempercepat larut telah digunakan untuk mencegah penolakan
humerus. 39

Others have experimented with various mechanisms to downregulate co-stimulation and alter the
immune response to interleukins. Lain telah bereksperimen dengan berbagai mekanisme untuk
downregulate co-stimulasi dan mengubah respon imun interleukin. Swine hearts have been
successfully xenografted into baboons treated with anti-CD154 antibodies and CD28/7 blockade.
40 , 41
Murine studies have suggested that acute vascular rejection can be attenuated by CD8alpha+
dendritic cells that secrete IL-12 and induce a Th1 slow cell-mediated response to the xenograft.
42
Finally, interrupting the initiation of acute humeral rejection by blocking IL-1 with receptor
antagonists appears promising in models of guinea pig hearts transplanted into rats treated with
43
cobra venom. Babi hati telah berhasil xenografted ke babon diobati dengan-CD154 antibodi
40 , 41
anti dan CD28 / 7 blokade. murine penelitian menunjukkan bahwa penolakan pembuluh
akut dapat dilemahkan oleh + dendritik sel CD8alpha bahwa IL mengeluarkan-12 dan
42
menginduksi sel lambat Th1- dimediasi menanggapi xenograft tersebut. Akhirnya,
mengganggu inisiasi penolakan humerus akut dengan menghalangi IL-1 dengan antagonis
reseptor muncul menjanjikan dalam model hati marmot ditransplantasikan ke tikus diperlakukan
dengan racun kobra. 43

Achieving accommodation Mencapai akomodasi

Accommodation is defined as graft survival despite the circulation of xenoreactive antibodies.

Akomodasi didefinisikan sebagai hidup korupsi meskipun sirkulasi antibodi xenoreactive. This
phenomenon was first identified in the late 1980s, when blood group O recipients were able to
tolerate transplantation of group A or B kidneys. 44 Fenomena ini pertama kali diidentifikasi pada
akhir tahun 1980an, ketika golongan darah O penerima mampu mentolerir transplantasi ginjal
kelompok atau B A. 44

In accommodation, the graft is given a break from attack when circulating antibodies are
removed from the system or when the complement cascade is interrupted. Dalam akomodasi,
graft diberikan istirahat dari serangan ketika antibodi yang beredar akan dihapus dari sistem atau
ketika cascade melengkapi terganggu. During this break from acute vascular rejection, the graft
is able to up-regulate and express protective genes, like heme oxygenase 1, which impart graft
resistance to injury. Selama ini istirahat dari penolakan vascular akut, graft ini mampu up-
mengatur dan mengekspresikan gen pelindung, seperti oxygenase, hem 1 yang memberikan
perlawanan gratifikasi untuk cedera. Although still unclear, other changes also appear to occur in
the function of circulating antibodies and the expression of surface antigens on the graft.
Meskipun masih belum jelas, perubahan lain juga tampak terjadi pada fungsi antibodi beredar
dan ekspresi antigen permukaan pada korupsi tersebut.
Studies have also shown that accommodation might be achieved by interrupting the complement
cascade with the administration of heparin sulfate. Studi juga menunjukkan bahwa akomodasi
mungkin dicapai dengan mengganggu komplemen bertumpuk dengan pemberian heparin sulfat.
This is because full activation of the complement cascade characteristically lacks the presence of
syndecan-4 phosphate. Hal ini karena aktivasi komplemen penuh kaskade bersifat tidak memiliki
kehadiran syndecan-4 fosfat. One group showed, however, that warfarin or low molecular weight
45
heparin failed to induce accommodation in pig hearts xenografted into primates. . Satu
kelompok menunjukkan, bagaimanapun, bahwa warfarin atau heparin berat molekul rendah
45
gagal untuk mendorong akomodasi di hati babi xenografted ke primata. .

Coagulation dysregulation as a barrier to xenotransplantation Koagulasi disregulasi

sebagai penghalang untuk xenotransplantation

The ability to generate pigs that express a human complement regulatory protein (hCRP) and/or
alpha 1,3 GT-KO pigs has largely overcome the barrier of HAR of a pig organ transplanted into
a primate. Kemampuan untuk menghasilkan babi yang mengekspresikan protein peraturan
manusia melengkapi (HCRP) dan / atau alpha 1,3 GT-KO babi sebagian besar mengatasi
penghalang dari HAR dari transplantasi organ babi ke sebuah primata. However, acute humoral
xenograft rejection (AHXR) presenting as microvascular thrombosis, consumptive coagulopathy,
or both remains a major hurdle to successful xenotransplantation. Namun, penolakan xenograft
akut humoral (AHXR) menyajikan sebagai trombosis mikrovaskuler, koagulopati konsumtif,
atau keduanya tetap merupakan rintangan utama untuk xenotransplantation sukses.

Until now, thrombosis was believed to result from antibody-mediated and complement-mediated
EC activation, initiating AHXR. Sampai sekarang, trombosis diyakini hasil dari aktivasi EC
antibodi-mediated dan melengkapi-mediated, memulai AHXR. Exposure of porcine ECs to
xenoantibodies, complement, and cells of the innate immune system results in EC activation and
loss of anticoagulant regulators on their surface, with a subsequent change to a procoagulant
phenotype. Paparan ECs babi untuk xenoantibodies, melengkapi, dan sel-sel hasil bawaan sistem
kekebalan tubuh dalam aktivasi EC dan hilangnya regulator antikoagulan pada permukaannya,
dengan perubahan berikutnya ke fenotipe procoagulant. In xenotransplantation, distinct,
immune-independent factors contribute to the development of coagulation disorders (eg,
molecular incompatibilities between pigs and primates that promote or fail to regulate
pathological clotting). Dalam xenotransplantation, berbeda, faktor kekebalan-independen
berkontribusi terhadap perkembangan gangguan koagulasi (misalnya, tidak kompatibel molekul
antara babi dan primata yang mempromosikan atau gagal untuk mengatur pembekuan patologis).
For example, porcine von Willebrand factor 46 and loss of porcine tissue factor inhibitor (TFPI) 47
46
initiate coagulation cascade in primates. Sebagai contoh, babi faktor von Willebrand dan
hilangnya faktor penghambat jaringan babi (TFPI) 47 memulai kaskade koagulasi pada primata.

GT-KO pigs that express an hCRP gene (eg, CD46 or hDAF ) have exhibited some protection
against the humoral-mediated immune response but do not overcome the problems of
coagulation. GT-KO babi yang mengekspresikan gen HCRP (misalnya, CD46 atau hDAF) telah
menunjukkan beberapa perlindungan terhadap dimediasi kekebalan respons humoral tetapi tidak
mengatasi masalah koagulasi.

The interactions between porcine ECs, platelets, and other blood cells are at the nexus of a
complex network that contributes to coagulation during AHXR. Interaksi antara ECs babi,
trombosit, dan sel-sel darah lainnya berada di perhubungan dari jaringan kompleks yang
memberikan kontribusi untuk koagulasi selama AHXR. According to the standard paradigm, the
process is initiated by the immune response against the graft, such that activation of porcine ECs
caused by antibodies with/without complement leads to expression of TF that triggers the
48 , 49
coagulation cascade. Loss of anticoagulant regulators, such as TFPI, ectonucleotide
triphosphate diphosphohydrolase-1 (CD39), and ecto-5′-nucleotidases (CD73) activity is
associated with platelet activation and aggregation. Menurut paradigma standar, proses ini
diawali dengan respon kekebalan terhadap korupsi, sehingga aktivasi ECs babi yang disebabkan
oleh antibodi dengan / tanpa pelengkap menyebabkan ekspresi TF yang memicu kaskade
48 , 49
koagulasi. Kehilangan regulator antikoagulan, seperti TFPI, ectonucleotide (CD39)
diphosphohydrolase trifosfat-1, dan ecto-5'-nucleotidases (CD73) aktivitas berhubungan dengan
aktivasi platelet dan agregasi. Administration of CD39 substitutes inhibits platelet activation and
50
aggregation, thereby significantly prolonging graft survival. Hearts from CD39-transgenic
51
mice were resistant to thrombosis in a mouse-to-rat xenotransplantation model. Administrasi
pengganti CD39 menghambat aktivasi dan agregasi platelet, sehingga secara signifikan
 50
memperpanjang hidup korupsi. Hearts dari-transgenik tikus CD39 resisten terhadap trombosis
dalam ke-tikus-tikus xenotransplantation model. 51

Future directions in coagulation dysregulation Arah Masa Depan disregulasi koagulasi

The resolution of coagulation dysregulation is critical to allow xenotransplantation to advance

sufficiently for clinical trials. Resolusi disregulasi koagulasi sangat penting untuk
memungkinkan xenotransplantation untuk maju cukup untuk uji klinis. Thrombosis manifests in
the graft, but systemic consumption coagulopathy may have more than one cause. Trombosis
mewujud dalam korupsi, tetapi koagulopati konsumsi sistemik mungkin memiliki lebih dari satu
penyebab. Therefore, in addition to genetic modification of the organ-source pig, systemic
medication may be necessary. Oleh karena itu, selain modifikasi genetik organ babi-sumber, obat
sistemik mungkin diperlukan.

GT-KO pigs that express an hCRP and one or more anticoagulant or antithrombotic genes are
anticipated to inhibit the generation of thrombosis and subsequent platelet activation. GT-KO
babi yang mengekspresikan HCRP dan satu atau lebih antikoagulan atau gen antitrombotik
diantisipasi menghambat generasi trombosis dan aktivasi platelet berikutnya. With Dengan
new cloning techniques (F2A system), mice transgenic for CD55/hTFPI/hCD39 have been
generated. teknik kloning baru (F2a sistem), tikus transgenik untuk CD55/hTFPI/hCD39 telah
dihasilkan. The same technology is expected to be successfully applied to generate pigs with
multiple gene modifications and will enable these pigs to become available in a shorter period of
50
time than through conventional breeding. Teknologi yang sama diharapkan dapat berhasil
diterapkan untuk menghasilkan babi dengan modifikasi beberapa gen dan akan memungkinkan
babi tersebut akan tersedia dalam waktu yang lebih singkat daripada melalui pemuliaan
konvensional. 50

Systemic medication Obat sistemik

Statins, inhibitors of HMG-CoA (3-hydroxy-3-methylglutaryl-CoA) reductase, used for

hypercholesterolemia, also have other independent effects, such as immunoregulatory, anti-
52 , 53
inflammatory, and anticoagulant actions. Statin, inhibitor dari HMG-CoA (3-hydroxy-3-
methylglutaryl-CoA) reduktase, digunakan untuk hiperkolesterolemia, juga memiliki efek
 52 , 53
independen lain, seperti, anti-inflamasi, dan antikoagulan tindakan immunoregulatory.

Atorvastatin reduces porcine EC activation induced by interferon gamma and inhibits the
proliferative response of primate peripheral blood mononuclear cells (PBMC) and CD4+T cells
when stimulated with porcine ECs. Atorvastatin mengurangi aktivasi babi EC disebabkan oleh
gamma interferon dan menghambat respon proliferatif dari primata sel mononuklear darah
perifer (PBMC) dan sel CD4 + T jika dirangsang dengan ECs babi. Simvastatin was shown to
prevent the induction of TF on human aortic ECs by thrombin, at least in part through inhibition
54
of rho-kinase-dependent Akt dephosphorylation. Lovastatin enhanced ecto-5′-nucleotidase
activity and membrane expression in ECs, consequently inhibiting platelet aggregation through
55
the action of adenosine. Simvastatin ditunjukkan untuk mencegah induksi TF pada ECs aorta
manusia dengan trombin, setidaknya sebagian melalui penghambatan kinase-bergantung Akt
54
dephosphorylation-rho. Lovastatin kegiatan ecto-5'-nucleotidase ditingkatkan dan ekspresi
membran di ECs, akibatnya menghambat platelet agregasi melalui aksi adenosin. 55

Antiplatelet agents Agen antiplatelet

Antiplatelet agents, such as antagonists of P2Y12 or GPIIbIIIa receptors, are expected to prevent
aggregation when platelets are activated during AHXR. agen antiplatelet, seperti antagonis
reseptor P2Y12 atau GPIIbIIIa, diharapkan untuk mencegah agregasi trombosit saat diaktifkan
selama AHXR. A high dosage of a GPIIbIIIa antagonist prolonged graft survival and decreased
56
platelet aggregations in a rodent model. If thrombosis in the graft is prevented by
antithrombotic gene modification, this systemic approach may offer survival benefits by the
prevention of systemic consumption coagulopathy.

Biologic Barriers to Xenotransplantation

The use of xenotransplantation products carries a natural and expected risk of transmitting
infectious pathogens. This risk is beyond the risk of infections known to be associated with
allotransplantation, which is a consequence of immunosuppression. This serious risk originates
from the potential of xenotransplantation for transmitting infectious agents from nonhuman
animals to humans. The HIV pandemic, Creutzfeldt-Jakob disease, Ebola virus outbreaks, and,
more recently, the severe acute respiratory syndrome scare have elicited serious concern about
the potential of inadvertent transmission of known and unknown infectious agents that may
spread to recipients and to their contacts and health care workers, quickly becoming a public
health issue.

Thus, for the following reasons, infectious risks associated with xenotransplantation may be far
greater than those noted with allotransplantation: 57

 The level of immune suppression and/or rejection may be greater in xenograft recipients,
enhancing the activation of latent pathogens, including viruses.
 Organisms carried by the graft may not be known human pathogens and/or may include
xenotropic organisms, ie, organisms that are not pathogens in the native host species but
which cause disease in other species, in this case, the human recipient.
 Microbiologic assays may not exist for some organisms derived from nonhuman species.
 Novel animal-derived organisms may cause novel and thus unrecognized clinical
syndromes.
 Genetic modification of the donor animals (one xenotransplantation strategy) or treatment
of the recipient with, for example, tolerance induction or antibody removal, may alter the
host's susceptibility to organisms.

Xenosis

The term xenosis has been coined to describe the transmission of infections by the
transplantation of xenogeneic tissues or organs. Xenosis, or xenozoonosis, potentially poses
unique epidemiological hazards owing to the efficiency of transmission of pathogens,
particularly viruses, with viable cellular grafts. When an infectious agent gains entry into a new
host species, its capacity to produce disease is unpredictable.

For example, in its natural host, the macaque monkey, cercopithecrine herpesvirus 1 (B virus)
infection has a clinical profile very similar to that of herpes simplex virus infection in humans.
However, B virus infection of humans or other non–macaque primates results in rapidly
58
progressive myeloencephalitis with a mortality rate of approximately 70%. This failure of the
pathogenic potential of a microbe in its host species to reliably predict the pathology that results
when it is introduced into another species is evident with many other zoonotic agents and
diseases.

Organisms of serious concern include herpesviruses and retroviruses, which can be screened for
and eliminated from the donor pool. Others include Toxoplasma gondii, Mycobacterium
tuberculosis, and encephalomyocarditis virus. Filoviruses (Marburg and Ebola), monkeypox
virus, and simian hemorrhagic virus are less likely to be found in animals reared in captivity in
the United States.

Retroviruses

Retroviruses, by virtue of the enzyme reverse transcriptase, become inserted into host
chromosomal DNA. Compelling arguments suggest that the HIV pandemic resulted from the
adaptation of simian retroviruses introduced across species lines into humans. Existing data
suggest that the HIV-2 pandemic in East Africa began with the horizontal transmission of simian
immunodeficiency virus from a sooty mangabey monkey into a human with subsequent
transmission through the human population. In Central Africa, horizontal cross-species
transmission of simian immunodeficiency virus from a different primate species, probably a
chimpanzee, resulted in the HIV-1 pandemic. Initial human infections before 1970 resulted in
more than a decade of insidious human-to-human transmission before AIDS was first recognized
as a public health problem in the 1980s.

Endogenous retroviruses exist as part of the genomic material of most, if not all, mammalian
species, including humans. Endogenous retroviruses cause equal concern and greater uncertainty
than the exogenous retroviruses. Endogenous retroviruses, presumably originating as exogenous
viruses that became permanently integrated into the host germ line, are vertically transmitted
through inheritance. In the host species, they are benign. However, endogenous viruses are
frequently xenotropic, ie, although the original host is refractory to infection, the viruses can
infect related species.

The increased phylogenetic distance between swine and humans presumably makes pigs safer
donors than nonhuman primates. This presumption has not been completely explored. The
biology and pathogenicity of a type C retrovirus identified in the blood of leukemic or irradiated
swine are incompletely characterized. Similarly, the discovery of porcine endogenous
retroviruses (PERVs) capable of infecting human cells in vitro has raised issues regarding the
safe clinical application of xenotransplantation. 59 , 60 , 61

Phylogenetic analysis reveals that PERVs are closely related to gibbon ape leukemia virus,
62 , 63
endogenous koala retrovirus, and inducible murine endogenous retrovirus. PERV RNA is
expressed in several porcine tissue types (eg, kidney, lung, liver, heart, pancreatic islets);
however, expression of virus mRNA does not necessarily correlate with the release of infectious
particles. Many human cells clearly express receptors specific for PERV A and B, whereas
PERV C–specific receptors cannot be detected in most instances. 64

Several viral pathogens have been identified in the xenografts from pigs, which are the most
common animal source of xenografts. These include, but are not limited to, porcine endogenous
retrovirus (PERV), porcine cytomegalovirus (PCMV), and porcine lymphotrophic herpes virus
(PLHV), and porcine circovirus type 2, (PCV). In New Zealand, pigs raised for
65
xenotransplantation were found to harbor encephalomyocarditis (EMCV) and hepatitis E.
Importantly, pigs do not have the exogenous retroviral equivalent of the HTLV or HIV virus.
Two strains of the PERV virus (strain A and B) are present in only a subset of swine and have
the potential to infect human cells in vitro. Importantly, the PCMV strains can be selected out of
the pool of potential xenografts by early weaning of piglets.

Experimental xenotransplantation of organs from swine to nonhuman primates has demonstrated

the absence of PERV transmission. One study suggested that decreased risk of transmission of
endogenous retroviruses from pigs to baboons is correlated to decreased amounts of circulating
66
anti–alpha Gal antibody. Others have shown an absence of PERV infection in baboons
67
receiving transgenic livers.
Over the past 10 years, many sensitive diagnostic assays have been developed to detect most
potential viruses associated with xenotransplantation of organs into humans. For example, 1
long-term follow-up study on 18 human recipients of pig islet cell transplants showed no
evidence of PLHV, PCMV, PCV, or PERV infection in any of the patients 9 years after
xenotransplantation. 68 No in vivo infection of human cells by the PERV virus has been reported
to date. By contrast, the transplantation of baboon livers and chimpanzee kidneys into humans
 69 69
had resulted in deaths due to illnesses not related to organ failure.

Japanese researchers are attempting to engineer transgenic pigs that would be genetically
incapable of harboring endogenous retroviruses. Such a breed of pigs would express the RNA
interference silence genes. 70

Transmissible spongiform encephalopathy

Transmissible spongiform encephalopathy is a uniformly fatal family of diseases of humans and

animals that causes irreversible cumulative brain damage. These diseases, which include
Creutzfeldt-Jakob disease, chronic wasting disease, and bovine spongiform encephalopathy, are
believed to be caused by a novel class of agents termed prions. Various reports have documented
the prions jumping the species barrier from cattle, squirrels, and rabbits to humans.
Transmissible spongiform encephalopathies have exhibited transmission into new hosts through
71 , 72
transplanted grafts and across species lines. Of these diseases, cows can be naturally
infected with bovine spongiform encephalopathy and pigs can be experimentally infected with
transmissible spongiform encephalopathy. 73

Strategies to avoid xenosis

Given the complexity of xenotransplantation and the uncertainties of issues surrounding it,
strategies to address xenosis are being developed, although a universally adopted guideline on
xenosis remains to be issued. The US Public Health Service agencies (ie, FDA, Centers for
Disease Control and Prevention, National Institutes of Health, and Healthcare Resource Services
Administration) and the Office of the Associate Secretary for Planning and Evaluation of the
Department of Health and Human Services are collaborating to develop an integrated approach
to address infectious disease issues in xenotransplantation.

Bach and colleagues have suggested a 3-tiered approach to policy development and decisions to
57
address the issue of xenosis. This method suggests approaching the issue at societal,
institutional, and individual (patient-physician) levels. Because the risk is societal and not merely
individual, the decision whether to undertake the procedure involves more than ensuring the
ability of the surgeon and the transplant team, the capacity of the institution, and the willingness
of the patient.

In situations in which the risks are collective, the public must be educated about the risk and
must be involved in the decision-making process. Therefore, the first part of the decision-making
process must occur at the level of social policy; the second part must occur at the level of the
institutions performing the xenografts, and the third part must occur at the level of individual
patients and physicians, especially affecting the processes of informed consent and medical
confidentiality.

Because of the risk of xenosis, all the major reports on xenotransplantation released to date have
recommended comprehensive monitoring and surveillance of xenograft recipients. The legal and
ethical problems associated with imposing such surveillance on recipients (and perhaps their
sexual partners) for what would likely be many years or for life and the details about the nature
and frequency of monitoring require further discussion. That patients manifesting signs of a
possible xenosis after transplantation would have to be quarantined is not inconceivable.

The maintenance of patient confidentiality, as in all areas of medicine, remains paramount and
further complicates the need for adequate monitoring of recipients. The community must be
educated about any risk that could arise from xenotransplantation, regardless of whether the
extent of that risk and the degree to which that risk is controllable can be precisely defined.
Finally, it would be helpful for the public to have a better understanding of the process by which
decisions are made in situations of uncertainty. 57

At the level of the hospital or research center, institutions must be responsible for establishing
and enforcing standards for quality of care, management of risk, monitoring of patients and their
contacts, and evaluation of the effectiveness of the procedure in accordance with public
guidelines and regulations. Institutions should avoid situations in which individuals proceed with
xenotransplantation in advance of adequate safeguards and should curtail clinical trials until
societal guidelines are available. 57

A new approach to informed consent as it relates to xenotransplantation is necessary. A patient's

agreement to participate in xenotransplantation must be based on perceptions of individual risks,
as is the case with any experimental or extreme procedure, and on the risk of new disease to
family, friends, close contacts, and society at large. Because of the need for monitoring for signs
of infection, the patient and others must commit to participate in such monitoring for a period
considered to be longer than the potential time necessary for an infection to manifest. Thus, the
xenotransplant recipient undertakes a social obligation to submit to close and frequent follow-up
monitoring, even if this means relinquishing certain freedoms in order to gain the potential
benefits of participation. 57

Ethical Issues Masalah Etis

The subject of ethics in relation to xenotransplantation has been widely explored. This includes
issues related to both humans and nonhuman animals. The concept that certain ethical principles
must be applied to experimentation conducted in humans is widely accepted. Such principles
include respect for persons, beneficence, and justice. These ethical issues are addressed in great
length by the International Xenotransplantation Association Ethics Committee's position paper. 74

Beneficence and risk-to-benefit analysis

Risk assessment is based on the principle that the possible harm of the research must be
outweighed by its probable benefits. Preclinical data, including nonhuman primate data, must
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adequately support the possibility of a successful outcome. In addition, for any ethically
conducted trials, risks to the patient and to society must be minimized.

Animals used for xenotransplantation should be bred in captive, closed colonies in order to
ensure the exclusion from the colony of known potential pathogens to humans. The extensive
human experience with short-term exposure to porcine materials, including patients receiving
porcine insulin, clotting factors, and temporary skin grafts, is reassuring. However, none of these
situations involves the long-term presence of large numbers of porcine cells or organs in an
immunocompromised individual.

Autonomy and informed consent

The potential risk of xenotransplantation to society elicits unique challenges in developing an
appropriate informed consent process. In addition to the research subject, the burden of risk is
also carried by close contacts, medical caregivers, and society, all of whom may reasonably
insist that the research subject agrees to life-long monitoring, avoids blood donation, and informs
close contacts about the xenotransplantation and its potential risk for spreading zoonotic
infections.

Asking a subject to agree to life-long monitoring effectively denies him or her the right to
withdraw from the study at any time. This is a denial of a fundamental individual right as
delineated in the Declaration of Helsinki and the US Code of Federal Regulations. 76

Some authors have even gone so far as to suggest the need for mandatory “Ulysses contracts”
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when obtaining informed consent to proceed with xenotranplantation. These contracts, which
currently exist in some psychiatric practices, are an advance directive from a patient to the
primary care provider given at a time when the patient is psychiatrically well. In this setting, the
patient essentially preauthorizes the physician to involuntarily commit him or her during times of
psychiatric relapse. In a similar fashion, a Ulysses contract for xenotransplantation could allow
the treating team to enforce a commitment made prior to surgery. Therefore, should the subject
change their mind in the future regarding their previous agreements, such as the right to
withdraw from the trial or to inform close contacts of the potential risks of their
xenotransplantation, there would be a binding contract enforceable by quarantine or detention,
thereby protecting society at large. 78

From a public health perspective, notification of close contacts and caregivers about potential
infectious risks surrounding a xenotransplantation recipient could violate principles of
confidentiality. This raises questions regarding whether it is necessary to obtain third party
informed consent during patient selection for transplant. 78

Another hurdle is that close contacts of xenotransplant recipients could be expected to refrain
from blood donation and agree to monitoring if this becomes necessary. Enforcement of such
rules could be deemed next to impossible given that intimate contacts may change multiple times
over a person's lifetime. 78
Given these difficult issues, societal input and governmental oversight regarding the decision of
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whether a country will proceed with xenotransplantation research are necessary. The
Department of Health and Human Services Secretary's Advisory Committee on
Xenotransplantation suggested that raising public awareness about the health concerns of
xenotransplantation is the only adequate mechanism to ensuring community-wide vigilance
toward the potential health hazards of xenosis. 78

Xenotourism

The potential risks of xenotransplantation will not respect the geographic borders of the country
in which the procedure is undertaken. In the absence of international regulations and monitoring
procedures, the most aggressive safety measures of any nation are likely to be unsuccessful. This
issue arises because of a constantly mobile population and the wide use of intercontinental air
travel, which can quickly spread an infectious agent to geographically distant locations. The
ethical principle of justice requires all nations to bear responsibility regarding the control of
infectious disease risks. This problem is highly complex and requires a globally respected
international treaty with a uniform immigration surveillance system to check for the entry of
potentially infectious pathogens.

Animal-related ethical issues

Xenotransplantation might give rise to a variety of psychosocial problems pertaining to

emotional and personal identity issues associated with implantation of organs from nonhuman
animals. While not a reason to remove xenotransplantation from consideration, these issues
should be thoroughly discussed with the potential recipient in advance.

The concept of rights for donor animals is controversial. Nonhuman primates such as baboons
have complex social behaviors, and various ethical concerns exist regarding their use. The use of
pigs is far less controversial. In a response to the use of animal-derived xenogeneic biologic
meshes for soft tissue repairs, People for the Ethical Treatment of Animals (PETA) stated that
they were “opposed to the use of animals and animal tissues for experimentation, medical
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training and clinical treatments…including the use of biological meshes." Various animal
rights activists are opposed to the idea of xenotransplantation because they maintain that humans
do not have right to breed and use other animals for their own needs. While these issues require
considerable debate, the accepted opinion is that animals used for research or clinical
xenotransplantation must be treated respectfully and humanely, and they must not be used
without institutional approval.

Religious views on xenotransplantation

Religion plays a significant role in the everyday life of many individuals and thus influences
lifestyles, eating habits, and medical treatments. The 3 major monotheistic religions have certain
aspects in common. All posit a hierarchy in the order of creation, in which humanity has a
unique place. 80

Furthermore, the Roman Catholic Church holds that humanity has a mandate to guide the life of
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creation toward the integral good. However, both Judaism and Islam forbid the raising and
consumption of pigs. Nevertheless, using pig organs for xenotransplantation is not regarded as
eating pork. Moreover, both Judaism and Islam allow for exceptions to dietary laws, particularly
in situations in which a human life might be saved. 76 , 81

Buddhism regards organ donation as a matter that should be left to an individual's conscience. A
Hindu tenet is that the body must remain whole in order to pass into the eternal life; therefore,
transplantation is not condoned. However, Hindu law does not prohibit individuals from
donating their organs or accepting an organ. With the exception of cows, which are sacred in
Hinduism, there are no prohibitions on using parts of animals to alleviate human suffering.
Interestingly, one of the oldest mythological accounts of xenotransplantation is described in
Hinduism, wherein Lord Ganesha (Lord Shiva's son) received a xenograft of an elephant head
after Lord Shiva inadvertently severed his head.

Popular perception of xenotransplantation

In light of the rapid advances in genetic engineering and immune modulating therapies, the
scientific and popular media have declared xenotransplantation as becoming a clinical reality
fraught with ethical controversy. Television shows like "Frontline" and "60 Minutes" have
discussed many of the issues mentioned above. Similarly, the medical literature reflects ethical
debates. Scientists at Harvard have questioned the ethical framework used to transplant pig islet
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cells into Mexican children. Others have interviewed patients to determine under which
clinical circumstances they would undergo xenotransplantation and identified a "reluctance" to
endorse the procedure.

In 2008, controversial issues surrounding xenotransplantation were explored at the Metropolitan

Museum of Modern Art by artist Elio Caccavale. In the Utility Pets exhibit, the works My
BioBoy and My BioPig depict a boy connected to a pig by an umbilical cord and challenge the
audience to contemplate "transhuman" creatures. In the scenario, the boy harmoniously coexists
with the pig while waiting for the day of xenotransplantation. The art work offers an alternative
to the potentially uncomfortable idea of organ farming and playfully displays inventions like The
Smoke Eater (which protects the pig from secondhand smoke) and The Toy Communicator
(which allows the boy and the pig to communicate when in different rooms). 83 83

Current Status and Future Directions

As previously mentioned, xenotransplantation and xenotransplantation products come under the

regulatory authority of the FDA. In 1997, the FDA formed the Xenotransplantation
Subcommittee of the BRMAC as an ongoing mechanism for open discussions of the scientific,
medical, social, ethical, and public health issues raised by xenotransplantation and the specific
ongoing and proposed protocols.

The FDA has developed a xenotransplantation action plan to provide a comprehensive approach
for the regulation of xenotransplantation that addresses the potential public health and safety
issues associated with xenotransplantation and to provide guidance to sponsors, manufacturers,
and investigators regarding xenotransplantation product safety and clinical trial design and
monitoring.

From time to time, the FDA publishes guidance documents to assist sponsors and investigators
interested in conducting clinical trials in the field of xenotransplantation. These documents
provide reasonably detailed and timely pragmatic guidance to sponsors regarding
xenotransplantation product safety and clinical trial development, including specific
recommendations for the procurement and screening qualification of source animals, the
manufacture and testing of xenotransplantation products, preclinical testing, clinical trial design,
and posttransplantation monitoring and surveillance of recipients of xenotransplantation
products. The FDA provides notice of and invites public comment on these draft documents. One
such final guidance document for the industry can be accessed on the Internet at
http://www.fda.gov/cber/guidelines.htm.{{Ref84 }

The FDA has sponsored, planned, or participated in numerous open public meetings and
workshops (both domestic and international) that partially or wholly focused on
xenotransplantation. These activities are essential for both sharing information and receiving
public input on issues relevant to xenotransplantation.

Although clearly an experimental procedure, investigators in clinical xenotransplantation have

been accused of using "the guise of bridge-to-transplantation" to appear acceptable to
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institutional review or ethics boards. However, the use of xenografts solely as bridges to
allotransplantation does not increase the donor pool; therefore, successful, permanent
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xenotransplantation must itself be viewed as the target of future clinical investigations. In the
future, clinical xenotransplantation may accomplish its intended goal of achieving prolonged
graft survival. Learning from the lessons of allotransplantation, clinicians performing
xenotransplantations must persevere under justifiable scrutiny.