1.000 ml Custodiol® contains:
0.8766 g Sodium chloride = 15.0 mmol/l
0.6710 g Potassium chloride = 9.0 mmol/l
0.1842 g Potassium hydrogen 2-ketoglutarate = 1.0 mmol/l
0.8132 g Magnesium chloride · 6 H2O = 4.0 mmol/l
3.7733 g Histidine · HCI · H2O = 18.0 mmol/l
27.9289 g Histidine = 180.0 mmol/l
0.4085 g Tryptophan = 2.0 mmol/l
5.4651 g Mannitol = 30.0 mmol/l
0.0022 g Calcium chloride · 2 H2O = 0.015 mmol/l
in sterile Water for injection
Anion: Cl- 50 mval
pH 7.02 – 7.20 at 25ºC (77° F) [pH 7.4 – 7.45 at 4ºC (39.2° F)] Osmolality: 310 mosmol/kg
Caution: Federal law restricts sale of this device to or on the order of a physician or licensed practitioner.
Indications for Use
Custodiol® HTK Solution is indicated for perfusion and flushing of donor kidneys, liver, pancreas and heart prior to removal from the donor or immediately after removal from the donor. The solution is left in the organ vasculature during hypothermic storage and transportation (not for continuous perfusion) to the recipient.
Warnings and Precautions
Warning: Perfusion of the kidney, liver, pancreas and/or heart should be carried out with a maximum hydrostatic pressure of 120 mmHg.
Warning: Custodiol® is not indicated for intravenous or intraarterial administration. It is indicated only for selective perfusion of the kidney, liver, pancreas and heart and for cooling of the surface areas, i.e., for the preservation of the donor organ during the transport from donor to recipient.
Custodiol® may not be used for systemic infusion.
Warning: Custodiol® is not indicated for continuous perfusion.
Warning: Keep out of reach of children.
Caution: The product must be used before the expiration date stated on the package.
Caution: The product must be stored according to the recommendations prior to use.
No side effects have been encountered that could be attributed to this product.
Interactions with other Medical Products
Interactions with such therapeutic agents as glycosides, diuretics, nitrates, antihypertensives, beta blockers and calcium antagonists, which are used perioperatively, have not been reported.
Overdoses (Symptoms, Countermeasures)
ln the case of entry of the HTK solution into the general circulation, the resultant change in the concentration of sodium and calcium are very slight. After checking sodium and calcium levels in the extracorporeal circulation both of these electrolytes should be replaced if necessary.
lnstructions for Use (Recommendations)
Required Equipment: Perfusion apparatus with a Y-piece for bottle or bags Perfusion cannula tube 2.5 to 3 mm Tube clamp Perfusion stand with a height setting of up to 200 cm with tape measure Cooling Equipment (5 to 8°C) for use in cardiac surgery Perfusion tube with an internal diameter of 6 mm Transport Container with sterile pouch for transport of the cooled organ from donor to recipient Filtration of Custodiol® is not necessary or recommended.
Tolerance of lschemia by the Kidney
The kidney may be stored with ice cold Custodiol® solution at about 2 to 4°C with a period of (cold) ischemia of up to 48 hours. Warm ischemia time, that is to say the average time period required for the completion of anastomosis of the vessels, is usually 30 minutes. Taking this time as a basis, the organ recovers completely with optimal immediate function within 24 hours.
Tolerance of Ischemia by the Liver
The liver may be stored with ice cold Custodiol® solution at about 2 to 4°C with a period of (cold) ischemia of up to 15 hours. Warm ischemia time, that is to say the average time period required for the completion of anastomosis of the vessels, is usually 30 minutes. Taking this time as a basis, the organ recovers completely with optimal immediate function within 24 hours.
Tolerance of Ischemia by the Pancreas
The pancreas may be stored with ice cold Custodiol® solution at about 2 to 4°C with a period of (cold) ischemia of up to 15 hours. Warm ischemia time, that is to say the average time period required for the completion of anastomosis of the vessels, is usually 30 minutes.
Tolerance of Ischemia by the Heart
The heart may be stored with ice cold Custodiol® solution at about 2 to 4°C with a period of (cold) ischemia of up to 4 hours. Warm ischemia time, that is to say the average time period required for the completion of anastomosis of the vessels, is usually 30 minutes.
lntroduction of Renal Perfusion
Following successful laparotomy, the kidney is prepared by ligature of the capsular vessels.The perfusion catheter for selective kidney perfusion is fixed in the renal artery using a tourniquet. Cold perfusion (2-4°C) is performed under hydrostatic pressure (maximum of 120 mmHg). Within the first minute of perfusion, the renal vein is incised and clamped off adjacent to the vena cava. The escaping perfusate is removed from the abdominal cavity. After approximately 10 minutes of perfusion, the kidney is resected before transplantation.
Introduction of Hepatic Perfusion
The donor should be heparinised appropriately, and the aorta or the iliac bifurcation and the portal vein will be exposed. The perfusion tubing should be of the largest possible diameter and the cannulae should have an internal bore of at least 5 mm. Because of the low viscosity of the solution,perfusion is performed under hydrostatic pressure only (maximum of 120 mmHg). Perfusion of the portal vein can be performed by cannulating the superior or inferior mesenteric vein and advancing the catheter up to the origin of the portal vein. After performing cannulation, clamping off the aorta and opening the vena cava, bubble-free perfusion is begun via both lines simultaneously. As a general rule, 8-12 liters of HTK at 2-4°C should be perfused (about 300 ml per kg of body weight) and this will require about 10 minutes.
Should the center decide to use the so-called aorto-single flush technique, the total amount of the preservation solution needed is perfused only via the aortal line. Once again, a pressurized infusion is not necessary or recommended. A Y-perfusion system is recommended in addition to perfusion tubing of the largest possible caliber and perfusion cannulae with an internal bore of at least Charrière 15 (5 mm). The time required for perfusion is extended by about 5 minutes.
At the implant site, the back-table preparation includes the reperfusion of approximately 500 ml cold HTK solution. The perfusion is stopped when the anastomoses of the inferior vena cava are completed at the end of the second warm ischemia time. It is permissible, in view of the flow properties and low potassium concentration of the HTK solution, to perform flushing of the organ or testing for leaks in the anastomoses with HTK solution itself, if necessary. Alternatively, any standard flushing solution may be used. Simultaneous reperfusion via the artery and the portal vein are preferable, though primary reperfusion through the portal vein alone is acceptable.
Introduction of Pancreatic Perfusion
There are two important considerations for perfusion of the pancreas. First, the pancreas is a low-flow organ and can be damaged by hyperperfusion. Secondly, even the gentlest manipulations can cause edema. Failing to allow for these factors can produce not only impairment of endocrine function, but perhaps more seriously, can cause damage to exocrine function and result in reperfusion pancreatitis.
When removing the pancreas, the surgeon must first of all assure adequate arterial perfusion via the celiac trunk, the splenic artery and the pancreaticodorsal artery (if present), together with the superior mesenteric and gastroduodenal arteries. Secondly, venous drainage must be safeguarded either by opening the portal vein, the inferior mesenteric vein, or the splenic vein at the hilum of the spleen, or by the physiological outflow into the portal vein drainage area. In practice, it is considered advisable, after appropriate dissection and exposure of the abdominal aorta, the vena cava, and the aorta above the celiac trunk, to divide the inferior mesenteric artery between ligatures, to clamp off the aorta below the diaphragm and then to run a total of 10 liters HTK into the distal part of the aorta, so as to perfuse the liver, pancreas, and the kidneys. The solution is perfused under gravity with the fluid level 1.5 meters above the heart. At this stage the mesenteric root should not be divided distal to a TA stapler suture, so that by perfusing the small intestine, the liver can be perfused via the portal vein. This will not only accelerate liver cooling, but will also provide a safeguard against overperfusion of the pancreas. After dividing the mesenteric root, the surgeon can then sever the mesocolon and the splenocelic ligament, separating the entire small and large intestine caudally. This will make surface cooling even more effective.
Introduction of Cardiac Perfusion
The inactivation of the heart renders it susceptible to overstretching. Decompression of the left ventricle must therefore be performed at the commencement of cardioplegia. For adult hearts the following recommendation is appropriate: The solution, cooled to 5° C – 8° C, is perfused into the coronary arteries by hydrostatic pressure of 100 mmHg (equivalent to initial height of perfusion bottle above level of heart = 140 cm). After cardiac arrest has ensued (within the first minute after starting perfusion) the perfusion bottle should be lowered to about 50-70 cm above the level of the heart, equivalent to 40-50 mmHg. In patients with pronounced coronary stenosis, a higher perfusion pressure (about 50 mmHg) will be necessary for a somewhat longer time. The overall perfusion time should be 6-8 minutes, so as to ensure homogeneous equilibration. Even for small hearts, a perfusion rate of 1 ml/min./gram-estimated-heart-weight at a perfusion pressure of 40-50 mmHg and a perfusion time of 6-8 min. should be enough to ensure equilibration. The heart may then be excised. The heart should tolerate a cold ischemic time of up to four hours.
Transport of a Donor Organ
The transport of a donor organ to the recipient utilizes a sterile pouch accommodating the size of the organ in an ice cold Custodiol® solution. The organ must be completely covered by the solution. The pouch is sealed with adhesive tape and is placed into a second container which is also filled with Custodiol® solution in order to prevent a breakdown of insulation and cooling by trapped air. The double-bagged organ is placed into a sterile plastic container and closed with a secure lid. The plastic bag is then placed into a transport container packed with ice for transport. Information about the donor, copies of the laboratory results and blood samples from the donor are also included. The transport of the donor organ in Custodiol® solution must be accomplished as quickly as possible.
Kidney Transplant Trials
A major multi-center prospective randomized clinical trial has been carried out in Europe comparing three perfusion and preservation solutions for use in kidney transplants.<sup>1</sup> The three solutions were the Custodiol® HTK solution, the Belzer UW solution, and the Euro-Collins (EC) solution. Fortyseven centers participated and followed a strict protocol. Over a thousand kidneys were included in the study. In the HTK-UW study, there were 342 donors and 611 transplants (the UW group had 168 donors and 297 transplants, the HTK group had 174 donors and 314 transplants). In the HTK-EC study, there were 317 donors and 569 transplants (the EC group had 155 donors and 277 transplants, the HTK group had 162 donors and 292 transplants).
This study directly compared kidney survival in the HTK group with the UW group, and also with the EC solution, and showed that for kidney transplants, the HTK solution performs as well overall as the UW solution, and significantly better than EC solution for initial nonfunction. The average cold ischemia time in the HTK-UW study was 25.8 hours in the HTK group and 25.5 hours in the UW group. In the HTK-EC group, the average cold ischemia time was 24.1 hours in the HTK group and 24.2 hours in the EC group. The overall kidney survival rates from the 47-center study for HTK versus UW, and HTK versus EC at four time points were:
Delayed graft function that required two or more dialysis sessions during the first week was 20% (107/544) in the pooled HTK groups, 25% (66/266) for the UW group, and 32% (85/268) for the EC group. Initial nonfunction (INF) occurred in 33% of the kidneys in both HTK and UW groups, and in the other study, INF occurred in 29% of the HTK group and43% of the EC group.
Liver Transplant Trials
Several clinical studies have been reported that examined the performance of Custodiol® HTK solution in liver transplants. These studies have collected data on survival rates and other outcome measures. The primary evidence for effectiveness has come from a four-center prospective clinical study carried out under the auspices of the Eurotransplant organization of Leiden, The Netherlands. The four centers were located at Essen, Innsbruck, Göttingen and Vienna. The result from this and other studies are discussed below.
Gubernatis summarized the experience at the Medizinische Hochschule Hanover, Clinic for Abdominal and Transplantation Surgery, for livers preserved in UW solution and in HTK solution. This was a retrospective study of transplants conducted at Hanover between 1988 and 1996. During this period there were 515 liver transplants using the UW solution and 232 using HTK solution. These transplants were carried out in 416 patients using UW and 197 using HTK (some were re-transplants). The survival curves for all patients out to five years were essentially indistinguishable and certainly not significantly different statistically. An update on the Hanover experience through 1999 showed that 461 livers had been preserved with HTK solution and 607 with UW solution. Prof. Gubernatis reiterated his earlier conclusion that the two solutions were equivalent in their ability to preserve the liver for transplant. A randomized prospective study was organized under the direction of Prof. J. Erhard at Essen, comparing 30 livers preserved with HTK solution with 30 livers preserved with UW solution. There were two cases of initial nonfunction (INF) in the UW group and one case of INF in the HTK group.
Graft survival at 3 months was 87 % in the HTK group and 80% in the UW group (p=0.21). Patient survival at 30 months was 77% in the HTK group and 74% in the UW group.
Pancreas Transplant Trials
In Transplantation,<sup>3</sup> Fridell, et al. reported a clinical study at Indiana University School of Medicine of pancreas transplantation where HTK and UW solutions were compared. On May 1, 2003, the transplant center switched from UW solution to HTK solution, and the last ten consecutive UW-preserved pancreata were compared to the first ten consecutive pancreata preserved with HTK. The study found no differences between two solutions in early graft function or graft survival. All 20 patients and pancreata were well at 30 days. All parameters of graft function were equivalent during the first week, at 14 days, and at 30 days. The authors conclude that “Within this range of cold ischemia time [11 ± 4 hrs], UW and HTK demonstrate similar efficacy in pancreas preservation”.
A study of 100 pancreas transplants at Chirurgische Klinik, Ruhr-Universität was reported by Riege, et al.<sup>5</sup> In 95 cases, UW solution was used and in five cases, HTK was used. All 100 transplants required initial insulin administration. In the HTK group, there were zero instances of primary non-function, vascular thrombosis, and hemodialysis, along with one case of graft pancreatitis. The comparable numbers in the much larger UW group were 0, 7, and 3. Patient survival at one year was 93 % in the combined groups, while graft survival was about 75 % (differential rates were not reported).
Becker, et al.<sup>6</sup> reported on the experience of 16 simultaneous kidneypancreas transplants at Medizinischen Hochschule Hannover during 1999-2001, all using HTK as cold storage solution. One pancreas graft failed due to thrombosis and one kidney-pancreas graft failed due to acute rejection, so the one-year pancreas graft survival was 87 % and the kidney survival was 93 %. All of the patients were alive at one year. Initial nonfunction was seen on one pancreas and initial dysfunction in one patient. There were four episodes of rejection.
Heart Transplant Trials
Several clinical studies have been reported that examined the performance of Custodiol® HTK Solution in heart transplants. These studies have collected data on survival rates and other outcome measures.
At the Bad Oeynhausen transplant center, during the period 1989-2002, 1233 hearts were preserved with the HTK Solution. 19 hearts were preserved with other solutions. The data reported here represent the entire experience of the center, with no cases excluded. The following table summarizes the experience at Bad Oeynhausen:
* The other solutions included UW, Roe, Ringer’s lactate, normal saline, Plasmalyte A, Plegisol, Carmichael’s and Stanford.
Adverse Events Observed in the Clinical Studies
There were no unexpected adverse events in these clinical studies. The adverse events that occurred were expected because of the nature of transplantation. None are believed to be affected by any of the solutions. Kidney failure rates in the first 48 hours were comparable in all groups: UW-15/297 and HTK-18/314; EC-15/277 and HTK-13/272.
In the HTK-UW kidney study, acute rejection episodes occurred in 99/314 (32%) in the HTK group and 105/297 (35%) in the UW group. In the HTK-EC study, acute rejection episodes occurred in 99/292 (34%) in the HTK group and 108/277 (39%) in the EC group.
There were no unexpected adverse events in these clinical studies. The adverse events that occurred were expected because of the nature of transplantation.
In the multi-center trial, primary dysfunction rate (PDF) was 10.3%, with the primary nonfunction rate (PNF) of 3.6%. Bile duct complications were seen in 19% of transplants. This compares with data from Eurotransplant on the UW solution: PDR of 15.2% and PNR of 7.8%.
There were no unexpected adverse events in these clinical studies. The adverse events that occurred were expected because of the nature of transplantation. In the clinical study at the University of Indiana, there were no differences in initial graft function or graft or patient survival at 30 days. In the clinical study at the University of Pittsburgh, one out of the 17 pancreata failed due to a donor-derived infection (the patient was successfully retransplanted). Markers of graft function were measured at day 1 and day 10. There were no significant differences except that at day 10, serum creatinine levels averaged 2.42 ± 0.48 mg/dL in the HTK group and 1.77 ± 0.46 mg/dL in the UW group, a result that was statistically significant. However, after 100 transplants using HTK at this center, the serum creatinine was not significantly different from levels that had been seen using UW. Becker, et al.6 reported on the experience at Medizinischen Hochschule.
Hannover of 16 simultaneous kidney-pancreas transplants during 1999- 2001, all using HTK as cold storage solution. One pancreas graft failed due to thrombosis and one kidney-pancreas graft failed due to acute rejection, so the one-year pancreas graft survival was 87% and the kidney graft survival was 93%. All of the patients were alive at one year. Initial nonfunction was seen on one pancreas and initial dysfunction in one patient. There were four episodes of rejection.
There were no unexpected adverse events in these clinical studies. The adverse events that occurred were expected because of the nature of heart transplantation.
In the Bad Oeynhausen experience, the primary dysfunction rate (PNF) was 1.9 %.
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