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1 日本集中治療医学会第 2 回関東甲信越支部学術集会 会長 : 布宮伸教授 ( 自治医科大学 ) テーマ : 臨床 集中治療 2018 年 6 月 30 日 ( 土 ) 宇都宮 特別講演 移植可能な臓器を造る ー臓器灌流培養法の開発 小林英司 慶応大学医学部臓器再生医学講座 COI; E.K. is a medical adviser for Screen Ltd.
2 Clinical Microsurgery in JMU Survival Rate (%) From 2001 to 2009 年 n= Year (Transplant Proc 2010) (J Hepatobriary Panc Sci 2013) (Transplant Proc 2009)
3 イスタンブール宣言 (Istanbul, 30 th April 3 rd May 2008) 1.Organ trafficking( 臓器取引 ) Transplant tourism( 移植ツーリズム ) Transplant commercialism( 移植商業主義 ) 等の内容を明確して 人道的 社会的 国際的に問題があるものに対し世界的に反対すること 2. 死体 ( 脳死 心停止 ) ドナーを自国で増やし 自国での臓器移植を増やすよう呼びかけること そのために国際的協力をすること 3. 生体ドナーは ドナー保護を最優先し 選定や移植に関わる総合的な保障等の制度を国家的に取り組むよう呼びかけること 152 professionals from 78 countries (Lancet 2008 年 7 月 6 日 )
4 The National Diet (6 Sep,2009)
5 NHK スペシャル 2009 人体 製造 ー再生医療の衝撃ー
6 戦略分類 移植可能な臓器作り 小動物によるプルーフ オフ コンセプト実験 大型動物での POC (1) 丸ごと使う ( 動物工場 ) (2) 発生原器を使う ( 胎仔原器グラフト ) (3)Vitro での再構築 ( 脱細胞充填 ) ( 組織再構築 ) (Ex vivo 再構築 ) 膵 (Kobayashi T, et al. Cell 2010) 膵 (Yamaguchi T, et al. Nature 2017) 腎 (Usui J, et al. Am J Path 2012) 肝 (Hata T, et al. Ann Surg 2013)* 腎 (Matsumoto K, et al. Stem Cells 2012)* 腎 (Mae S, et al Nature Communi 2013) 腎 (Taguchi A, et al. Cell Stem Cell 2014) 肝 (Takebe T, et al. Nature 2013)) 心 (Ott HC, et al. Nature Med 2008) 腎 (Ross EA, et al. JASN 2009) 肝 (Uygun BE, et al. Nature Med 2010) 肺 (Ott HC, et al. Nature Med 2010) 心 (Sekine H, et al. Nature Com 2013) * 膵 (Matsunari H, et al. PNAS 2013) 肝 (Fisher JE, et al. Liver Transplant 2013) 肝 (Hsu H, et al Transplant Proc 2017)* 豚ヒトキメラ (Wu J, et al Cell 2017) 膵 (Hammerman M, et al. Organogenesis 2012) 腎 (Yokote S, et al. PNAS 2015)* 腎 (Orland G, et al. Ann Surg 2012) 肝 (Yagi H, et al. Cell Transplant 2012) 心 (Kitahara H, et al. Interact Cardio Thrac Surg 2016) 脾臓 骨髄を含め多種臓器 (Kobayashi E, et al. unpublished)* * 著者ら (2013 年内閣府生命倫理委員会資料小林英司より改編 )
7 戦略 (1) Creating the human liver in Pigs 動物の体内でヒトの臓器を作る Human original Stem cell 京都大学畑先生 上本教授 Chimeric liver (Hata T, et al. Ann Surg 2013)
8 白熱する 動物の体内でヒトの臓器を作る 第 3 次ブタブーム (Wu J, et al. Cell 2017) (Yamaguchi T, et al. Nature2017)
9 課題 ブタを bioreactor としてヒト臓器を発生させる倫理的課題 受精卵 胚胎胞 胎仔 新生仔 ヒト幹 ( 前駆 ) 細胞 キメラ率 全身局所 (+) (++) (±) (++) (±) (+) ( 小林英司 第 4 回動物性集合胚の取り扱いに関する作業部会 2014 年 3 月 20 日 文部科学省 )
10 戦略 (2) 臓器の芽を患者体内で育てる 慈恵医大横尾教授 明治大学長嶋教授
11 戦略 (2) 3D プリンターで作った肝臓の芽 を患者に移植する 九州大学柳先生 田口教授佐賀大学中山教授 (Yanagi Y, et al. Scientific Report 2017) 11
12 肝芽は 異所性では育たない
13 なぜ肝芽が異所では育たないか? 肝臓維持に必要な解剖学
14
15 課題 外科技術を応用した 臓器の芽 の移植法 ( 腎 肝 ) ( 小林英司 日本外科学会誌 ( 総説 )2018)
16 戦略 (3) Ex vivo の還流で組織を積み上げる 東京女子医大関根先生 清水教授 45 min 90 min 18.3min (Sekine H, et al. Nature Comm 2013)
17 臓器を培養する?!
18 Organ Donation and Utilization in US ( ) DCD; Donation after Cardiac Death ECD; Expanded Criteria Donor SCD; Standard Criteria Donor ( R.S.Sung, et al. Am J Trasuplntation 8(2); 922, 2008)
19 Impact of NHBD liver transplantation in King s college Hospital NHBD (Muiesan P. 2008)
20 Hypothermic Machine Preservation in Human Liver Transplantation: The First Clinical Series (Guarrera JV, et al. Am J Transplant 2009)
21 (Guarrera JV, et al. Am J Transplant 2009)
22 Changing Patterns of Organ Donation in Japan ten years after the Declaration of Istanbul Brain death donor Donor cardiac death Number of cases The first OTL Revisinon of OTL DOI ( Kobayashi E. Transplantation in press)
23 An Oxygenated and Transportable Machine Perfusion System Fully Rescues Liver Grafts Exposed to Lethal Ischemic Damage in a Pig Model of DCD Liver Transplantation (Compagnon P, et Transplantation 2017)
24 A randomized trial of normothermic preservation in liver transplantation NMP device and circuit. OrganOx metra (generation 1) Image of liver during normothermic machine perfusion 50 NATURE VOl MAY 2018
25 A randomized trial of normothermic preservation in liver transplantation NMP device and circuit;organox 50 NATURE VOl MAY 2018
26 Four types of Non-Heart Beating Donor (NHBD) Categories I: dead on arrival Categories II: unsuccessful resuscitation uncontrolled Categories III: withdrawal of life-supporting therapy Categories IV: cardiac arrest in a brain-dead donor controlled (Kootstra G, et al. Transplant Proc 1995)
27 Don Quixote Project for Organ Resurrection (Kobayashi E with Screen Ltd. from 2015)
28 Hypothermic temperature effects on organ survival and restoration Process controller Bubble trap Pump B Organ chamber Relative intensity min 50 min 80 min 100 min Perfusate reservoir Oxygenator Heater Pump Perfusate receiver Survival rate (%) resurrected liver transplantation UW stored liver transplantation Partial hepatectomy Days after transplantation (Ishikawa J, et al. Scientific Reports 2015)
29 In 1912, Dr. Alexis Carrel was awarded the Nobel Prize in Physiology or Medicine for pioneering vascular suturing techniques ( ) A New techniques in vascular sutures in 1902
30 The Culture of Whole Organs Background 1812 Le Gallois Proposal for idea 1866 de Cyron Brown-Sequard Frog heart Beating for 48 hours Liver Urea production Brain circulation A cat's thyroid gland, varying in weight from 85 to 110 mgs, demands about 230 cc of nutrient fluid. The solutions contain protein split-products, hemin, cysteine, insulin, thyroxine, glutathione, vitamin A, ascorbic acid, blood serum, et. The apparatus is kept in an incubator at a temperature of 37-38C. Thyroid glands were kept more than 20 days with pulsating arteries and active circulation.
31 THE SERIAL CULTIVATION OF HUMAN DIPLOID CELL STRAINS Dagrammatic representation of the history of cell strains and the phenomenon of cell alteration. Phase I, or the primary culture, terminates with the formation of the first confluent sheet. Phase II is characterized by luxuriant growth necessitating many subcultivations. Cells in this phase are termed cell strains. An alteration may occur at any time giving rise to a cell line whose potential life is infinite. Conversely, cell strains characteristically enter Phase III and are lost after a finite period of time. (L. Hayflick and PS Moorhead. Experimental Cell Research 1961)
32 "In-Site" Perfusion Technique for Rinse Solution in Liver Transplantation (Kobayashi E. Transplantation Direct2017)
33 A Novel Machine Perfusion System Continuously from Ex-vivo to In-situ on Marginal liver transplantation (TTS 2018, Madrid)
34 Donor Cardiac Death (DCD) Model in the Pig A.Clamping of the thoracic Aorta B.Systemic Injection of KCL solution C.Donation of the marginal liver graft D. Massive colts from the graft liver
35 The rigidity mechanism The kink less character The cylindrical tube The triangular tube Applied stress Stress diffusion Collapsed shapes image The flow was stopped at 150 Non-stop
36 New technology for sewing vessels while perfusing organs Triangular tube A cross section
37 Ectopic Liver Transplantation for the damaged liver A B
38 Modulating Portal Hemodynamics With Vascular Ring Allows Efficient Regeneration After Partial Hepatectomy in a Porcine Model (Petru O, et al. Ann Surg 2018)
39 Angiography of portal vein after modeling portal hemodynamics in ectopic liver transplantation (Yoshimoto S, et al, Transplantation Direct submitted)
40 Acknowledgement / 共同研究者 慈恵医科大学高血圧内科 明治大学農学部発生工学研究室 北里大学獣医学部 横尾隆 岩井聡美 慶應義塾大学医学部 循環器内科 遠山周吾 藤田淳 福田恵一 心血管外科 川口新治 平野暁教 志水秀行 消化器外科 八木洋 北川雄光 消化器内科 杉本真也 佐藤俊朗 自治医科大学先端医療技術開発センター 東京医科歯科大学再生医学関矢一郎 松成ひとみ 長嶋比呂志 花園豊 京都大学医学部胆管膵 移植外科八木真太郎 上本伸二 九州大学医学部小児外科柳佑典 田口智章 佐賀大学医学部臓器再生医工学講座中山功一 東京女子医科大学先端生命医科学研究所 理化学研究所多細胞システム形成研究センター石川潤 辻孝 関根秀一 清水達也 国立成育医療センター先端医療開発室許懐哲 絵野沢伸 日本獣医生命大学獣医看護袴田陽二
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第 45 回関東腎研究会 (2018 年 1 月 20 日 大手町 ) ヒト由来幹細胞から 腎臓 を作る戦略 Eiji Kobayashi, MD,PhD Keio University, School of Medicine COI: EK is a medical adviser for Sysmex Ltd. and, Screen Ltd. 自己紹介 ホームページアクセスください 慶應義塾大学医学部臓器再生医学寄附講座小林英司研究室
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東京都医工連携 HUB 機構 (2018 年 11 月 1 日 日本橋 ) 医工連携セミナー医療者と大手医療機器メーカーが語る医療機器開発の成功ポイント 臓器再生医学研究におけるアカデミアと企業の協創 小林英司慶応大学医学部臓器再生医学寄付講座 (COI 関連 ) 客員教授 非常勤講師 客員研究員 等東京医科歯科大学 自治医科大学 旭川医科大学 日本獣医生命科学大学 京都大学医学部 慈恵医科大学 東京女子医大
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