Huang Yuting, Kruse Robert L, Ding Hui, Itani Mohamad I, Morrison Jonathan, Wang Zack Z, Selaru Florin M, Kumbhari Vivek
Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, United States of America.
PLoS One. 2021 Apr 28;16(4):e0249931. doi: 10.1371/journal.pone.0249931. eCollection 2021.
The biliary system is routinely accessed for clinical purposes via endoscopic retrograde cholangiopancreatography (ERCP). We previously pioneered ERCP-mediated hydrodynamic injection in large animal models as an innovative gene delivery approach for monogenic liver diseases. However, the procedure poses potential safety concerns related mainly to liver or biliary tree injury. Here, we sought to further define biliary hydrodynamic injection parameters that are well-tolerated in a human-sized animal model. ERCP was performed in pigs, and hydrodynamic injection carried out using a novel protocol to reduce duct wall stress. Each pig was subjected to multiple repeated injections to expedite testing and judge tolerability. Different injection parameters (volume, flow rate) and injection port diameters were tested. Vital signs were monitored throughout the procedure, and liver enzyme panels were collected pre- and post-procedure. Pigs tolerated repeated biliary hydrodynamic injections with only occasional, mild, isolated elevation in aspartate aminotransferase (AST), which returned to normal levels within one day post-injection. All other liver tests remained unchanged. No upper limit of volume tolerance was reached, which suggests the biliary tree can readily transmit fluid into the vascular space. Flow rates up to 10 mL/sec were also tolerated with minimal disturbance to vital signs and no anatomic rupture of bile ducts. Measured intrabiliary pressure was up to 150 mmHg, and fluid-filled vesicles were induced in liver histology at high flow rates, mimicking the changes in histology observed in mouse liver after hydrodynamic tail vein injection. Overall, our investigations in a human-sized pig liver using standard clinical equipment suggest that ERCP-guided hydrodynamic injection will be safely tolerated in patients. Future investigations will interrogate if higher flow rates and pressure mediate higher DNA delivery efficiencies.
临床上通常通过内镜逆行胰胆管造影术（ERCP）进入胆道系统。我们之前在大型动物模型中率先开展了ERCP介导的流体动力注射，作为一种针对单基因肝病的创新基因递送方法。然而，该操作存在潜在的安全问题，主要与肝脏或胆管树损伤有关。在此，我们试图进一步确定在人体大小的动物模型中耐受性良好的胆道流体动力注射参数。对猪进行ERCP，并采用一种新方案进行流体动力注射，以降低胆管壁压力。每头猪都接受多次重复注射，以加快测试并判断耐受性。测试了不同的注射参数（体积、流速）和注射端口直径。在整个操作过程中监测生命体征，并在操作前后收集肝酶指标。猪耐受了反复的胆道流体动力注射，只有偶尔、轻微、孤立的天冬氨酸转氨酶（AST）升高，且在注射后一天内恢复到正常水平。所有其他肝脏检测结果均未改变。未达到体积耐受性的上限，这表明胆管树可以很容易地将液体传输到血管空间。流速高达10 mL/秒时也能耐受，对生命体征的干扰最小，且胆管无解剖学上的破裂。测得的胆管内压力高达150 mmHg，高流速时肝脏组织学检查中出现充满液体的囊泡，类似于水动力尾静脉注射后小鼠肝脏中观察到的组织学变化。总体而言，我们使用标准临床设备在人体大小的猪肝中进行的研究表明，ERCP引导的流体动力注射在患者中能安全耐受。未来的研究将探讨更高的流速和压力是否能介导更高的DNA递送效率。
