Vincent Mayoral1,2*†
Tom Darius3,4†
Sarah Bruneau1†
Christophe Masset1†Jérôme Rigaud5†Gilles Blancho1†
Thomas Prudhomme1†Julien Branchereau1,5†
Benoît Mesnard1,5†- 1Center for Research in Transplantation and Translational Immunology, Nantes Université, CHU Nantes, INSERM, UMR 1064, Nantes, France
- 2Department of Urology, Charles Nicolle Hospital, University of Rouen Normandy, Rouen, France
- 3Institut de Recherche Experimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
- 4Surgery and Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- 5Department of Urology and Transplantation Surgery, Nantes University Hospital, Nantes, France
The increasing use of extended kidney grafts to bridge organ shortage has led to delayed and impaired graft function, warranting the development of new preservation strategies. In addition to hypothermic machine perfusion, the addition of pharmacological agents to preservation solutions has been primarily investigated, with a few promising agents making their way into clinical trials. This review aimed to identify and summarize current literature studies on pharmacological treatment additives for hypothermic kidney graft preservation. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A comprehensive literature search was performed using Medline and Cochrane Library databases until 1 December 2023. All studies published in English reporting on pharmacological supplementation of preservation solutions to improve hypothermic kidney graft preservation were included. A total of 67 records were retrieved, all of which were preclinical except one. Of these, 8 were conducted on cellular models, 21 on ex vivo kidneys, and 38 on animal kidney transplantations. A total of 40 pharmacological agents were evaluated based on the key markers of ischemia–reperfusion injury (IRI) pathophysiology, most of them showing promise in kidney preservation. Although promising, with numerous preclinical studies identifying various effective additives, the pharmacological treatment additive strategy to improve hypothermic kidney preservation has still not been translated into clinical practice. Clinical investigations should be promoted to support few ongoing trials offering encouraging outcomes.
1 Introduction
Kidney transplantation is the gold standard for the treatment of end-stage renal disease, with living donor kidneys yielding superior long-term outcomes (Lentine et al., 2024). To cope with increasing demands and limited graft availability, the use of expanded criteria donors (ECDs) and donors after circulatory death (DCD) is increasing, further extending the limits of donor eligibility criteria (Lomero et al., 2020). These extended kidney grafts are prone to ischemia–reperfusion injuries (IRIs), resulting in an increased incidence of delayed graft function (DGF) and its related costs and recipient morbidity (Barreda Monteoliva et al., 2022). Improving the protection of these vulnerable organs would be beneficial to optimize the limited supply of kidney grafts. Many strategies have been investigated to reduce IRI and improve graft and patient survival (Moers et al., 2012; Mesnard et al., 2022; Branchereau et al., 2022). Hypothermic machine perfusion (HMP) has already been demonstrated to be superior to static cold storage (SCS) in decreasing DGF in DCD and ECD kidneys, especially when applied as a continuous preservation strategy, and has been implemented worldwide in clinical practice for decades (Tingle et al., 2024). Pharmacological treatment additives are another key strategy for improving the efficacy of organ preservation solutions and have been increasingly investigated in recent years using multiple agents with distinct mechanisms of action. Nevertheless, despite these efforts, no clinical implementation has been achieved yet. Considering the wide spectrum of agents and strategies reported to date, the aim of this review was to summarize the nature and extent of research on pharmacologically improved hypothermic kidney preservation.
2 Methods
A scoping review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The primary objective of the report was to retrieve all published data addressing the improvement of hypothermic kidney preservation for transplantation through the addition of pharmacological agents to preservation solutions. The review protocol had been registered at the Open Science Framework DOI 10.17605/OSF.IO/3VA4X and can be accessed at https://archive.org/details/osf-registrations-3va4x-v1.
Two authors (VM and BM) agreed on the key words to conduct the literature search. Searches were performed in the Medline and the Cochrane Library as [(“Kidney Transplantation” [Mesh]) AND “Organ Preservation Solutions/pharmacology” [Mesh]] and (“Kidney transplantation” [Title/Abstract/Keyword] AND “Preservation” [Title/Abstract/Keyword]), respectively. Databases were accessed between 11 November 2023 and 1 December 2023. Relevant quoted articles in the reference list of already identified articles were also included. Article selection and removal of duplicates were managed using Zotero 6.0.36. Scanning of titles and abstracts was performed by two authors (VM and BM), and full-text reading for eligibility was conducted by the first author. Final decision for inclusion was based on consensus of both authors. In case of discrepancies, a third author resolved concerns regarding eligibility (JB). All published articles written in English until 1 December 2023 reporting on the use of a pharmacologically supplemented preservation solution to reduce IRI in any model of hypothermic kidney preservation, from cellular preclinical investigations to clinical studies, were included. Exclusion criteria included the lack of pharmacological additives to standard organ preservation fluids, absence of a clear statement regarding pharmacological additive usage, or no use of a preservation solution. Abstract-only articles, reviews, and unpublished data were also excluded. Oxygen supplementation and its transporters, along with vasodilators without specific activity against IRI, were not covered under the scope of this review.
Study characteristics and results were then charted for the following information: first author and year of publication, country where the study was conducted, type of study (preclinical or clinical), investigated pharmacology, characteristics of the hypothermic preservation model (individuals studied and preservation conditions), pharmacology doses, and results obtained. All the collected data were exported into an Excel sheet by the first author and then reviewed and agreed by all the authors. The results were presented for their general characteristics and outcomes, before being detailed one by one for relevant data from clinical to preclinical studies, grouped by pharmacology family and mechanism of action.
3 Results
3.1 Charting process and data summary
The literature search found 609 articles, of which 493 were identified from databases and 116 were collected from the citation list of the included studies among these 493 articles. After removal of duplicates and retracted articles, 583 were screened for title and abstract, with 146 selected for full-text review. After exclusion of 79 ineligible articles not focused on preservation solution supplementation in a kidney transplantation model, the charting process led to the inclusion of 67 articles (Figure 1).
Figure 1. Flow chart diagram.
Of these 67 records, all, except three, were preclinical studies, 8 of which used a cellular-only-based model, 21 studied an ex vivo kidney model including 7 normothermic reperfusion strategies, and 38 performed animal kidney transplantation (whether allo- or syngeneic- or autotransplantation). Most of the studies were conducted using a porcine or murine model (whether isolated kindeys or transplantation model). The total number of pharmacological agents investigated in the selected studies was 40 (Table 1). The main purpose of the studies was to evaluate the roles of these agents in reducing renal IRI based on various outcomes as markers of oxidative stress (reactive oxygen species [ROS] levels, DNA damage, lipid peroxidation, and pro-/antioxidant enzyme activity), cell metabolism (ATP content, mitochondrial integrity and function, and lactate levels), inflammatory parameters (cytokine and chemokine levels and adhesion and prothrombotic molecule expression), cytoprotective signaling pathway activity (HO-1 and HIF1α), cell death (apoptosis and its effectors, LDH), kidney perfusion parameter kinetics, glomerular and tubular kidney function (glomerular filtration rate, proteinuria, urinary ion balance, and tubular damage urinary markers), histological kidney lesions (tubular necrosis, fibrosis, and immune cell infiltrate), kidney fibrosis scarring (epithelial–mesenchymal transformation effectors), transplanted animal survival, and primary non-function of the kidney.
Table 1. Included studies on pharmacological supplementation of hypothermic kidney preservation solutions.
3.2 Insights from clinical studies
The main clinical study was conducted by Nicholson et al. (1996) and tested the calcium channel blocker nicardipine, which was supposed to limit IRI, added to Euro-Collins solution used in SCS to evaluate its impact on DGF (Nicholson et al., 1996). A total of 65 consecutive dead brain donors (DBDs) were enrolled, resulting in 127 kidney transplantations, including 62 with nicardipine adjunction; however, no difference in DGF was found. More recently, phase I clinical trials investigating the oxygen transporter and antioxidative agent M101 and the anticoagulant Corline Heparin Conjugate (CHC, also known as Renaparin) have also been reported (Le Meur et al., 2020; Sedigh et al., 2022). No significant difference in adverse events was found for either drug in the early to mid-term period, with mitigated results on kidney function; however, the study designs were not suitable for drawing definitive conclusions. Compared to the few clinical studies available to date, numerous preclinical studies have investigated a wide range of pharmacological agents, including antioxidants, metabolism-targeted treatments, gaseous agents, anticoagulants, anti-apoptotic agents, and anti-inflammatory agents.
3.3 Pharmacological agents from preclinical studies
3.3.1 Antioxidants
3.3.1.1 Flavonoids
Flavonoids belong to a family of natural polyphenolic compounds widely recognized as antioxidants. In two studies involving porcine proximal tubular cell models, researchers have found that adding certain flavonoids to preservation solutions resulted in preserving cell morphology and integrity, reducing ROS formation, and decreasing ATP depletion (Ahlenstiel et al., 2006; Karhumäki et al., 2007). One study focused on tanshinone IIA supplementation during ex vivo rat kidney cold storage in Celsior and found concordant results with an upregulation of superoxide dismutase (SOD) and a decrease in pro-oxidant and pro-apoptotic factors (Zhang et al., 2012). So far, resveratrol is regarded as one of the most studied flavonoid since two studies have confirmed its protective effects in DCD porcine autotransplantation models for SCS and HMP supplementation; however, both studies tested two different formulations of resveratrol (ADD10 and Vectisol) (Cassim et al., 2022; Soussi et al., 2019). Functional benefit was confirmed by improved tubular function and reduced creatininemia and fibrosis in the post-transplant setting up to 3 months.
3.3.1.2 Direct scavengers
Apart from flavonoids, many other compounds have been screened for their ability to scavenge ROS. In four studies involving tubular and endothelial cell models, lazaroids were shown to prevent lipid peroxidation and reduced oxidative stress, preserving cell structure and limiting apoptosis (Killinger et al., 1992; Salahudeen et al., 1999; Salahudeen et al., 2000; Salahudeen et al., 2001). Five studies were conducted on ex vivo rat, rabbit, dog, and pig kidneys. Of these, two focused on mitoquinone and showed better preservation of mitochondrial respiration chain activity after 4 h–24 h of cold storage, with decreased superoxide and peroxynitrite levels. These effects resulted in less apoptosis and an improvement in histological lesion scores after 48 h of cold ischemia (Mitchell et al., 2011; Parajuli et al., 2012). One study on PrC-210 added to the UW solution resulted in reduced caspase activity and acute tubular necrosis at 30 h of cold storage (Verhoven et al., 2020). Only a slight benefit of Trolox, a water-soluble vitamin E analog, has been reported on MDA levels and Schiff bases in two studies (McAnulty and Huang, 1997; McAnulty and Huang, 1996). Furthermore, five studies conducted on ex vivo rat, dog, and pig kidney models focused on vitamin C, zinc, and selenium for preservation fluid supplementation, respectively; however, a negative impact on cytolysis and oxidative stress markers was recorded, although data were limited (McAnulty and Huang, 1997; McAnulty and Huang, 1996; Ostróżka-Cieślik et al., 2018; Ostróżka-Cieślik et al., 2021; Ostróżka-Cieślik et al., 2020a). After investigations showing improved cell viability and decreased neutrophil adhesion in human endothelial cells, Lec-SOD was directly introduced into a rat kidney allotransplantation model (Koo et al., 2001). Reduced apoptosis and immune cell infiltration up to 24 weeks, along with decreased proteinuria, were found (Nakagawa et al., 2002). Similarly, although the iron chelator deferoxamine showed promise for lipid peroxide reduction in four studies on kidney tubular cells (Salahudeen et al., 1999; Salahudeen et al., 2000; Salahudeen et al., 2001; McAnulty and Huang, 1997), introduction into a syngeneic rat kidney transplant model found improvement in tubular necrosis and glomerular filtration rate during the first 10 days (Huang et al., 2003). Two studies on porcine autotransplantation investigated propofol and M101 for fluid supplementation. Due to its intrinsic SOD activity, M101 supplementation has demonstrated benefit in improving kidney functional and histological outcomes up to 3 months in 24-h static cold-stored kidneys (Thuillier et al., 2011). However, after 23 h of hypothermic perfusion of DCD kidneys with propofol, no improvement in kidney function or histology was found, despite previous benefit in isolated porcine tubular cells (Snoeijs et al., 2011).
3.3.2 Mitochondrial metabolism-targeted treatments
Targeting cell metabolism is another strategy to enhance organ preservation through conservation of ATP stocks. Ten studies investigated trimetazidine in porcine models. Trimetazidine supplementation of UW or Euro-Collins during 24–72 h of SCS of porcine kidneys demonstrated improved perfusion parameters during 2 h of normothermic reperfusion. In addition, improvements in glomerular and tubular function [ex vivo glomerular filtration rate (GFR) and reabsorption fraction of sodium] and oxidative and kidney injury markers in the perfusate, urine, or tissue [lactate, LDH, and trimethylamine N-oxide (TMAO)] were observed, along with reduction in histological lesions (Hauet et al., 1997; Hauet et al., 1998a; Hauet et al., 1998b; Hauet et al., 1998c). These results were confirmed in porcine autotransplantation studies with up to 4 months of follow-up and using various preservation solutions (Goujon et al., 2000; Hauet et al., 2000; Faure et al., 2003; Faure et al., 2004a; Faure et al., 2004b; Baumert et al., 2004). One study on rat syngeneic transplantations after 4 h of cold storage in UW supplemented with propionyl-L-carnitine has shown a significant decrease in creatininemia and granulocyte infiltration in the first 24 h (Mister et al., 2002). Lastly, one rat kidney transplantation study investigated fumarate, but it was associated with increased mortality and histological lesions, with worst kidney functional outcomes indicated by creatininemia and proteinuria up to 6 months (Ploetz et al., 2011).
3.3.3 Gasotransmitters
Inspired by the physiological role of endogenous gaseous signaling molecules, gaseous-derived pharmacologies have attracted interest. In five studies investigating different forms of hydrogen sulfide donors from cellular to rat and porcine transplantation models, sodium hydrogen sulfide (NaHS), the synthetic mitochondria-targeted AP39, and sodium thiosulfate (STS) have demonstrated benefits in improving cold preservation of kidneys. Using a 24-h SCS in the UW preservation method, animal survival was increased up to 1 month, with reduced creatininemia and acute tubular necrosis, confirmed by reduction in the expression of Kim-1 and NGAL tubular injury markers during the first 2 weeks (Lobb et al., 2012; Lobb et al., 2015; Lobb et al., 2017; Juriasingani et al., 2018; Juriasingani et al., 2022; Zhang et al., 2022). Decreased levels of ROS production, pro-inflammatory cytokines, and granulocyte infiltration were also observed at day 14 (Lobb et al., 2012; Lobb et al., 2017; Zhang et al., 2022). Notably, only one study investigated hypothermic perfusion using a 24-h cold preservation period for DCD porcine kidneys perfused with NaHS-supplemented UW and reported short-term benefits in perfusion flow, renal vascular resistance, and first-week creatininemia (Juriasingani et al., 2022).
Carbon monoxide (CO) has also been tested in three preclinical studies. After dissolving CO into UW to reach a reproducible concentration of 40.6 μM, the effect of CO was tested in rat and porcine kidney transplantations using a 24–48-h SCS method (Nakao et al., 2008; Yoshida et al., 2010; Ozaki et al., 2012). A downregulation of HO-1 cytoprotective signaling pathway mRNA expression was observed, indirectly suggesting reduced free heme release induced by IRI. A reduction in early oxidative markers, pro-inflammatory cytokines, and apoptosis was found. Mid-term outcomes were also improved, as evidenced by GFR and proteinuria at day 28, immune cell infiltrate and fibrosis at day 14, and animal survival up to 100 days. Lastly, a histological study was performed on discarded ex vivo human kidneys after 24 h of SCS in UW and following 3–12 h of normothermic reperfusion and revealed a concordant decrease in TUNEL apoptosis after 6 and 12 h of reperfusion (Ozaki et al., 2012).
The effect of preservation fluid supplemented with dissolved hydrogen was investigated in two studies. Using a rat syngeneic kidney transplantation model, glomerular function, tubular injury, and interstitial fibrosis showed significant improvement at 3 months following a 24-h cold storage period (Abe et al., 2012). Extending the cold storage period up to 36 h resulted in a better animal survival rate at day 100, with improved oxidative, inflammatory, and apoptosis parameters. Although descriptive, animal survival, kidney function, and in vivo ultrasonography kidney blood perfusion up to 100 days seemed enhanced in a DCD porcine allotransplant model during short-term cold storage (Nishi et al., 2021).
3.3.4 Anticoagulants
The use of heparin-derived molecules has been investigated in several porcine kidney models. Two studies investigated thrombalexin and CHC. After HMP and normothermic reperfusion, both have shown better perfusion parameters during normothermic machine perfusion (NMP), and CHC also demonstrated improved glomerular function and tubular injuries (Sedigh et al., 2019; Hamaoui et al., 2016). Fondaparinux and melagatran were investigated in four studies involving DCD pig autotransplant models after 1 h warm ischemia time (WIT). Of note, supplementation of the preservation solution, with or without an intravenous injection, at the time of transplantation, was studied. Fondaparinux improved creatinine clearance at 1 month and reduced kidney histological scarring and epithelial–mesenchymal transformation markers at 3 months (Tillet et al., 2015). In addition to demonstrating increased viability with lower oxidative stress and activation in a porcine endothelial cell model, melagatran improved glomerular and tubular function up to 3 months, with reduced pro-inflammatory gene expression and epithelial–mesenchymal transformation markers (Giraud et al., 2009; Favreau et al., 2010; Thuillier et al., 2010). Histological findings were consistent with reduced tubular atrophy, cell infiltration, and fibrosis. It is worth noting that no difference in bleeding was observed in any of the in vivo studies.
3.3.5 Anti-apoptotic agents
Direct inhibition of apoptosis by targeting caspases has been tested to improve kidney graft quality. Pan-caspase inhibition by Q-VD-OPh in two studies and exclusive caspase-3 inhibition by small interfering RNA (siRNA) in three studies have been reported. A reduction in caspase activity and cell death was observed, after Q-VD-OPh supplementation in murine kidney tubular cells, resulting in lower creatininemia, apoptosis, and tubular lesions at 1 week after kidney syngeneic transplantation in mice (Jani et al., 2004; Nydam et al., 2018). Yang et al. reported the use of caspase-3 siRNA in normothermic reperfusion pig kidney and autotransplant models after supplementation for SCS. Although caspase-3 expression, apoptosis, and histological lesions were decreased after 24 h of cold storage and 3 h of normothermic reperfusion, worst outcomes were initially observed after autotransplantation (Yang et al., 2011; Yang et al., 2013). A poor serum stability of the siRNA and systemic compensative responses led the authors to modify the siRNA and associate systemic injection of siRNA at the time of autotransplantation. Up to 2 weeks, the efficacy of the new siRNA was confirmed, which was supported by an improved anti-inflammatory systemic cytokine expression profile, enhanced glomerular function, and reduced tubulointertitial injuries (Yang et al., 2014).
3.3.6 Anti-inflammatory agents
FR167653 is a potent anti-inflammatory drug that inhibits the MAPK–p38 signaling pathway. rhBMP-7 impairs fibrosis development by inhibiting epithelial–mesenchymal transition. Although the use of UW supplemented with FR167653 in a DCD porcine kidney autotransplantation after 24 h of SCS showed an improvement in glomerular filtration and proteinuria, with reduced inflammatory cytokine expression, both treatments demonstrated better tubular cell preservation, with less mesenchymal transition up to 3 months, along with increased HIF-1α expression levels (Ćelić et al., 2018; Doucet et al., 2008). Blockage of the complement system by the C5aR antagonist A8 has also been described in a murine syngeneic transplant study, resulting in improved animal survival at day 2, with better kidney tissue preservation and decreased inflammatory cytokine release (Lewis et al., 2008). Data on LH, prolactin, zinc-N-acetylcysteine, and growth factors were scarce, with only eight cellular and ex vivo kidney studies focused on their ability to promote cell viability and nephroprotection (Ostróżka-Cieślik et al., 2018; Ostróżka-Cieślik et al., 2021; Ostróżka-Cieślik et al., 2020a; Ostróżka-Cieślik et al., 2020b; Singh et al., 2013; McAnulty et al., 2002; Kwon et al., 2007; Petrinec et al., 1996).
4 Discussion
4.1 Current state of investigations into pharmacological agents
The aim of this review was to gather and summarize the investigations of all the tested pharmacological agents used as treatment additives to the preservation fluid to improve hypothermic kidney graft preservation. Sixty-seven studies were included, three of which were clinical trials, including one negative phase III and two encouraging phase I studies. Other clinical trials on preservation solution pharmacology supplementation have been registered, without any publication so far. Although some may have provided negative outcomes and were not published, hopeful recent trials are ongoing and summarized in Table 2. Three of these clinically investigated molecules previously identified in preclinical research have been included herein. The results of the M101 phase III clinical trial are yet to be published, whereas CHC phase II and STS phase I trials are still ongoing (NCT04181710, OXYOP21; CTIS2022-501389-23-02, RENAPAIR022; NCT042921843). Among the remaining pharmacological agents identified in preclinical studies, the vast majority showed a benefit in IRI prevention, and the most promising agents evaluated in porcine transplant studies were trimetazidine (six studies), melagatran (three studies), and ADD-10 and Vectisol (resveratrol), CO, hydrogen, fondaparinux, FR167653, and the stabilized caspase-3 siRNA (one study each). Despite the need for confirmatory results due to limited number of individuals studied, lack of a DCD model with HMP preservation, and short-term outcome evaluations in most studies, we believe that translation into clinical investigations of melagatran and FR167653 should be encouraged.
Table 2. Registered clinical investigations on pharmacological agents for hypothermic kidney preservation fluid supplementation.
4.2 Pathophysiological mechanisms and scientific issues
Interestingly, the complexity of IRI pathophysiology led to the investigation of a wide variety of pharmacological agents, as summarized in Figure 2. As a cornerstone of IRI, oxidative stress and ROS formation have been a major target to improve kidney preservation during cold storage (Ostróżka-Cieślik, 2022). Many antioxidants have been investigated so far, including flavonoids, acting by direct scavenging or upregulation of endogenous enzymes (Cheng et al., 2024). They also demonstrated other promising properties for fighting against IRI, such as antithrombotic and anti-inflammatory properties (Ahlenstiel et al., 2003; Rauf et al., 2017). However, their difficulty to cross the mitochondrial membrane, where ROS are generated, have questioned their potential, leading to the development of modified mitochondria-targeted antioxidants, such as mitoquinone and PrC-210, whose clinical use remains largely investigatory (Ogurlu et al., 2024). Free iron is a major contributor to oxidative stress, which promotes ROS and lipid peroxide formation, leading to cytochrome degradation, free heme deposition, and ferroptosis (Huang and Salahudeen, 2002; Pefanis et al., 2019). This paved the way for the use of iron chelator deferoxamine and carbon monoxide, the latter being endogenously produced by heme oxygenases (HOs) through catalysis of heme (Nakao et al., 2008). However, the most promising results have been observed with hydrogen sulfide, along with its biological effector known as thiosulfate (Zhang et al., 2021; Wu et al., 2025). Thiosulfate presents antioxidant effects, by direct scavenging and increasing endogenous enzyme activity, along with iron- and calcium-chelating and vasodilatory properties. As previously mentioned, the beneficial effects of sulfate donor molecules on kidney graft preservation demonstrated in six of the included studies have led to an ongoing clinical trial (). Another strategy to improve organ preservation is to optimize cell metabolism and preserve ATP stocks. Although its mechanism of action is not fully understood, trimetazidine has been thoroughly investigated in many porcine kidney autotransplant models due to its protecting effects on myocardial ischemia (Dézsi, 2016). Shifting cell metabolism from lipid to glucose oxidation to optimize limited oxygen supply in early ischemia and managing cell acidosis are the main hypotheses of action (Morin et al., 2001). To the best of our knowledge, despite yielding interesting mid-term results, no clinical study has been initiated so far. Contrary to trimetazidine, propionyl-L-carnitine promotes lipid β-oxidation, demonstrating positive but still limited results. Although surprising, its effect may be explained through its ability to promote endogenous antioxidant enzyme activity, to scavenge superoxide and hydrogen peroxide, and to chelate iron (Ostróżka-Cieślik, 2022). Alterations in kidney vasculature are also a source of concern since endothelium impairment can lead to thrombosis or trigger immune cell recruitment, initiating alloimmune response and potential chronic graft injury. The use of heparins has been investigated to cope with the loss of the protective glycocalyx and endothelial cell injuries related to IRI. Thombalexin and CHC have been modified to target and bind the endothelium or cover the exposed extracellular matrix, preventing from thrombosis initiation and leukocyte adhesion (Ma et al., 2024). Although the aforementioned effects of thrombalexin have been confirmed in discarded human kidneys during NMP, a phase II clinical trial involving CHC is currently ongoing (Hamaoui et al., 2016) CTIS2022-501389-23-02, RENAPAIR022.
Figure 2. Pathophysiological mechanisms of the reported pharmacological treatment additives.
However, the complexity of IRI pathophysiology has presented significant challenges, and some studies with negative outcomes have also been reported. Based on a previous positive study in a rat model of ischemic heart, fumarate was investigated for its potential to improve kidney preservation; however, it led to increased graft injuries (Ploetz et al., 2011). This phenomenon may be due to succinate accumulation, which in turn triggers a burst of ROS during reperfusion (Chouchani et al., 2014). Another example is the use of vitamin C. Although having a strong preventing and scavenging effect on ROS, vitamin C is also known to act as a prooxidant in the presence of free transition metals (Gęgotek and Skrzydlewska, 2022). As free iron is released during IRI (Huang and Salahudeen, 2002), this characteristic may explain why vitamin C was associated with no benefit or even increased oxidative stress in the included studies, whether used alone or in combination with deferoxamine (McAnulty and Huang, 1997; McAnulty and Huang, 1996; Ostróżka-Cieślik et al., 2018). Surprisingly, only very few preclinical reports were negative among those screened, while pharmacological agents that have been clinically investigated were even scarcer. An evident publication bias that limits the spreading of negative experimental reports impairs the progress of this pharmacology-based strategy for improved organ preservation (Saat et al., 2016).
4.3 Study limitations and overview of pharmacological supplementation strategies
Beyond the preclinical design of most of the studies which still limits the clinical value of the tested pharmacological agents, the extreme heterogeneity of methodology used must be highlighted. Indeed, differences in the individuals studied (type of cell, type of animal, DBD, or DCD), preservation solutions used (UW, HTK, EC, or Celsior), hypothermic preservation settings (temperature, static or machine perfusion assisted, machine device, or duration of preservation), and modalities of preservation solution addition impair comparability of the investigations and translation to clinical studies (Table 1). Notably, administration of the drug to the kidney during SCS remains unclear in some studies. It was not always specified whether the kidney was flushed with the augmented solution, raising questions about the delivery of the pharmacological agents if the organ was only immersed in the supplemented solution without being rinsed. Thus, caution must still be exercised to the interpretation of these outcomes. Moreover, the opening of the kidney capillaries during machine perfusion and the recurrent circulation of the drug added to the perfusion fluid, repeatedly pumped into the kidney, advocate for the use of machine perfusion to optimize pharmacology delivery (Schutter et al., 2021). Fitting to the current trend to widen clinical indications of hypothermic and normothermic perfusion, pharmacologic adjunct evaluation should now incorporate machine perfusion (Malinoski et al., 2023; Hosgood et al., 2023).
Different treatment modalities to better preserve the kidney can be used. This review focused on ex vivo kidney graft treatment through supplementation of the preservation solution which we believe to be the best and safest strategy. The treatment of the donor involves ethical issues, and recipients face the burden of potential side effects. Moreover, the post-reperfusion treatment strategy is rather inopportune as IRI has already been initiated and it can be challenging to mitigate. A higher and risky systemic posology to reach an effective dose into the graft could also be necessary. Direct targeting of the kidney graft during the ex vivo preservation period can overcome all these issues: a minimal effective dose without any exposure of the recipient before the initiation of IRI for a better prevention. The timing of treatment addition can also be chosen, from the beginning of the preservation period to few hours before the transplant surgery. Yet, the hypothermic preservation method can be criticized since the metabolism of the pharmacological agent is limited. Indeed, the landscape of kidney preservation modalities is evolving, although these approaches have not yet been integrated into current clinical practices. All investigations conducted in hypothermic settings presented herein are not applicable to studies involving different temperatures or oxygenated preservation methods, and subnormothermic or normothermic perfusion, even with controlled rewarming techniques, will significantly alter the future of the ex vivo pharmacological strategy (Ogurlu et al., 2024; Resch et al., 2020; Hosgood et al., 2015). For instance, we can anticipate that each additive or combination would have a preferred usage and timing of adjunction, depending on their mechanism of action to fit the occurring stage of IRI pathophysiology. Thus, antioxidants and metabolic stabilizers could be mostly suitable for oxygenated HMP to overcome electron and prooxidant accumulation, while control rewarming would benefit from anti-apoptotic agents and gasotransmitters (STS) to manage oxidative stress, chelate ions, promote cell survival, and favor capillary vasodilation, before using anticoagulants and anti-inflammatory agents during NMP to optimize capillary density and prevent from kidney scarring and immune cell trigger. Moreover, a recent review has also highlighted differences in kidney graft lesion profiles depending on their DBD or DCD origin, with the former exhibiting stronger inflammatory responses whereas the latter inducing predominant cell death lesions (Yang et al., 2024). Additive choices could also depend on the donor profile, favoring anti-inflammatory agents for DBD and anti-apoptotic agents for DCD. However, since hypothermic preservation is the gold standard to date, the clinical impact of the discovery of a treatment or a combination of drugs under the usual preservation conditions would be tremendous.
4.4 Limitations of the review and investigation perspectives
This review provides a comprehensive overview of the pharmacological agents investigated for supplementation of the hypothermic kidney graft preservation fluid, although the number of databases screened was limited. We believe that the wide spectrum of the searching terms and the extensive reading of the articles’ reference list must have covered the essential available literature. Furthermore, although other molecules have been tested in the general setting of kidney IRI or in kidney transplantation for donor/recipient treatment, the scope of this review was to focus on kidney graft hypothermic fluid supplementation only since no other review gathered the up-to-date research on this specific topic, to our knowledge. Yet, although many interesting preclinical findings have been highlighted, external validity of the pharmacological addition strategy is still limited. Beyond the aforementioned heterogeneity of models and protocols, it should not be overlooked that extrapolation of improvements observed in preclinical settings with any pharmacological intervention suffers from the intrinsic inaccuracy of models, voluntarily designed to induce sufficient injuries to maximize drug benefit, which is far from the clinical practice optimization spirit of achieving the best patient outcomes. Consequently, benefits of using certain additives become less obvious when best practices such as minimizing ischemia time and properly utilizing machine perfusion techniques are already being implemented. We believe that investigations in this field would benefit from fundamental research to better understand IRI pathophysiology and from standardization of hypothermic preservation settings, along with preclinical models, such as pig autotransplantation with 1-h WIT induced by kidney arterial clamping for DCD models. As previously mentioned, new preservation technologies such as normothermic perfusion, controlled rewarming, and oxygenated hypothermic perfusion should also be implemented to fit the future standards of preservation, even while traditional methods such as SCS play crucial roles for economic reasons. Publication of negative studies would also be of great interest and should be encouraged, implying modifications of scientific journal policy standards. By improving kidney preservation with hope to enhance long-term graft survival and to decrease the overall cost of chronic kidney disease, economic support from public institutions or the industry would be a win–win opportunity, aiming at the benefit of patients. Investigations should continue, with the aim of eventually translating findings into clinical practice.
5 Conclusion
In the era of extended kidney graft transplantations, research on improving graft preservation to manage IRI is of particular importance. Although not new, pharmacology supplementation of the preservation solution remains a promising strategy for its safety and ease of application in the clinic. This review provided an overview of all the investigated treatments in the hypothermic setting, with numerous positive preclinical results. However, the complexity of IRI pathophysiology and the lack of negative data publications impair the translation into clinical studies. Although research into pharmacological improvement in kidney graft preservation should be encouraged and would benefit from standardization and the implementation of new preservation technologies, the results of some hopeful ongoing clinical investigations are yet to be published.
Author contributions
VM: Investigation, Conceptualization, Validation, Writing – review and editing, Funding acquisition, Supervision, Writing – original draft, Formal analysis, Methodology, Visualization, Data curation, Project administration, Resources, Software. TD: Formal analysis, Writing – original draft, Methodology, Visualization, Supervision, Validation, Writing – review and editing. SB: Writing – review and editing, Validation, Supervision, Methodology, Writing – original draft, Formal analysis, Visualization. CM: Formal analysis, Visualization, Validation, Writing – review and editing, Supervision. JR: Writing – review and editing, Formal analysis, Validation, Visualization, Supervision. GB: Formal analysis, Visualization, Validation, Supervision, Writing – review and editing. TP: Writing – review and editing, Formal analysis, Validation, Supervision, Writing – original draft, Visualization, Methodology. JB: Formal analysis, Visualization, Validation, Project administration, Writing – review and editing, Funding acquisition, Supervision, Methodology, Writing – original draft, Conceptualization, Investigation. BM: Project administration, Investigation, Conceptualization, Validation, Writing – review and editing, Funding acquisition, Supervision, Writing – original draft, Formal analysis, Methodology, Visualization, Data curation.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This work was supported by a grant from the Association Française d’Urologie 2023 (VM).
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Footnotes
Abbreviations:CHC, Corline Heparin Conjugate; CO, carbon monoxide; DBD, dead brain donor; DCD, donors after circulatory death; DGF, delayed graft function; ECD, expanded-criteria donor; EC, Euro-Collins preservation solution; GFR, glomerular filtration rate; HIF-1α, hypoxia inducible factor 1α; HMP, hypothermic machine perfusion; HO-1, heme oxygenase 1; HTK, histidine–tryptophan–ketoglutarate preservation solution; IRI, ischemia–reperfusion injury; NaHS, sodium hydrogen sulfide; NMP, normothermic machine perfusion; PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews; ROS, reactive oxygen species; SCS, static cold storage; SOD, superoxide dismutase; STS, sodium thiosulfate; TMAO, trimethylamine N-oxide; TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labeling; UW, University of Wisconsin preservation solution; WIT, warm ischemia time.
1Available at: https://clinicaltrials.gov/study/NCT04181710.
2Available at: https://trialsearch.who.int/Trial2.aspx?TrialID=CTIS2022-501389-23-02.
3Available at: https://clinicaltrials.gov/study/NCT04292184.
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Keywords: kidney transplantation, organ preservation, drug therapy, tissue donor, reperfusion injury
Citation: Mayoral V, Darius T, Bruneau S, Masset C, Rigaud J, Blancho G, Prudhomme T, Branchereau J and Mesnard B (2026) Improving kidney transplantation through the addition of pharmacological agents to hypothermic preservation solutions: a scoping review. Front. Pharmacol. 16:1692398. doi: 10.3389/fphar.2025.1692398
Received: 25 August 2025; Accepted: 30 November 2025;
Published: 23 January 2026.
Edited by:
Gabriel Schnickel, University of California, San Diego, United StatesReviewed by:
Wenlong Sun, Shandong University of Technology, ChinaChengliang Yang, University of British Columbia, Canada
Copyright © 2026 Mayoral, Darius, Bruneau, Masset, Rigaud, Blancho, Prudhomme, Branchereau and Mesnard. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Vincent Mayoral, dmluY2VudC5tYXlvcmFsQGV4dC5pbnNlcm0uZnI=
†ORCID: Vincent Mayoral, orcid.org/0009-0006-6265-6621; Tom Darius, orcid.org/0000-0002-8151-4286; Sarah Bruneau, orcid.org/0000-0002-1552-0725; Christophe Masset, orcid.org/0000-0002-7442-2164; Jérôme Rigaud, orcid.org/0000-0003-2845-9019; Gilles Blancho, orcid.org/0000-0003-0356-5069; Thomas Prudhomme, orcid.org/0000-0003-3601-9339; Julien Branchereau, orcid.org/0000-0002-8460-9352; Benoît Mesnard, orcid.org/0000-0002-3314-1892