Identification of pharmacological inducers of a reversible hypometabolic state for whole organ preservation

Reviewer #1 (Public Review):

Summary:
In this study of metabolism using Xenopus, explanted porcine hearts and limbs, and human organs-on-chips, Sperry et al studied the ability of WB3 to slow metabolism and mobility. The group developed WB3, an analog of SNC80, void of SNC80's delta-opioid receptor binding capacity, and studied its metabolic impact. The authors concluded that SNC80 and its analog WB3 can induce "biostasis" and produce a hypometabolic state which holds promise for prolonging organ viability in transplant surgery as well as other potential clinical benefits.

Strengths:
This study also opens new avenues for therapeutic possibilities in areas such as trauma, acute infection, and brain injuries. The overall methodology is acceptable, but certain concerns should be addressed.

Weaknesses:
1. In cardiac and renal transplantation, cold preservation in ice remains a common practice for transporting explanted hearts to donors which remains a cheap and easily accessible way of preserving organs. While ex-vivo mechanical circulatory platforms have been developed and are increasingly being utilized to prolong organ viability, cold preservation remains widely used. The authors perfused explanted hearts with oxygenated perfusion preservation devices at subnormothermic temperatures (20-23C) which is even much lower than routinely used in clinical cardiopulmonary bypass scenarios (28-32C) (in the discussion, the authors allude to SNC80's possible "protective effect" in cardiac bypass). It is unclear how much of the hypometabolic state is related to WB3 administration versus hypothermia. The study will benefit from a comparison of WB3 administration and hypothermia in Xenopus, explanted porcine organs versus cold preservation alone to show distinction in biostasis parameters.

2. The authors selected SNC80 based on a literature survey where it was identified based on its ability to induce hypothermia and protect against the effects of spinal cord ischemia in rodents. While this makes sense, were other drugs (eg. Puerarin) considered? The induction of hypothermia and spinal cord protective effect of SNC80 may be multifactorial and not necessarily related to its biostatic effects as the authors describe. Please provide some more context into the background of SNC80.

3. In most of the models, the primary metric that the authors utilize to characterize metabolic activity is oxygen consumption, which is a somewhat limited indicator. For instance, this does not provide any information, however, on anaerobic metabolic activity. In addition, the ATP/ADP ratio was found to decrease in the organ chips where SNC80 was utilized, but similar findings were not presented for the other models.

4. The authors should provide a more detailed explanation of SNC80's mechanisms of interaction with proteins related to transmembrane transport, mitochondrial activity, and metabolic processes. What is the impact of SNC80 on mitochondrial function, particularly ATP production and mitochondrial respiration? Are there changes in mitochondrial membrane potential, electron transport chain activity, or oxidative phosphorylation? In this context, the authors discuss the potential role of NCX1 as a binding target for SNC80 and its various mechanisms in slowing metabolism. However, no experiments have been done to confirm this binding in the present study. Co-immunoprecipitation studies using appropriate antibodies against SNC80 and NCX1 should be considered to demonstrate their direct binding. Additionally, surface plasmon resonance (SPR) or isothermal titration calorimetry (ITC) experiments could be employed to quantify the binding affinity between SNC80 and NCX1, providing further evidence of their interaction. These experiments would elucidate the binding mechanism between SNC80 and NCX1 and reveal more information on the mechanism of action for SNC80.

5. The manuscript notes that histological analysis was conducted, but it seems that only example images are provided, such as Figure 4f. Quantified histological data would provide a more thorough understanding of tissue integrity.

6. Some of the points mentioned in the discussion and conclusion are rather strong and based on possible associations such as SNC80's potential vasodilatory capacity conferring a cardioprotective effect, and ability to reversibly suppress metabolism across different temperatures and species. Please tone this down and stay limited to the organs studied. Further, the reversibility of the findings may be more objectively assessed by biomarkers with decreased immunofluorescence in response to ischemia such as troponin I for the heart and albumin for the liver. Additionally, an investigation of proteins involved in inflammation, hypoxia, and key cell death pathways using immunohistochemistry analysis can better describe the impact of treatment on apoptosis/necroptosis.

7. What could be the underlying cause of the observed increase in intercellular spacing after SNC80 administration in porcine limbs which also seems to be evident in the heart histology samples? This seems to be more prominent in the SNC80 compared to the vehicle group.

8. In the Discussion section, it would be valuable to provide a concise interpretation of the lipidomic data, particularly explaining how changes in acylcarnitine and cholesterol ester levels may relate to tadpole metabolism, hibernation, or other biological processes.

9. What are the limitations or disadvantages of the study? Does SNC80 possess any immunomodulatory properties that might affect the outcomes of organ transplantation? Are there specific organs for which SNC80 may not be a suitable preservation agent, and if so, what are the reasons behind this?

Reviewer #2 (Public Review):

Summary:
This manuscript titled "Identification of pharmacological inducers of a reversible hypometabolic state for whole organ preservation" reports the effects of delta opioid receptor activator SNC80 and its modified analog WB3 with ~1,000 times less delta opioid receptor binding activity on metabolic state.

Strengths:
This is an interesting study with potentially broad implications for organ preservation.

Weaknesses:
There are several limitations that raise concerns.

1. The authors developed an analog of a known delta opioid receptor activator SNC80 with three orders of magnitude lesser binding with the delta opioid receptor WB3. This will likely reduce the undesirable effects of SNC80 while preserving the metabolic slowing needed for organ preservation. Yet, most experiments were done with SNC80, not the superior modification, WB3, shown in only a limited set of experiments, Figure 3.

2. The heart is one of the most challenging organs to preserve, and some experiments are done to establish the metabolic effects of SNC80. However, the biodistribution study, shown in Figure 2, conspicuously omitted the heart.

3. I do not understand the design of the electrophysiology and contractility experiments with the porcine hearts. How did you defibrillate the hearts after removal and establishing perfusion? Lines 173-175 on Page 7 state: "After defibrillation with epinephrine, the P and QRS waveforms were visible in ECGs from 3 of 4 SNC80-treated hearts (Table S1), suggesting that those hearts regain atrial and ventricular polarization." Please clarify. Defibrillation is done with an electric shock. Also, please show the ECG recordings to support your conclusions about "polarization." What did you mean by "polarization"? Depolarization? Repolarization? Or resting potential. To establish a normal physiological state, please show ECG waveforms and present data on basic ECG characteristics: heart rate, PQ and QT intervals, and P and QRS durations. I recommend perfusion of the porcine heart with WB3, not only SNC80.

4. Pathology data also raises concerns. The histology images shown in Figure 4f are not quantified, and they show apparently higher levels of tissue disruption in SNC80-treated tissue vs vehicle-treated. The test (lines 169-171) confirms this concern: "In some hearts treated with SNC80, greater waviness of muscle fibers was observed, possibly indicating a state of muscle contraction." It will be helpful to measure markers of apoptosis and necrosis and to apply TTC viability staining.

5. The apparent state of contracture suggests a higher degree of myocardial damage and a high intracellular calcium level in SNC80-treated hearts. The authors suggested that the sodium-calcium exchanger NCX is a possible target of SNC80 and could be responsible for the "hypometabolic state." However, NCX1 is critically important in the extrusion of cytosolic Ca2+ during the diastolic phase. Failure to remove excessive calcium and restore ionic homeostasis would lead to calcium overload and heart failure.

6. I am surprised the authors did not consider using the gold standard assay for measuring mitochondrial function in cells by the Seahorse Cell Mito Stress Test.

Reviewer #3 (Public Review):

In this manuscript, Sperry and colleagues identify SNC80 as a compound that can slow metabolism and mimic hibernation, thereby prolonging tissue viability in organ transplantation and cardiovascular disease settings. Overall, the use of varied and relevant model systems is a strength of this study.

The authors perform a literature search to identify SNC80 as a promising hit. However, the details of the literature search, a list of other potential hits, and the criteria for identification of SNC80 are not described. The hypometabolic effect of SNC80 exposure is well-characterized in the Xenopus model. Furthermore, the authors show that SNC80 localises to the brain, but do not discuss several studies that have pointed to convulsions induced by exposure to high doses of SCN80, and whether this would be apparent in the Xenopus studies. The authors have promising data on the WB3 morpholino that retains or even improves on the hypometabolism phenotype of SCN80 while likely not retaining delta opioid activity. However, this is not functionally demonstrated. Moreover, WB3 is not used in any of the other assays and models used in the study. In the setting of cardiac transplant surgery, co-administration of SNC80 reduces metabolic activity and inflammation, although it is unclear if there is an improvement in recovery of organ function due to SCN80. The reversible induction of hypometabolic status is also demonstrated in two different organ chips. These models could identify the differential response of epithelial cells and vascular cells to drug perfusion, but the authors have mostly focused on the former. Finally, the authors identify specific targets for the hypometabolic effect of SNC80, which is a valuable resource for other screening studies and can form the basis for future work.