ASTADAN, CHANTELLE GAYLE B.

BS CHE 3
ChE 325 10:30 11:30 MWF

25 MAY 2015

Animal Agriculture: Gene Knockout

Upon picking the broad topic of Animal Agriculture, it got me thinking how I would
relate this to Biotechnology. Remembering all the lessons we had, surely there are a vast of
choices for this. One thing that I was sure about was that I was going to share my insights on a
particular application of biotechnology in animal agriculture. Honestly, I did not like the topic I
got because I personally am not interested in this field. But as I surf through the Internet for
several possible applications to work on, I found one that got my attention namely, Gene
Knockout.
First let me define the term gene knockout. A gene knockout is a genetically engineered
organism that carries one or more genes in its chromosomes that have been made inoperative
(have been "knocked out" of the organism). The term also refers to the process of creating such
an organism, as in "knocking out" a gene.
Now, what makes this technology interesting? For several years now, scientists have been
trying to use gene knock out technology to create possible replacement organs from other species
for humans. Among the several purposes of Gene knockout, this one is what made me choose
this application. We all know that the best organ donor for humans is still a human itself. But
even with a consenting person to donate his or her organ for an in need patient, I believe that this
should be a last resort and not be the only answer. With all the advances in science and
technology, surely there are a lot of choices. One of these advances and a possible choice is
xenotransplantation.
As what we have learned in our Biotechnology subject, every living organism is made up
of a gene that makes it unique and different from other species. Primarily, knowing this makes
me think that incorporating an organ of certain specie to a different one is clearly impossible. My
basis for this is like the mechanism of donating blood, another topic we discussed previously.
There are four types of blood A, B, AB and O. In blood transfusion, factors like antigen and
antibodies are taken into consideration. For example, blood type A can receive only blood type A
and O and not from B because they contain antibodies for B antigen. And when a blood of type B
is transfused into a person of blood type A, that person will show signs of rejection and this
sometimes can be fatal to a sick person and cause him or her to die. Our immune system is the
one that will recognize the B antigen from the blood type B and fight it with the antibodies for B
antigen that is already present in a person with blood type A. Relating this to the topic of
xenotransplantation, having a pig organ transplanted to a person will have the same reaction as to
that of wrong type of blood being transfused.

As of now, pigs are the most viable organ donors to humans among other species because
they have vital organs that are comparable in size of those in humans. But as every living
organism, pigs also have genetic markers that are recognized as foreign and rejected by our
immune system. This is where gene knockout comes in. By genetic engineering, the gene
responsible for the protein making the marker is knocked out so that when an organ is
transplanted, there is lesser chance of rejection. Even with a smaller chance of rejection of organs
or cells from pigs or other possible organ donors due to gene knockout, anti-rejection drugs are
still given to patients in order to completely ensure the survival of the organ transplanted.
Isnt this a better choice than having a completely healthy person give up his or her
organ? For me, the answer is yes. Id rather gamble with this procedure than having someone I
know or not know give up his organ because I know that when that person does, he or she will
also be at risk of not having a normal life again.
Other issues being scrutinized about xenotransplantation are the complications one might
contract upon having a pigs organ transplanted. The articles I have read said that there has been
no reported case of infection of human cells by porcine endogenous retroviruses (PERV) up to
date. For example, 1 long-term follow-up study on 18 human recipients of pig islet cell
transplants showed no evidence of PERV infection in any of the patients 9 years after
xenotransplantation.
As of now, xenotransplantation shows future promising results. Although most of the
researches regarding this are still in their experimental stages and not yet fully accepted by our
society due to various reasons, I believe that once this is perfected it can save many lives. Not
just the lives of those who are sick and in need of new and healthy organs but also those who are
willing to donate their fully and completely healthy organs.

References:
Gene knockout. (n.d.). Retrieved May 24, 2015 from
http://webcache.googleusercontent.com/search?
q=cache:RhGK50vpERAJ:www.biotec.uniba.it/area_docenti/documenti_docente/materiali_d
idattici/43_knockout.PDF+&cd=14&hl=en&ct=clnk&client=opera
Animal Biotechnology. (20062015). In About Bioscience. Retrieved May 24, 2015 from
http://www.aboutbioscience.org/topics/animalbiotechnology
Samdani, T. (2014). Xenotransplantation. Retrieved May 24, 2015 from
http://emedicine.medscape.com/article/432418-overview#showall
Xenotransplantation
Author: Tushar Samdani, MBBS, MRCS, DNB; Chief Editor: Ron Shapiro, MD

Overview
Xenotransplantation involves the transplantation of nonhuman tissues or organs into human recipients.
The concept was pioneered a century ago, when transplanting human organs was considered ethically
controversial. Grafts were quickly rejected, however, because of unknown forces later identified as
immune responses.
Interest in xenotransplantation reemerged during the 1960s, when large advances were made in
immunology. Chimpanzee kidneys have been transplanted into patients with renal failure. [1] In 1984, a
baboon heart was transplanted into a newborn infant, Baby Fae, who had hypoplastic left heart
syndrome and lived 20 days after heart surgery.[2] A baboon liver was transplanted to a patient with
hepatic failure.[3] Porcine islet cells of Langerhans have been injected into patients with type 1 diabetes
mellitus.[4] Porcine skin has been grafted onto burn patients, [5] and pig neuronal cells have been
transplanted into patients with Parkinson (Parkinsons) disease and Huntington (Huntingtons) disease.[6]
During these advances, several obstacles to the success of xenotransplantation have been identified.
These include, but are not limited to, (1) preventing hyperacute rejection, (2) preventing acute vascular
rejection, (3) facilitating immune accommodation, (4) inducing immune tolerance, (5) preventing the
transmission of viruses from xenografts into humans, and (6) addressing the ethical issues surrounding
animal sources for xenografts and the appropriate selection of recipients (given that xenotransplantation
remains experimental).[7]The purpose of this review is to identify the obstacles and recent progress made
in the field of xenotransplantation.
The rationale of xenotransplantation
The motivation for using animal sources for organ or tissue transplantation is driven by supply and
demand. According to the most current report from the United Network for Organ Sharing (UNOS), more
than 107,241 Americans were waiting for organ transplantation as of May 2010. [8] In 2009, 28,464 patients
had transplants, and approximately 40% of listed candidates on waiting list were younger than 50 years.
In light of the lack of supply of human organs for transplantation, several alternatives have been
investigated and debated. Implantable mechanical devices have been explored in the field of cardiac
transplantation. Recently, research has increased in the area of transplanting embryonic cells across
species and growing kidneys and endocrine pancreas cells in situ. [9, 10] Organs from pigs have been the
focus of much of the research in xenotransplantation, in part because of the public acceptance of killing
pigs and the physiologic similarities between pigs and human and nonhuman primates.
Xenotransplantation of organs from chimpanzees and baboons has been avoided, however, because of
ethical concerns and fear of transmission of deadly viruses (see Biologic Barriers to Xenotransplantation).
Xenografts have been proposed as appropriate for infants who are physically too small to accommodate
organs retrieved from adult or pediatric donors. Additionally, organs from animal sources could be
transplanted into patients currently excluded from the human organ transplantation list. Finally, most
patients perceive xenotransplantation as an acceptable bridge to transplantation of human organs in lifethreatening situations.[11]
Definition

Xenotransplantation refers to any procedure that involves the transplantation, implantation, or infusion
into a human recipient of either (1) live cells, tissues, or organs from a nonhuman animal source or (2)
human body fluids, cells, tissues, or organs that have had ex vivo contact with live nonhuman animal
cells, tissues, or organs. (US Food and Drug Administration [FDA], 1999; FDA, 2001).
Xenotransplantation products must be alive, and circulation and return of patients' blood must occur
through live nonhuman cells. For example, human skin cells grown outside the body on a layer of
nonhuman cells and then used in humans for skin reconstruction can also be considered a
xenotransplantation product. This latter category of procedures was included in the definition because
scientists believe that the potential for transmission of an infectious disease with such a procedure may
be similar to that of implanting live nonhuman animal cells, tissues, or organs directly into a human
recipient.
Xenotransplantation products include those from transgenic or nontransgenic nonhuman animals and
composite products that contain xenotransplantation products in combination with drugs or devices.
These include, but are not limited to, porcine fetal neuronal cells, encapsulated porcine islet cells,
encapsulated bovine adrenal chromaffin cells, baboon bone marrow, and external liver-assist devices
using porcine liver or porcine hepatocytes. Nonliving biological products or materials from nonhuman
animals, such as porcine heart valves and porcine insulin, are not classified as xenotransplantation
products for the purposes of this definition.
Xenotransplantation products are subject to regulation by the FDA under section 351 of the US Public
Health Service Act [42 U.S.C. 262] and the Federal Food, Drug and Cosmetic Act [21 U.S.C. 321 et seq].
In accordance with the statutory provisions governing premarket development, xenotransplantation
products are subject to FDA review and approval.
Depending on the relationship between donor and recipient species, the xenotransplant can be described
as concordant or discordant. Concordant species are phylogenetically closely related species. These
species combinations include mouse to rat, baboon to cynomolgus monkey, or, presumably, nonhuman
primate to human. Discordant species, on the other hand, are not closely related (eg, pig to mouse, pig to
human).
A concordant recipient takes several days to reject an organ, whereas a discordant recipient mounts a
violent, hyperacute response that leads to xenograft loss within a few minutes to a few hours. This
difference in time to rejection is related to the presence or absence of preformed natural antibodies in
discordant species pairs (described in Immunologic Barriers to Xenotransplantation).
Choosing the Donor Species
Chimpanzees were generally thought to be the best nonhuman primate donor compared with baboons or
rhesus monkeys. However, their availability rapidly dwindled in the 1960s, and they were later listed as
endangered species. Consequently, scientists sought other potential animal sources for organs for
xenotransplantation. Species such as baboons, although existing in greater abundance compared with
chimpanzees, fare poorly in captivity, have a long gestation, and have few offspring.
The FDA's Biologic Response Modifiers Advisory Committee (BRMAC), after conducting an in-depth
investigation of this issue and convening public hearings, noted its findings and concern on this matter in
the federal register dated January 2001.[15] In this document, the BRMAC raises concern regarding

interspecies transmission of xenogeneic infectious agents. It also notes the potential for subsequent
transmission of a xenogeneic infectious agent from the recipient to the recipient's close contacts, and
propagation through the general human population, as an additional risk and a recognized public health
concern.
The BRMAC has also identified the potential risk of insertional mutagenesis associated with the infection
of xenotransplant recipients, their close contacts, and the general population with xenogeneic
retroviruses. In addition to potential horizontal transmission of infectious agents from the recipient of a
xenotransplantation product to the recipient's contacts, BRMAC is concerned regarding vertical
transmission of infectious agents from the recipient to progeny during gestation (ie, transmission from
mother to fetus of infectious agents across the placenta or during parturition).
Vertical transmission of xenogeneic infectious agents could result in the development of infectious
disease in progeny. In addition, vertical transmission of xenogeneic viruses can result in insertional
mutagenesis with disruption of normal human development or integration into the germline, resulting in
transmission to future generations. The BRMAC considered nonhuman primate donors to pose the
greatest threat of transmitting latent, intracellular, or unidentified organisms, including retroviruses, and
recommended that nonhuman primates not be used as sources of xenotransplantation products until
more information is available to assess safety issues.
This led investigators to seek other animal sources. Monkeys are not considered acceptable organ
donors for both practical and ethical reasons. In addition to being uncomfortably close to humans on the
evolutionary ladder, they also produce few offspring, are slow to mature, and would be difficult to rear
under the sterile conditions required to minimize contamination by shared pathogens.
Most investigators agree that pigs have the potential to be the prime candidates for organ donation. Pigs
are plentiful, are quick to mature, breed well in captivity, have large litters, and have vital organs roughly
comparable in size to those of humans. Because they are already being used in the consumer market,
their use in xenografting is less likely to elicit major objections from society. Because humans have had
prolonged and close contact with pigs, their use for the purpose of xenotransplantation is believed to be
less likely to introduce any new infectious agents. However, use of pig xenografts is associated with major
immunologic barriers, resulting in hyperacute rejection (HAR) when transplanted into a nonhuman primate
or human recipient.
Immunologic Barriers to Xenotransplantation
Immunology of Xenograft Rejection
Hyperacute rejection
Transplanting solid organs from animal sources into humans results in rapid loss of the xenograft
because of hyperacute rejection. In this dramatic immunologic reaction, preformed antibodies circulating
in human blood bind to the vascular epithelium of the animal organ and trigger a cascade that quickly
results in thrombosis of the graft.
Humans have preformed antibodies known as xenoreactive natural antibodies (XNAs), which are directed
against nonprimate species. XNAs appear in the early neonatal period following colonization of the large
bowel by coliform bacteria. These antibodies primarily consist of immunoglobulin M but also probably

include the immunoglobulin G and immunoglobulin A classes. Their binding is characterized by avidity
and surprising uniformity.
Most XNAs recognize carbohydrate moieties associated with bacterial cell walls. Most human XNAs are
directed against terminal carbohydrate, Gal1, and 3a-GalbGlcNAC-R, in which a galactosyl residue is
linked to another galactosyl residue. This process is controlled by an enzyme galactosyl transferase.
Humans lack this enzyme, and the carbohydrate epitope is therefore perceived as a foreign antigen and
antibodies arise against it. This carbohydrate moiety is expressed on pig cells. Thus, humans have
naturally occurring antibodies (ie, XNAs) against pig cells.
XNAs recognize porcine glycoproteins of the integrin family. Antibody binding initiates complement
activation through the classic pathway, triggering a number of effector mechanisms. These mechanisms
may include loss of heparan sulfate from endothelial cells (EC) mediated by C5a and xenoreactive
antibody, a change in endothelial cell shape mediated by C5b-7 or the membrane attack complex,
procoagulant changes mediated by the membrane-attack complex, and neutrophil adhesion mediated by
iC3b.[16]
The immunologic cascades triggered during hyperacute rejection destroy very discordant xenografts
within minutes to hours. This process is characterized by immediate engorgement and discoloration of the
organ. Under light microscopy, interstitial hemorrhages and platelet microthrombi are evident.
Immunohistologically, dense deposition of various immunoglobulins and multiple complement
components is noted throughout the vascular bed. The anaphylatoxins C3a and C5a generated in the
process stimulate basophils and mast cells to release histamine, which, in turn, results in platelet
degranulation.
Binding of histamine and serotonin to receptors on endothelial cells stimulate the expression of plateletactivating factor and P-selectin. Platelet-activating factor dramatically increases vascular permeability and
endothelial cell contraction, resulting in platelet and RBC sludging within the microcirculation. This
complex interplay of complement components, platelets, and endothelial cells leads to platelet
aggregation, coagulation, fibrin deposition, and hemorrhage, typically culminating in thrombosis and
ischemic necrosis within minutes of engraftment.
Acute vascular rejection
If the transplanted organ is not rejected within minutes to hours, a more delayed type of immunologic
response ultimately leads to thrombosis of the graft within hours to days. This process known as delayed
xenograft rejection or acute vascular rejection.
Under light microscopy, focal infarcts, interstitial hemorrhages, and widespread coagulation of
microvasculature are observed. DXR is characterized by progressive infiltration of monocytes and natural
killer cells (over several days), endothelial cell activation, platelet and fibrin deposition, and cytokine
expression. Only very small numbers of T cells are noted (~5%). The role of macrophages and natural
killer cells in DXR has yet to be determined; however, neither XNAs nor T cells are essential for DXR in
complement-depleted rats.
Although endothelial cell activation is believed to play a key role, factors that trigger it are not well defined.
Endothelial activation is type II in nature because it involves gene induction and protein synthesis. This
includes a shift to a procoagulant state, secretion of chemokines such as membrane cofactor protein-1,

and induction of leukocyte adhesion molecules such as E-selectin, intercellular adhesion molecule-1, and
vascular cell adhesion molecule-1.
Overcoming Xenograft Rejection
To devise therapeutically effective strategies to defeat HAR and DXR, a detailed understanding and
identification of complex inflammatory pathways and key events are indispensable. This involves in-depth
study of both donor and recipient factors that play critical roles in mounting and sustaining a rejection
response. This section focuses on approaches proposed to circumvent xenograft rejection.
Experimental xenotransplantation
Several experimental designs have been developed for xenotransplantation of these genetically modified
organs. In the ex vivo model, the genetically transformed porcine organ is infused with human blood or
serum to see if hyperacute rejection occurs. Alternatively, in the life-sustaining model, genetically modified
pig organs have been transplanted into baboons or monkeys undergoing immunosuppressive therapy.
Xenotransplantation may be performed orthotopically such that the native organ is removed and the
transplanted organ occupies the anatomic location.
Xenotransplantation of organs from transgenic pigs for CD55 (hDAF) has been extensively studied over
the last five years with mixed results. Researchers recently showed that higher levels of CD55 expression
in transgenic pigs increase survival of grafts in baboons that have undergone xenotransplantation.
[28]
CD55 transgenic porcine hearts have been successfully transplanted orthotopically into baboons, with
a median survival of 14.6 days.[29] Organs transgenic for CD55 also appear resistant to cellular lysis by
human serum.[30] In other ex vivo models involving xenotransplantation of transgenic pig lungs into
baboons, however, hyperacute rejection has been reported upon perfusion of the graft. [31]
Many groups have prolonged survival of CD55 (hDAF) transgenic pig organs with infusion of various
agents or soluble antibodies. For example, reduced myocardial damage has been reported in ex vivo
experiments in which CD55 transgenic grafts were perfused with GPIIb/IIIa inhibitor tirofiban. [32] In other
experiments, CD55 transgenic pig hearts have been transplanted into baboons that were also
administered soluble Gal-glycoconjugates to block baboon antibodies from binding to the Gal moiety on
renal endothelium. These grafts survived for 3 months.[33]AntinonGal antibodies have been suggested to
be involved in the ultimate acute humeral xenograft rejection of the kidneys. [34] Other groups have
attempted life-supporting xenotransplantation of transgenic CD55 pig kidneys in baboons with infusion of
soluble complement receptor type 1, TP 10. These grafts ultimately failed because of chronic deposition
of complement in the endothelium.[35]
Biologic Barriers to Xenotransplantation
The use of xenotransplantation products carries a natural and expected risk of transmitting infectious
pathogens. This risk is beyond the risk of infections known to be associated with allotransplantation,
which is a consequence of immunosuppression. This serious risk originates from the potential of
xenotransplantation for transmitting infectious agents from nonhuman animals to humans. The HIV
pandemic, Creutzfeldt-Jakob disease, Ebola virus outbreaks, and, more recently, the severe acute
respiratory syndrome scare have elicited serious concern about the potential of inadvertent transmission
of known and unknown infectious agents that may spread to recipients and to their contacts and health
care workers, quickly becoming a public health issue.

Thus, for the following reasons, infectious risks associated with xenotransplantation may be far greater
than those noted with allotransplantation:[59]

The level of immune suppression and/or rejection may be greater in xenograft recipients,
enhancing the activation of latent pathogens, including viruses.
Organisms carried by the graft may not be known human pathogens and/or may include
xenotropic organisms, ie, organisms that are not pathogens in the native host species but which cause
disease in other species, in this case, the human recipient.
Microbiologic assays may not exist for some organisms derived from nonhuman species.
Novel animal-derived organisms may cause novel and thus unrecognized clinical syndromes.
Genetic modification of the donor animals (one xenotransplantation strategy) or treatment of the
recipient with, for example, tolerance induction or antibody removal, may alter the host's susceptibility to
organisms.
Xenosis
The term xenosis has been coined to describe the transmission of infections by the transplantation of
xenogeneic tissues or organs. Xenosis, or xenozoonosis, potentially poses unique epidemiological
hazards owing to the efficiency of transmission of pathogens, particularly viruses, with viable cellular
grafts. When an infectious agent gains entry into a new host species, its capacity to produce disease is
unpredictable.
For example, in its natural host, the macaque monkey, cercopithecrine herpesvirus 1 (B virus) infection
has a clinical profile very similar to that of herpes simplex virus infection in humans. However, B virus
infection of humans or other nonmacaque primates results in rapidly progressive myeloencephalitis with
a mortality rate of approximately 70%.[60] This failure of the pathogenic potential of a microbe in its host
species to reliably predict the pathology that results when it is introduced into another species is evident
with many other zoonotic agents and diseases.
Organisms of serious concern include herpesviruses and retroviruses, which can be screened for and
eliminated from the donor pool. Others include Toxoplasma gondii, Mycobacterium tuberculosis, and
encephalomyocarditis virus. Filoviruses (Marburg and Ebola), monkeypox virus, and simian hemorrhagic
virus are less likely to be found in animals reared in captivity in the United States.
Retroviruses
Retroviruses, by virtue of the enzyme reverse transcriptase, become inserted into host chromosomal
DNA. Compelling arguments suggest that the HIV pandemic resulted from the adaptation of simian
retroviruses introduced across species lines into humans. Existing data suggest that the HIV-2 pandemic
in East Africa began with the horizontal transmission of simian immunodeficiency virus from a sooty
mangabey monkey into a human with subsequent transmission through the human population. In Central
Africa, horizontal cross-species transmission of simian immunodeficiency virus from a different primate
species, probably a chimpanzee, resulted in the HIV-1 pandemic. Initial human infections before 1970
resulted in more than a decade of insidious human-to-human transmission before AIDS was first
recognized as a public health problem in the 1980s.
Endogenous retroviruses exist as part of the genomic material of most, if not all, mammalian species,
including humans. Endogenous retroviruses cause equal concern and greater uncertainty than the
exogenous retroviruses. Endogenous retroviruses, presumably originating as exogenous viruses that

became permanently integrated into the host germ line, are vertically transmitted through inheritance. In
the host species, they are benign. However, endogenous viruses are frequently xenotropic, ie, although
the original host is refractory to infection, the viruses can infect related species.
The increased phylogenetic distance between swine and humans presumably makes pigs safer donors
than nonhuman primates. This presumption has not been completely explored. The biology and
pathogenicity of a type C retrovirus identified in the blood of leukemic or irradiated swine are incompletely
characterized. Similarly, the discovery of porcine endogenous retroviruses (PERVs) capable of infecting
human cells in vitro has raised issues regarding the safe clinical application of xenotransplantation. [61, 62, 63]
Phylogenetic analysis reveals that PERVs are closely related to gibbon ape leukemia virus, endogenous
koala retrovirus, and inducible murine endogenous retrovirus. [64, 65] PERV RNA is expressed in several
porcine tissue types (eg, kidney, lung, liver, heart, pancreatic islets); however, expression of virus mRNA
does not necessarily correlate with the release of infectious particles. Many human cells clearly express
receptors specific for PERV A and B, whereas PERV Cspecific receptors cannot be detected in most
instances.[66, 67]
Several viral pathogens have been identified in the xenografts from pigs, which are the most common
animal source of xenografts. These include, but are not limited to, porcine endogenous retrovirus (PERV),
porcine cytomegalovirus (PCMV), and porcine lymphotrophic herpes virus (PLHV), and porcine circovirus
type 2, (PCV). In New Zealand, pigs raised for xenotransplantation were found to harbor
encephalomyocarditis (EMCV) and hepatitis E.[68] Importantly, pigs do not have the exogenous retroviral
equivalent of the HTLV or HIV virus. Two strains of the PERV virus (strain A and B) are present in only a
subset of swine and have the potential to infect human cells in vitro. Importantly, the PCMV strains can be
selected out of the pool of potential xenografts by early weaning of piglets.
Experimental xenotransplantation of organs from swine to nonhuman primates has demonstrated the
absence of PERV transmission. One study suggested that decreased risk of transmission of endogenous
retroviruses from pigs to baboons is correlated to decreased amounts of circulating antialpha Gal
antibody.[69]Others have shown an absence of PERV infection in baboons receiving transgenic livers. [70]
Over the past 10 years, many sensitive diagnostic assays have been developed to detect most potential
viruses associated with xenotransplantation of organs into humans. For example, 1 long-term follow-up
study on 18 human recipients of pig islet cell transplants showed no evidence of PLHV, PCMV, PCV, or
PERV infection in any of the patients 9 years after xenotransplantation. [71] No in vivo infection of human
cells by the PERV virus has been reported to date. By contrast, the transplantation of baboon livers and
chimpanzee kidneys into humans had resulted in deaths due to illnesses not related to organ failure. [72]
Japanese researchers are attempting to engineer transgenic pigs that would be genetically incapable of
harboring endogenous retroviruses. Such a breed of pigs would express the RNA interference silence
genes.[73]
Ethical Issues
Beneficence and risk-to-benefit analysis
Risk assessment is based on the principle that the possible harm of the research must be outweighed by
its probable benefits. Preclinical data, including nonhuman primate data, must adequately support the

possibility of a successful outcome.[78]In addition, for any ethically conducted trials, risks to the patient and
to society must be minimized.
Animals used for xenotransplantation should be bred in captive, closed colonies in order to ensure the
exclusion from the colony of known potential pathogens to humans. The extensive human experience
with short-term exposure to porcine materials, including patients receiving porcine insulin, clotting factors,
and temporary skin grafts, is reassuring. However, none of these situations involves the long-term
presence of large numbers of porcine cells or organs in an immunocompromised individual.
Autonomy and informed consent
Xenotourism
Animal-related ethical issues
Religious views on xenotransplantation
Popular perception of xenotransplantation
Current Status and Future Directions
As previously mentioned, xenotransplantation and xenotransplantation products come under the
regulatory authority of the FDA. In 1997, the FDA formed the Xenotransplantation Subcommittee of the
BRMAC as an ongoing mechanism for open discussions of the scientific, medical, social, ethical, and
public health issues raised by xenotransplantation and the specific ongoing and proposed protocols.
The FDA has developed a xenotransplantation action plan to provide a comprehensive approach for the
regulation of xenotransplantation that addresses the potential public health and safety issues associated
with xenotransplantation and to provide guidance to sponsors, manufacturers, and investigators regarding
xenotransplantation product safety and clinical trial design and monitoring.
From time to time, the FDA publishes guidance documents to assist sponsors and investigators interested
in conducting clinical trials in the field of xenotransplantation. These documents provide reasonably
detailed and timely pragmatic guidance to sponsors regarding xenotransplantation product safety and
clinical trial development, including specific recommendations for the procurement and screening
qualification of source animals, the manufacture and testing of xenotransplantation products, preclinical
testing, clinical trial design, and posttransplantation monitoring and surveillance of recipients of
xenotransplantation products. The FDA provides notice of and invites public comment on these draft
documents. One such final guidance document for the industry can be accessed on the Internet
athttp://www.fda.gov/cber/guidelines.htm.[87]
The FDA has sponsored, planned, or participated in numerous open public meetings and workshops
(both domestic and international) that partially or wholly focused on xenotransplantation. These activities
are essential for both sharing information and receiving public input on issues relevant to
xenotransplantation.
Although clearly an experimental procedure, investigators in clinical xenotransplantation have been
accused of using "the guise of bridge-to-transplantation" to appear acceptable to institutional review or

ethics boards.[88]However, the use of xenografts solely as bridges to allotransplantation does not increase
the donor pool; therefore, successful, permanent xenotransplantation must itself be viewed as the target
of future clinical investigations.[89] In the future, clinical xenotransplantation may accomplish its intended
goal of achieving prolonged graft survival. Learning from the lessons of allotransplantation, clinicians
performing xenotransplantations must persevere under justifiable scrutiny.