Systematic production of human kidney organoids for transplantation in porcine kidneys during ex vivo machine perfusion

Organoids derived from human pluripotent stem (hPS) cells hold promise for therapeutic purposes. However, technological advances to overcome their massive production while ensuring differentiation fidelity are still lacking. Here we report a procedure sustaining the derivation of kidney organoids from hPS cells (hPSC-kidney organoids) using a scalable, reproducible and affordable approach that allows hPSC-kidney organoid differentiation into different renal cell types. Using single-cell RNA sequencing, confocal image analysis, metabolic assays and CRISPR–Cas9 engineering for generation of fluorescent reporters, we show that hPSC-kidney organoids exhibit transcriptional variety and cellular composition following cell-to-cell contact. We infuse human kidney organoids into ex vivo porcine kidneys using normothermic machine perfusion, and demonstrate in vivo engraftment of hPSC-kidney organoids. We further evaluate the immune response, confirming the feasibility and viability of the procedure. We identify cells of human origin after normothermic machine perfusion and in vivo transplantation by means of in situ hybridization, immunohistochemistry, confocal microscopy, image analysis and quantification, in vivo imaging, and flow cytometry. This work provides a foundation for using hPSC-kidney organoids for ex vivo cell-based therapies in clinical trials.