Restrictive Fluid Management In Liver Transplantation (REFIL) (REFIL-2)

Effects of an Intraoperative Low-splanchnic Blood Volume Restrictive Fluid Management Strategy Compared to a Cardiac Output Optimized Liberal Fluid Management Strategy on Postoperative Outcomes in Liver Transplantation: A Multicenter Randomized Controlled Trial (REFIL-2)

The goal of the REFIL-2 study is to evaluate the effectiveness of a low splanchnic blood volume restrictive fluid management strategy (a strategy that involves limiting fluid administration and prioritizing the use of medications that raise blood pressure during surgery, combined with phlebotomy) in improving patients' recovery after surgery. The study compares the low splanchnic blood volume restrictive fluid management strategy to an optimized cardiac-output liberal fluid management strategy (which involves administering more fluids to raise blood pressure with less reliance on medications). Outcomes important to patients will be measured.

This study (REFIL-2) had a vanguard phase (internal pilot) that included 138 patients (NCT05647733). The patients included in the vanguard pilot phase were not compared between groups but only analyzed descriptively using aggregated data. Only feasibility metrics were compared (see NCT05647733). These 138 patients were thus rolled into the REFIL-2 trial and included in the final sample size reported herein.

Study Overview

• Status: Recruiting
• Conditions: End-stage Liver Disease (ESLD); Liver Transplantation (LT)
• Intervention / Treatment: Procedure: Low splanchnic blood volume restrictive fluid management strategy; Procedure: Optimized cardiac output liberal fluid management strategy; Procedure: Phlebotomy

Detailed Description

People with advanced liver disease have poor blood circulation, and too much blood accumulates in the abdomen (a condition known as high intra-abdominal blood volume). However, liver transplantation (LT) is a complex surgery during which the patient can lose a significant amount of blood and blood pressure can fluctuate widely. Therefore, restricting fluids and using medications to raise blood pressure is a strategy that could reduce blood loss and potentially also certain complications after surgery. Furthermore, phlebotomy appears to reduce intra-abdominal blood volume, blood loss, drops in blood pressure, and the need for red blood cell transfusions, potentially improving recovery after surgery. This study therefore aims to determine the best way to manage fluids during a liver transplantation by comparing these two care strategies. Another goal of the study is to measure the cost-effectiveness of the proposed intervention.

Hypothesis: An intraoperative low splanchnic blood volume restrictive fluid management strategy is superior to an optimized cardiac-output liberal fluid management strategy in reducing postoperative severe complications after liver transplantation

Design: Multicenter blinded parallel arm randomized controlled trial

Study population: Adult patients undergoing a liver transplantation for end-stage liver disease (ESLD)

All participants will be followed during their index hospitalization up to post-transplantation Day 30 (whichever comes first), and for 12 months post-transplantation to assess some clinical outcomes, quality of life (QoL), and survival (being alive beyond the index hospitalization).

Participation in this study lasts 12 months.

The results of this study will help determine whether or not to recommend a low splanchnic blood volume restrictive fluid management strategy for people who undergo a liver transplantation.

This study is conducted in two phases: a pilot phase, which demonstrated feasibility across Canada, followed by the current larger-scale phase (REFIL-2).

• Study Type: Interventional
• Enrollment (Estimated): 866
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: François Martin Carrier, MD; Phone Number: 514-890-8000; Email: francois.martin.carrier.med@ssss.gouv.qc.ca
• Study Contact Backup: Name: Manuela Mbacfou, MSc; Phone Number: 31576 514-890-8000; Email: manuela.mbacfou.temgoua.chum@ssss.gouv.qc.ca

Study Locations

• Canada
  • British Columbia
    • Vancouver, British Columbia, Canada, V5Z 1M9
      • Recruiting
      • Vancouver General Hospital (VGH)
      • Contact: JeiEung Park, MD; Phone Number: 604-875-4111; Email: jeieung.park@vch.ca
      • Principal Investigator: JeiEung Park, MD
  • Ontario
    • London, Ontario, Canada, N6G 2V4
      • Recruiting
      • London Health Sciences Centre (LHSC)
      • Principal Investigator: Nelson Javier Gonzalez Valencia, MD
      • Contact: Nelson Javier Gonzalez Valencia, MD; Phone Number: 519-661-2111; Email: nelson.gonzalezvalencia@lhsc.on.ca
  • Quebec
    • Montreal, Quebec, Canada, H4A 3J1
      • Recruiting
      • McGill University Health Centre (MUHC)
      • Contact: Stanislas Kandelman, MD; Phone Number: 514-934-1934; Email: stanislas.kandelman.med@ssss.gouv.qc.ca
      • Principal Investigator: Stanislas Kandelman, MD
    • Montreal, Quebec, Canada, H2X 0C1
      • Recruiting
      • Centre Hospitalier de l'Universite de Montreal (CHUM)
      • Sub-Investigator: Michael Chassé, MD
      • Contact: Manuela Mbacfou, MSc; Phone Number: 31576 514-890-8000; Email: manuela.mbacfou.temgoua.chum@ssss.gouv.qc.ca
      • Principal Investigator: François Martin Carrier, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Adult ≥ 18 years old
2. Undergoing liver transplantation (LT)
3. End-stage liver disease (ESLD) (with or without hepatocellular carcinoma) as the indication for transplantation.

Exclusion Criteria:

1. Undergoing LT for an indication other than ESLD (e.g., acute liver failure, primary liver cancer without ESLD, retransplantation, amyloid neuropathy, polycystic liver disease, or any other indication not associated with ESLD)
2. Undergoing combined solid organ transplantations

3. Any of the following conditions:

   • severe chronic renal failure (GFR < 15 ml/minute/1.73 m2 [CKD-EPI equation] or already on renal replacement therapy (RRT))
   • severe anemia (hemoglobin level < 80 g/L)
   • hemodynamic instability (norepinephrine equivalent > 10 ug/min)
4. Physician refusal to enroll the patient.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Restrictive group - Low splanchnic blood volume restrictive fluid management strategy; A phlebotomy (a procedure where the patient's blood is drawn, similar to a blood donation, without fluid replacement) at the start of the surgery combined with fluid restriction (use of vasopressor preferentially to treat hemodynamic instability with tolerance to relative hypovolemia defined as a Pulse Pressure Variation (PPV) or Stroke Volume (SVV) up to 18%). Fluids will be administered to compensate for blood loss and/or treat severe hemodynamic instability. Blood collected by phlebotomy will always be transfused back at the beginning of the reperfusion phase, during which fluid management will be based on goal-directed therapy (GDT) using either PPV or SV, as in the control group.	Procedure: Low splanchnic blood volume restrictive fluid management strategy; Hemodynamic goal-directed restrictive fluid management strategy; Other Names: Restrictive; Procedure: Phlebotomy; Blood drawn in a blood donation bag prior to dissection and transfused back after graft reperfusion
Active Comparator: Liberal group - Optimized cardiac output liberal fluid management strategy; Goal-directed therapy (GDT): Patients will receive 250 ml fluid boluses until SV stops increasing by more than 10% or until PPV is below 12%. Fluids will thus be used preferentially to treat hemodynamic instability. Fluids will also be administered to compensate for blood loss and/or treat severe hemodynamic instability.	Procedure: Optimized cardiac output liberal fluid management strategy; Permissive hemodynamic goal-directed fluid management strategy that optimizes cardiac output throughout surgery; Other Names: Liberal

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of participants with at least one severe complication	Incidence of at least one severe complications defined as a complication of grade ≥ 3 according to the Dindo-Clavien scale (grade 1 to 5)	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of participants who were transfused at least one unit of red blood cells (RBC) during the perioperative period of surgery	Incidence of participants transfused at least 1 unit of RBC during the perioperative period of surgery	During surgery (from entrance in the operating to exit of the operating room) and up to 48 hours after surgery (from exit of the operating room to 48 hours after exit of the operating room)
Number of participants who were transfused at least one unit of red blood cells (RBC) during surgery	Incidence of at least one RBC transfusion during surgery	Intraoperative (from entrance in the operating room to exit of the operating room)
Intraoperative blood loss	Blood loss as estimated by clinicians	Intraoperative (from entrance in the operating room to exit of the operating room)
7-day quality of recovery	Quality of recovery measured using the 15-item Quality of Recovery (QoR-15) score. Each item is scored on an 11-point numerical rating scale (0-10) for a total between 0 and 150, 0 being the worst possible recovery and 150 being a perfect recovery.	One time point: 7 days after surgery (transplantation)
Number of participants with a 7-day graft dysfunction	Incidence of graft dysfunction (as per Olthoff's definition)	One time point: 7 days after surgery (transplantation)
Number of participants with a 7-day acute kidney injury (AKI)	Acute kidney injury (AKI) of KDIGO grade 2 or 3	Over 7 days after surgery (criteria met at any day from surgery to day 7 after surgery)
Number of participants who were transfused at least one unit of red blood cells (RBC) up to hospital discharge	Incidence of at least one RBC transfusion from surgery to hospital discharge	From surgery to hospital discharge (from entrance in the operating room to hospital discharge) or 30 days, whichever comes first
Number of participants who were transfused at least one unit of any labile blood product up to hospital discharge	Incidence of at least one labile blood product transfused from surgery up to hospital discharge	From surgery to hospital discharge (from entrance in the operating room to hospital discharge) or 30 days, whichever comes first
Number of participants with at least one postoperative hemorrhagic complication up to hospital discharge	Incidence of at least one postoperative hemorrhagic complication, defined as any bleeding episode associated with a drop of hemoglobin of 20 g/L within 24 hours of bleeding, requiring 2 blood units within 24 hours of bleeding, a surgical hemostasis or an angioembolization.	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants with postoperative acute kidney injury (AKI) up to hospital discharge	Incidence of any postoperative acute kidney injury (AKI) (any grade as per KDIGO criteria) up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants requiring renal replacement therapy (RRT) up to hospital discharge	Incidence of postoperative requirement for renal replacement therapy (RRT) [hemodialysis or hemofiltration] up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants with at least one postoperative graft complication up to hospital discharge	Incidence of at least one postoperative graft complication (primary non-function, vascular, biliary) or retransplantation up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants with at least one postoperative infectious complication up to hospital discharge	Incidence of any postoperative infectious complication (other than pneumonia) up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of patients with a postoperative wound dehiscence up to hospital discharge	Incidence of postoperative wound dehiscence or evisceration up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of patients with at least one postoperative pulmonary complication up to hospital discharge	Incidence of any postoperative pulmonary complications (atelectasis, pneumonia, pulmonary oedema) up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants with at least one postoperative thromboembolic complication up to hospital discharge	Incidence of at least one thromboembolic complication (deep vein thrombosis, pulmonary embolism, myocardial infraction, stroke, mesenteric ischemia) up to hospital discharge	Up to hospital discharge (from surgery to hospital discharge) or 30 days, whichever comes first
Number of participants with a postoperative ICU readmission up to hospital discharge	Incidence of ICU readmissions after initial discharge (from the planned postoperative ICU or step-down unit admission) to hospital discharge	From initial ICU discharge (planned postoperative ICU or step-down unit admission) to hospital discharge or 30 days, whichever comes first
Number of days not in an intensive care unit (ICU) at 30 days after surgery (30-day ICU-free days over 30 days)	Number of days alive and not hospitalized in an ICU. 0 means 30 consecutive days in the ICU or death within 30 days without any day without being in an ICU from surgery to death. 30 means no days hospitalized in an ICU from surgery to the 30-day time point.	From surgery to 30 days after surgery
Number of days without organ support at 30 days after surgery (30-day organ support free days)	Number of days alive without renal replacement therapy, mechanical ventilation or vasopressor 30 days after surgery. 0 means 30 consecutive days with any organ support or death within 30 days without any day without organ support from surgery to death. 30 means no days with organ support from surgery to the 30-day time point.	From surgery to 30 days after surgery
Hospital length of stay	Length of hospital stay (days)	From surgery to hospital discharge (up to 12 months after surgery)
Quality of life score	Quality of life (QoL) score using the 36-item Short Form health survey questionnaire (SF-36). Score ranges from 0 (worst possible health) to 100 (best possible health).	Two time points: 6 and 12 months after surgery
Rate of hospital readmissions	Number of postoperative hospital readmissions over 12 months after surgery	From hospital discharge after surgery to 12 months after surgery
Rate of 1-year graft complications	Time to any graft complication (vascular or biliary) to 1 year after surgery	From surgery to 12 months after surgery
Rate of 1-year graft survival	Time to graft lost (death of retransplantation) up to 1 year after surgery. Censoring will occur if lost to follow-up or 1 year after surgery.	From surgery to 12 months after surgery
Rate of 1-year recipient survival	Time to death up to 1 year after surgery. Censoring will occur if lost to follow-up or at 12 months after surgery.	From surgery to 12 months after surgery.
Costs of the intervention	Complication-related costs (total and subcomponent costs including complications, ressource utilization and hospital readmissions)	Up to 12 months post-transplantation

Collaborators and Investigators

• Sponsor: Centre hospitalier de l'Université de Montréal (CHUM)
• Collaborators: Canadian Institutes of Health Research (CIHR); Canadian Donation and Transplantation Research Program (CDTRP); Canadian Perioperative Anesthesia Clinical Trial (PACT) Group
• Investigators: Principal Investigator: François Martin Carrier, MD, Centre Hospitalier de l'Universite de Montreal (CHUM)

Publications and helpful links

General Publications

• Parikh A, Washburn KW, Matsuoka L, Pandit U, Kim JE, Almeda J, Mora-Esteves C, Halff G, Genyk Y, Holland B, Wilson DJ, Sher L, Koneru B. A multicenter study of 30 days complications after deceased donor liver transplantation in the model for end-stage liver disease score era. Liver Transpl. 2015 Sep;21(9):1160-8. doi: 10.1002/lt.24181.
• Thacker JK, Mountford WK, Ernst FR, Krukas MR, Mythen MM. Perioperative Fluid Utilization Variability and Association With Outcomes: Considerations for Enhanced Recovery Efforts in Sample US Surgical Populations. Ann Surg. 2016 Mar;263(3):502-10. doi: 10.1097/SLA.0000000000001402.
• Shin CH, Long DR, McLean D, Grabitz SD, Ladha K, Timm FP, Thevathasan T, Pieretti A, Ferrone C, Hoeft A, Scheeren TWL, Thompson BT, Kurth T, Eikermann M. Effects of Intraoperative Fluid Management on Postoperative Outcomes: A Hospital Registry Study. Ann Surg. 2018 Jun;267(6):1084-1092. doi: 10.1097/SLA.0000000000002220.
• Carrier FM, Chasse M, Wang HT, Aslanian P, Iorio S, Bilodeau M, Turgeon AF. Restrictive fluid management strategies and outcomes in liver transplantation: a systematic review. Can J Anaesth. 2020 Jan;67(1):109-127. doi: 10.1007/s12630-019-01480-y. Epub 2019 Sep 25.

Helpful Links

• Website

Study record dates

Study Major Dates

• Study Start (Actual): February 15, 2026
• Primary Completion (Estimated): November 1, 2030
• Study Completion (Estimated): November 1, 2031

Study Registration Dates

• First Submitted: June 15, 2026
• First Submitted That Met QC Criteria: July 8, 2026
• First Posted (Actual): July 10, 2026

Study Record Updates

• Last Update Posted (Actual): July 10, 2026
• Last Update Submitted That Met QC Criteria: July 8, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Liver Diseases; Phlebotomy; Liver Transplantation; Transfusions; Fluid Management; Hemodynamic Management
• Additional Relevant MeSH Terms: Digestive System Diseases; Liver Failure; Hepatic Insufficiency; Liver Diseases; End Stage Liver Disease; Investigative Techniques; Therapeutics; Specimen Handling; Clinical Laboratory Techniques; Diagnostic Techniques and Procedures; Diagnosis; Punctures; Surgical Procedures, Operative; Blood Specimen Collection; Phlebotomy
• Other Study ID Numbers: 22.206

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: End-of-study knowledge translation (KT) planned

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No