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Effect of Discarding Initial Reperfusion Blood on Hemodynamics, Liver Function, and 30-Day Outcomes in Liver Transplantation

3 juni 2026 uppdaterad av: Joel Avancini Rocha Filho, University of Sao Paulo General Hospital

Assessment of the Impact of Discarding the Initial Reperfusion Blood on Early Liver Function, Cardiovascular and Metabolic Changes and on 30-Day Liver and Renal Outcomes. A Prospective Randomized Trial in Liver Transplantation

Hepatic reperfusion during liver transplantation remains a critical phase associated with significant hemodynamic and systemic disturbances, despite advances in surgical and anesthetic management. This phase is characterized by the release of acidotic, hypothermic, and hyperkalemic blood containing metabolic byproducts and inflammatory mediators resulting from ischemia-reperfusion injury.

Clinically, reperfusion is associated with hemodynamic instability, including reductions in cardiac output and arterial pressure, as well as cardiac dysfunction and arrhythmias, often requiring pharmacologic support. These alterations may affect not only immediate intraoperative stability but also short- and long-term outcomes for both the patient and the graft.

The abrupt restoration of blood flow to the transplanted liver leads to the systemic release of accumulated metabolites, reactive oxygen species, and inflammatory mediators, contributing to a systemic inflammatory response that may impact distant organs, including the kidneys and heart.

Several revascularization strategies have been investigated to mitigate reperfusion-related injury: initial reperfusion via the portal vein, initial reperfusion through the hepatic artery, and simultaneous reperfusion through the portal vein and hepatic artery.

A less frequently used and insufficiently studied strategy, not routinely or systematically implemented, involves diverting the initial reperfusion blood from the graft to the surgical field, followed by the restoration of hepatic blood outflow to the systemic circulation.

This study hypothesizes that discarding the initial reperfusion blood via the infrahepatic vena cava will attenuate early hemodynamic, metabolic, and inflammatory changes and reduce postoperative complications compared to conventional reperfusion techniques.

Studieöversikt

Status

Har inte rekryterat ännu

Betingelser

Intervention / Behandling

Detaljerad beskrivning

Hepatic reperfusion during liver transplantation remains a critical phase associated with significant hemodynamic and systemic disturbances, despite advances in surgical and anesthetic management. This phase is characterized by the release of acidotic, hypothermic, and hyperkalemic blood containing metabolic byproducts and inflammatory mediators resulting from ischemia-reperfusion injury.

Clinically, reperfusion is associated with hemodynamic instability, including reductions in cardiac output and arterial pressure, as well as cardiac dysfunction and arrhythmias, often requiring pharmacologic support. These alterations may compromise immediate intraoperative stability and have been associated with adverse short- and long-term outcomes for both the recipient and the graft.

The abrupt restoration of blood flow to the transplanted liver results in the systemic release of accumulated metabolites, reactive oxygen species, and inflammatory mediators, triggering a systemic inflammatory response that may extend beyond the liver and affect distant organs, including the kidneys and heart.

Several revascularization strategies have been investigated to mitigate reperfusion-related injury, including portal vein, hepatic artery, and simultaneous reperfusion approaches. However, none have consistently demonstrated a clear benefit in reducing ischemia-reperfusion injury or improving clinical outcomes. An alternative and less explored strategy involves diverting and discarding the initial reperfusion blood from the graft before restoring venous outflow to the systemic circulation.

Patients listed for liver transplantation at the study center will be systematically screened for eligibility. Written informed consent will be obtained from all eligible participants prior to enrollment, in accordance with institutional ethical standards.

This study is a prospective randomized clinical trial designed to evaluate whether discarding the initial reperfusion blood via the infrahepatic vena cava attenuates early hemodynamic, metabolic, and inflammatory disturbances and improves postoperative outcomes compared with conventional reperfusion techniques.

Studietyp

Interventionell

Inskrivning (Beräknad)

132

Fas

  • Inte tillämpbar

Kontakter och platser

Det här avsnittet innehåller kontaktuppgifter för dem som genomför studien och information om var denna studie genomförs.

Studiekontakt

Studera Kontakt Backup

Deltagandekriterier

Forskare letar efter personer som passar en viss beskrivning, så kallade behörighetskriterier. Några exempel på dessa kriterier är en persons allmänna hälsotillstånd eller tidigare behandlingar.

Urvalskriterier

Åldrar som är berättigade till studier

  • Vuxen
  • Äldre vuxen

Tar emot friska volontärer

Nej

Beskrivning

Inclusion Criteria:

  • Adults aged 18 years or older
  • Candidates for liver transplantation at Hospital das Clínicas, University of São Paulo Medical School (HCFMUSP)
  • Able to provide written informed consent

Exclusion Criteria:

  • Inability to provide informed consent
  • Previous liver surgery
  • Fulminant hepatitis
  • Specific liver diseases associated with severe electrolyte disturbances
  • End-stage renal disease requiring dialysis
  • Combined organ transplantation
  • Living donor liver transplantation
  • Liver retransplantation
  • Highly sensitized patients with limited availability of blood products
  • Hematologic diseases
  • Portal vein thrombosis involving more than 50% of the lumen
  • Portopulmonary hypertension (mean pulmonary artery pressure > 20 mmHg), diagnosed preoperatively or intraoperatively

Studieplan

Det här avsnittet ger detaljer om studieplanen, inklusive hur studien är utformad och vad studien mäter.

Hur är studien utformad?

Designdetaljer

  • Primärt syfte: Behandling
  • Tilldelning: Randomiserad
  • Interventionsmodell: Parallellt uppdrag
  • Maskning: Ingen (Open Label)

Vapen och interventioner

Deltagargrupp / Arm
Intervention / Behandling
Experimentell: Reperfusion Blood Discard
Liver transplantation with discarding of the initial 180 mL of reperfusion blood via the infrahepatic vena cava prior to restoration of hepatic blood outflow to the systemic circulation
Procedur: Reperfusion Blood Discard
Discarding of the initial 180 mL of reperfusion blood from the graft via the infrahepatic vena cava during liver transplantation prior to restoration of hepatic venous outflow to systemic circulation.
Aktiv komparator: Conventional Reperfusion
Standard liver transplantation without discarding the initial reperfusion blood.
Procedur: Standard Liver Transplantation
Conventional liver transplantation without discarding the initial reperfusion blood.

Vad mäter studien?

Primära resultatmått

Resultatmått
Åtgärdsbeskrivning
Tidsram
Peak alanine aminotransferase (ALT)
Tidsram: Within 72 hours after transplantation
Peak serum ALT level (U/L) as a biomarker of early graft injury following liver transplantation.
Within 72 hours after transplantation

Sekundära resultatmått

Resultatmått
Åtgärdsbeskrivning
Tidsram
Arterial Pressure
Tidsram: Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1.
Monitoring arterial pressure (systolic, diastolic e medium) Unit of Measure: mmHg.
Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1.
Cardiac Rhythm
Tidsram: Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1
Cardiac rhythm monitoring with electrocardiography in ECG lead 2 and V5
Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1
Cardiac Output
Tidsram: Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1.
Monitoring continuous cardiac output. Unit of Measure: L/min.
Intraoperative, during reperfussion, 30 minutes after reperfusion, and postoperative day 1.
Arterial serum potassium levels
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial potassium levels (Unit of measure: mEq/L).
Intraoperative and daily from postoperative day 1 up to day 7.
Blood coagulation thromboelastometry
Tidsram: Intraoperative (at the start of surgery, 5 minutes after reperfusion, and at the end of surgery).
Assessment of intraoperative coagulation changes using rotational thromboelastometry (ROTEM), including EXTEM and FIBTEM parameters, and activated clotting time (ACT).
Intraoperative (at the start of surgery, 5 minutes after reperfusion, and at the end of surgery).
International normalized ratio (INR)
Tidsram: Daily up to 72 hours after transplantation.
Assessment of graft function using international normalized ratio (INR).
Daily up to 72 hours after transplantation.
Aspartate aminotransferase levels (AST)
Tidsram: Daily up to 7 days and weekly up to 30 days after transplantation.
Assessment of graft injury using serum levels of AST (Unit of measure: U/L).
Daily up to 7 days and weekly up to 30 days after transplantation.
Serum Tumor Necrosis Factor-alpha (TNF-α)
Tidsram: At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum levels of inflammatory mediator TNF-α (Unit of measure: pg/mL).
At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum B-type natriuretic peptide (BNP)
Tidsram: At the start of surgery, 30 minutes after reperfusion and postoperative day 1.
Assessment of BNP levels as a marker of cardiac hemodynamic stress. Unit of Measure: pg/mL.
At the start of surgery, 30 minutes after reperfusion and postoperative day 1.
Serum creatinine levels
Tidsram: Up to 30 days after transplantation.
Assessment of serum creatinine levels to evaluate renal function (Unit of measure: mg/dL),
Up to 30 days after transplantation.
Postoperative complications
Tidsram: Within 30 days after transplantation.
Complications graded according to the Clavien-Dindo classification.
Within 30 days after transplantation.
ICU length of stay
Tidsram: Up to 30 days after transplantation.
Days of length of stay in the intensive care unit.
Up to 30 days after transplantation.
Hospital length of stay
Tidsram: Up to 30 days after transplantation.
Total hospital length of stay in days.
Up to 30 days after transplantation.
Arterial serum sodium levels
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial serum sodium levels (Unit of measure: mEq/L).
Intraoperative and daily from postoperative day 1 up to day 7.
Arterial serum lactate levels
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial serum lactate levels (Unit of measure mg/dL),
Intraoperative and daily from postoperative day 1 up to day 7.
Arterial serum calcium levels
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial serum calcium levels (Unit of measure mg/dL),
Intraoperative and daily from postoperative day 1 up to day 7.
Serum glucose levels
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in serum glucose levels (Unit of measure: mg/dL).
Intraoperative and daily from postoperative day 1 up to day 7.
Arterial serum pH
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial pH units.
Intraoperative and daily from postoperative day 1 up to day 7.
Arterial serum bicarbonate
Tidsram: Intraoperative and daily from postoperative day 1 up to day 7.
Perioperative changes in arterial serum bicarbonate (Unit of measure mmol/L)
Intraoperative and daily from postoperative day 1 up to day 7.
Factor V activity levels
Tidsram: Daily up to 72 hours after transplantation .
Assessment of graft function using Factor V activity levels measure as percentage.
Daily up to 72 hours after transplantation .
Alkaline phosphatase levels
Tidsram: Daily up to 7 days and weekly up to 30 days after transplantation.
Assessement of graft function using alkaline phosphatase levels (Unit of measure: U/L),
Daily up to 7 days and weekly up to 30 days after transplantation.
Gamma-glutamyl transferase levels
Tidsram: Daily up to 7 days and weekly up to 30 days after transplantation.
Assessment of liver function using serum levels of gamma-glutamyl transferase up to 7 days and weekly up to 30 days after transplantation (Unit of measure: U/L).
Daily up to 7 days and weekly up to 30 days after transplantation.
Serum ammonia levels
Tidsram: Daily up to 7 days and weekly up to 30 days after transplantation.
Assessment of serum ammonia levels to evaluate liver function.(Unit of measure: mcmol/L).
Daily up to 7 days and weekly up to 30 days after transplantation.
Serum urea levels
Tidsram: Up to 30 days after transplantation.
Assessment of serum urea levels to evaluate renal function (Unit of measure: mg/dl),
Up to 30 days after transplantation.
Urine output
Tidsram: Up to 30 days after transplantation.
Assessment of renal function measured by daily urine output.
Up to 30 days after transplantation.
Need for renal replacement therapy
Tidsram: Up to 30 days after transplantation.
Need for renal replacement therapy (hemodialysis or continuous renal replacement therapy).
Up to 30 days after transplantation.
Serum Interleukin-6 (IL-6) levels
Tidsram: At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum levels of inflammatory mediator IL-6 (Unit of measure: pg/mL),
At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum Tumor Necrosis Factor-alpha (TNF-α) levels
Tidsram: At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum levels of inflammatory mediator TNF-α levels. (Unit of measure: pg/mL)
At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum Interleukin-17 (IL-17) levels
Tidsram: At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.
Serum levels of inflammatory mediator IL-17 (Unit of measure: pg/mL).
At the start of surgery, end of surgery, postoperative day 1, and postoperative day 3.

Samarbetspartners och utredare

Det är här du hittar personer och organisationer som är involverade i denna studie.

Sponsor

University of Sao Paulo General Hospital

Utredare

  • Huvudutredare: Joel Avancini Rocha Filho, MD, PhD, Hospital das Clínicas, University of São Paulo Medical School
  • Studierektor: Estela Regina Ramos Figueira, MD, PhD, Hospital das Clínicas, University of São Paulo Medical School
  • Studierektor: Maria Jose Carvalho Carmona, MD, PhD, Hospital das Clínicas, University of São Paulo Medical School
  • Studierektor: Wellington Andraus, MD, PhD, Hospital das Clínicas, University of São Paulo Medical School
  • Studierektor: Rui Carlos Detsch Junior, MD, Hospital das Clínicas, University of São Paulo Medical School
  • Studierektor: Luciana Bertocco Paiva Haddad, MD, PhD, Hospital das Clínicas, University of São Paulo Medical School

Studieavstämningsdatum

Dessa datum spårar framstegen för inlämningar av studieposter och sammanfattande resultat till ClinicalTrials.gov. Studieposter och rapporterade resultat granskas av National Library of Medicine (NLM) för att säkerställa att de uppfyller specifika kvalitetskontrollstandarder innan de publiceras på den offentliga webbplatsen.

Studera stora datum

Studiestart (Beräknad)

1 juli 2026

Primärt slutförande (Beräknad)

1 februari 2028

Avslutad studie (Beräknad)

1 februari 2028

Studieregistreringsdatum

Först inskickad

15 april 2026

Först inskickad som uppfyllde QC-kriterierna

3 juni 2026

Första postat (Faktisk)

8 juni 2026

Uppdateringar av studier

Senaste uppdatering publicerad (Faktisk)

8 juni 2026

Senaste inskickade uppdateringen som uppfyllde QC-kriterierna

3 juni 2026

Senast verifierad

1 april 2026

Mer information

Termer relaterade till denna studie

Nyckelord

Ytterligare relevanta MeSH-villkor

Andra studie-ID-nummer

  • 92854125.8.0000.0068
  • 2025/09932-0 (Annat bidrag/finansieringsnummer: São Paulo Research Foundation (FAPESP))

Plan för individuella deltagardata (IPD)

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NEJ

IPD-planbeskrivning

Individual participant data will not be shared due to institutional and privacy considerations.

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