Early Allograft Dysfunction, Hyperfibrinolysis, Ischemic Reperfusion Injury, Liver Transplantation
Conditions
Keywords
Liver transplantation, Early allograft dysfunction, Ischemic reperfusion injury, Portal and arterial ex vivo HTK flush
Brief summary
The purpose of this study is to determine whether the Tacrolimus added to histidine-tryptophan-ketoglutarate (HTK) solution given through intraportal and intraarterial infusion during back-table procedure is capable of reducing the degree of early allograft liver dysfunction, as assessed by postoperative levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), during first 7 postoperative days and by serum and histochemical markers of liver injury and inflammation.
Detailed description
Early allograft liver dysfunction remains a significant complication of cadaveric liver transplantation with resource consuming and costly treatment, increased risk of multiorgan failure and 6-months mortality. Ischemic reperfusion injury (IRI) is a main reason for early allograft liver dysfunction. Inflammatory response to brain death in donor can precipitate the extent of dysfunction after reperfusion in recipient (1). Clear inflammatory pathways in response to IRI have been reported to be associated with early allograft liver dysfunction (2,3). It was shown that ex vivo intraportal tacrolimus perfusion suppressed inflammation and immune response in the transplanted liver on a genome-wide basis (4). We hypothesize that Tacrolimus added to HTK solution given through intraportal and intraarterial back-table infusion is capable of reducing the degree of early allograft liver dysfunction, as assessed by incidence of postreperfusion hyperfibrinolysis, postoperative levels of AST,ALT, during 1-7 postoperative days as well as serum and histochemical markers of liver injury and inflammation compared to no intraportal and intraarterial back-table infusion.
Interventions
DRUGTacrolimus
1000 ml of HTK solution (Custodiol, Dr. Franz Köhler Chemie GmBH) cooled to 2-4˚C containing 20 ng/ml Tacrolimus would be given through intraportal (under gravity pressure of 40 cm H2O) and intraarterial infusion (under pressure of 40-50 mm Hg) followed by intraportal infusion of 200 ml 5% solution of Albumin containing 20 ng/ml Tacrolimus under gravity pressure of 40 cm H2O.
Sponsors
Republican Scientific and Practical Center for Organ and Tissue Transplantation
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
DOUBLE (Caregiver, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 69 Years
Healthy volunteers
No
Inclusion criteria
* Donor: age 15-65 years macrovesicular steatosis \< 40% (macroscopy or biopsy) sodium \<165 mmol/l ICU stay and ventilation \< 11 days cold ischemia time \< 13 hours AST \< 200 U/l ALT \< 200 U/l bilirubin \< 50 μmol/l application of norepinephrine is allowed * Recipient age: 18-69
Exclusion criteria
Recipient: * live donor liver transplant * reduced and split grafts * multi organ failure
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Early Allograft Dysfunction | 1-7 postoperative days after liver transplant procedure | Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. Early allograft dysfunction will be assessed on the basis of highest levels of AST and ALT during 1-7 postoperative days. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Ischemic Reperfusion Injury of the Liver Allograft | liver biopsy taken at 2 hours after portal reperfusion | Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. A wedge resection of small (5x5mm) part of liver segment-III will be sampled at 2 hours after venous reperfusion. Rate of necrosis, inflammation, vascular thrombosis, cluster of differentiation (CD) 68 and High mobility group box 1 protein (HMGB1) staining will be assessed thereafter. |
| Inflammatory Response to Reperfusion | 0 and 20 min after portal reperfusion, 1 and 3 postoperative day | Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. After unclamping portal vein but before unclamping the inferior vena cava and after venting of first 100 ml of blood a 5 ml sample of blood (code is HV) from a tube inserted into caval suture line will be taken. Another 5 ml sample of blood (code is C) will be taken by puncture of one of hepatic veins 20 min later. Samples (5 ml each) of peripheral blood will be taken on 1st and 3d postoperative day (POD). P-selectin, interleukin-6, interleukin-8, tumor necrosis factor alfa (TNF-a) and macrophage inflammatory protein 1 alpha (MIP-1a) will be determined in samples HV and C. Interleukin-8, elastase, TNF-a and vascular endothelial growth factor (VEGF) will be determined in samples of 1st and 3d POD. |
| Postreperfusion Hyperfibrinolysis | 15 min and 2 hours after portal reperfusion | Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. Peripheral blood samples will be taken 15 min and 2 hours after portal reperfusion. Hyperfibrinolysis will be diagnosed by Thromboelastometry (ROTEM) if one or more following criteria are met: LI30\<85% or ML\>15% or LI60\<85% or A10 in Extem is by 15% is less then A10 in Aptem. |
Countries
Belarus
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Tacrolimus + HTK During back-table operation 1000 ml of HTK solution cooled to 2-4˚C containing 20 ng/ml Tacrolimus would be given through intraportal (under gravity pressure of 40 cm H2O) and intraarterial infusion (under pressure of 40-50 mm Hg) followed by intraportal infusion of 200 ml 5% solution of Albumin containing 20 ng/ml Tacrolimus under gravity pressure of 40 cm H2O.
Tacrolimus: 1000 ml of HTK solution (Custodiol, Dr. Franz Köhler Chemie GmBH) cooled to 2-4˚C containing 20 ng/ml Tacrolimus would be given through intraportal (under gravity pressure of 40 cm H2O) and intraarterial infusion (under pressure of 40-50 mm Hg) followed by intraportal infusion of 200 ml 5% solution of Albumin containing 20 ng/ml Tacrolimus under gravity pressure of 40 cm H2O. | 43 |
| HTK Only During back-table operation 1000 ml of HTK solution cooled to 2-4˚C would be given through intraportal (under gravity pressure of 40 cm H2O) and intraarterial infusion (under pressure of 40-50 mm Hg) followed by intraportal infusion of 200 ml 5% solution of Albumin under gravity pressure of 40 cm H2O. | 43 |
| Total | 86 |
Baseline characteristics
| Characteristic | Total | Tacrolimus + HTK | HTK Only |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 2 Participants | 1 Participants | 1 Participants |
| Age, Categorical Between 18 and 65 years | 84 Participants | 42 Participants | 42 Participants |
| Age, Continuous | 50 years | 50 years | 50 years |
| Gender Female | 39 Participants | 18 Participants | 21 Participants |
| Gender Male | 47 Participants | 25 Participants | 22 Participants |
| Region of Enrollment Belarus | 86 participants | 43 participants | 43 participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 8 / 12 | 20 / 22 |
Outcome results
Primary
Early Allograft Dysfunction
Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. Early allograft dysfunction will be assessed on the basis of highest levels of AST and ALT during 1-7 postoperative days.
Time frame: 1-7 postoperative days after liver transplant procedure
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Tacrolimus + HTK | Early Allograft Dysfunction | 6 Participants |
| HTK Solution Only | Early Allograft Dysfunction | 18 Participants |
Secondary
Inflammatory Response to Reperfusion
Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. After unclamping portal vein but before unclamping the inferior vena cava and after venting of first 100 ml of blood a 5 ml sample of blood (code is HV) from a tube inserted into caval suture line will be taken. Another 5 ml sample of blood (code is C) will be taken by puncture of one of hepatic veins 20 min later. Samples (5 ml each) of peripheral blood will be taken on 1st and 3d postoperative day (POD). P-selectin, interleukin-6, interleukin-8, tumor necrosis factor alfa (TNF-a) and macrophage inflammatory protein 1 alpha (MIP-1a) will be determined in samples HV and C. Interleukin-8, elastase, TNF-a and vascular endothelial growth factor (VEGF) will be determined in samples of 1st and 3d POD.
Time frame: 0 and 20 min after portal reperfusion, 1 and 3 postoperative day
Secondary
Ischemic Reperfusion Injury of the Liver Allograft
Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. A wedge resection of small (5x5mm) part of liver segment-III will be sampled at 2 hours after venous reperfusion. Rate of necrosis, inflammation, vascular thrombosis, cluster of differentiation (CD) 68 and High mobility group box 1 protein (HMGB1) staining will be assessed thereafter.
Time frame: liver biopsy taken at 2 hours after portal reperfusion
Secondary
Postreperfusion Hyperfibrinolysis
Protocol is restricted to liver transplants performed with classic technique with sequential portal-arterial reperfusion. Peripheral blood samples will be taken 15 min and 2 hours after portal reperfusion. Hyperfibrinolysis will be diagnosed by Thromboelastometry (ROTEM) if one or more following criteria are met: LI30\<85% or ML\>15% or LI60\<85% or A10 in Extem is by 15% is less then A10 in Aptem.
Time frame: 15 min and 2 hours after portal reperfusion