Prophylactic terlipressin infusion for severe postreperfusion syndrome in patients undergoing deceased donor liver transplantation: the TIPS-DDLT randomized controlled trial

Severe postreperfusion syndrome (PRS) is a critical and potentially catastrophic event during deceased donor liver transplantation (LT). Terlipressin has been widely used as a renoprotective agent during the perioperative period of LT. This study was designed to evaluate whether prophylactic terlipressin would reduce the occurrence of severe PRS in deceased donor LT. METHODS: In this single-center, randomized, double-blind trial, we randomly assigned adults who underwent deceased donor LT to receive 1 mg of terlipressin or placebo immediately after portal vein (PV) clamping. The primary outcome was the incidence of severe PRS after PV declamping, defined according to hypotension-based criteria per the Peking criteria. RESULTS: Between March 2019 and January 2021, we enrolled 64 patients and randomly assigned 32 to the terlipressin group and 32 to the control group. Severe PRS was significantly less frequent in the terlipressin group than in the control group (9.4 vs. 53.1%; OR, 0.09; 95% CI, 0.02–0.36; P<0.001). The vasopressor requirements for inferior vena cava clamping and severe PRS were significantly reduced by the intervention compared to controls (all P<0.01). Prophylactic terlipressin stabilized the mean arterial pressure (P=0.001) and heart rate (P=0.040) at 30 min after anhepatic phase but increased the pulmonary capillary wedge pressure (PCWP) at 5 min after reperfusion (P=0.003). Patients in the terlipressin group had a decreased right PV flow velocity following reperfusion (P=0.001), a longer postoperative mechanical ventilation time (P=0.029), a lower initial poor graft function rate (P=0.012), and lower peak alanine transaminase levels (P=0.032) after transplantation. CONCLUSION: The prophylactic use of terlipressin reduces the incidence of severe PRS in deceased donor LT. However, concerns remain regarding elevated PCWP.