Grant: Project Grant

People who receive a liver transplant often face serious complications afterward, such as problems with the graft, infections, or the need for intensive care. While doctors use different methods during surgery to manage blood pressure and fluids, it's not yet clear which approach works best for these patients. Some evidence suggests that removing a small amount of blood before surgery (phlebotomy) and giving fluids sparingly could reduce bleeding, lower the need for blood transfusions, and improve recovery. However, past studies were small and results uncertain, so surgical teams around the world still use varying techniques. This study will be a large, international clinical trial to find out whether a "restrictive" fluid strategy is better than a "liberal" one during the first part of liver transplant surgery. The restrictive approach involves removing blood before surgery and giving fluids only to replace blood loss or treat dangerous drops in blood pressure. The liberal approach does not remove blood and gives fluids more generously. The main question is whether the restrictive approach can lower the number of serious complications (such as those needing surgery, intensive care, or causing major disability) before patients leave the hospital. Researchers will also look at blood loss, the need for transfusions, kidney injury, organ function, infections, breathing or heart problems, quality of recovery, survival, and quality of life up to a year after surgery. Over five years, 866 adult liver transplant patients will be enrolled at 11 hospitals in Canada and France. The trial builds on earlier pilot studies showing such a project is possible. Results will give surgeons and anesthesiologists clear evidence about the safest way to manage fluids during liver transplant surgery, potentially improving recovery and survival for thousands of patients each year.