Safety and Efficacy of Treprostinil in Ischemia and Reperfusion Injury in Adult Orthotopic Liver Transplantation

Prostaglandin-class drugs, including prostacyclin and its analogs, could represent an important advance toward the goal of reducing transplant related morbidity, mortality and associated costs by minimizing the effect of ischemia and re perfusion injury of the liver graft. Additionally, the reduction in serum creatinine and reduced need for post operative dialysis observed in some studies has implications in protecting the kidneys from the nephrotoxic affects of the immunosuppressant agents, especially during the early post-operative period. Routine use of prostaglandins (PGE1 and PGI2), however, was limited by its instability and short half life.

Treprostinil, as a prostanoid (prostacyclin analog), is expected to facilitate restoration of the blood supply to the revascularized graft and provide the well-characterized protective effects of this class of compounds in liver transplant patients. Treprostinil has the advantage of a longer elimination half-life than other prostanoids previously tested in these patients. Treprostinil is expected to significantly protect the graft from ischemia and re perfusion injury.

This is a pilot study to evaluate the safety, pharmacokinetics and preliminary efficacy of Treprostinil in orthotopic liver transplant patients as a first step to evaluate its use in prevention of ischemia and reperfusion injury of the grafted liver.

Inclusion criteria

• Have signed appropriate informed consent.
• Be between 18 years and 65 years of age.
• Have been accepted as a liver transplant candidate at the University of Pittsburgh Medical center (UPMC).
• Be receiving a cadaver donor liver transplant.
• Be treated in accordance with the standard of care protocol(s) currently in effect for liver transplant recipients at the UPMC, including immunosuppression and other elements of pre- and post-operative care.

Exclusion criteria

Subjects must not:

• Be receiving a living donor liver transplant.
• Be receiving a donor liver with a cold ischemia time less than 5 hours or greater than 12 hours.
• Be receiving any investigational drug (a drug other than Treprostinil administered under an IND) or participating in any other investigational study, with the exception of alemtuzumab (Campath).
• Be receiving any prostanoid to treat portopulmonary hypertension.
• Have had a failed liver transplant within the previous 180 days.
• Be undergoing multi-organ transplantation (transplantation of organs other than liver at the same time as the liver transplantation procedure).
• Have fulminant hepatic failure
• Model for end stage liver diseases (MELD) score of > 40
• Hepatitis C positive donor liver
• On renal replacement therapy at the time of study
• Be receiving any non-standard immunosuppression protocol or other non-standard treatment that could affect interpretation of the study results.
• Those currently receiving treatment for portopulmonary hypertension.
• Those with significant cardiovascular disease including treatment with inotropes.
• Have any known hypersensitivity to prostaglandins, prostacyclin or treprostinil.
• If female, be pregnant or nursing (as confirmed by urine pregnancy test at Baseline).
• HIV positive
• Individuals who are allergic to iodine
• Individuals who are receiving methylene blue
• A donor liver with macrosteatosis greater than 40% if biopsy results are available