Influence of Argipressin on Blood Loss During Hepatic Resection; a Double-blinded, Randomized Placebo-controlled Trial (ARG-01)
Phase: PHASE4
Conditions: Colon Cancer Liver Metastasis, Inflammatory Response, Vasopressin Causing Adverse Effects in Therapeutic Use
Sponsor: Kristina Svennerholm

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
1 
 
Clinical Study Protocol 
 
Study product: 
Argipressin 
 
Study code: 
ARG-01 
 
EudraCT No: 
2021-001806-32 
 
Date: 
250228 
 
 
 
 
Influence of Argipressin on blood loss during liver resection; a 
double-blinded, randomized, placebo-controlled trial (ARG-01) 
 
Principle 
Investigator: 
 
Kristina Svennerholm, MD, PhD 
Department of Anesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3429336 
kristina.svennerholm@vgre
gion.se 
Study centre: 
Department of Anesthesia and Intensive Care  
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3428607 
caroline.pihl@vgregion.se 
(Department Assistant) 
Co-investigator: 
Ellinor Wisén, MD 
Department of Anesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
Tel: +46 31 3428171 
ellinor.wisen@vgregion.se 
 
 
 
Co-workers: 
 
Lena Sand-Bown, MD, PhD 
Department of Anesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3428157 
lena.sand@vgregion.se 
 
 
Andreas Kvarnström, MD, PhD 
Department of Anesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3426617 
andreas.kvarnstrom@vgr
egion.se 
 
 
Sven-Erik Ricksten, MD; PhD, Professor 
Department of Anesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3427433 
sven.erik.ricksten@vgregi
on.se 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
2 
 
Magnus Rizell, MD, PhD 
Department of Transplantation Surgery 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden  
 
Aldina Pivodic 
Department of Clinical Neuroscience, Institute of 
Neuroscience and Physiology, Sahlgrenska Academy, 
University of Gothenburg, Gothenburg, Sweden  
APNC Sweden, Gothenburg, Sweden  
 
Tel: +46 70 5259301 
magnus.rizell@vgregion.se 
 
 
 
Tel: +46 709471412 
aldina.pivodic@apnc.se 
Study monitor: 
Gothia Forum  
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Tel: +46 31 3429679 
Sponsor and 
research 
principal: 
 
 
 
 
Research 
Principal 
Region Västra Götaland,  
Sahlgrenska University Hospital 
Kristina Svennerholm, 
Department of Anaesthesia and Intensive Care,  
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
University of Gothenburg 
Sahlgrenska Academy, Institute of Clinial Sciences 
Jovanna Dahlgren, Head of Department 
Medicinaregatan 3, plan 5 
41390 Göteborg 
 
 
 
 
The following amendments and administrative changes have been made since final 
protocol date: 
 
original 
Oct 26 2021 
 
Version 2 
Dec 2, 2021  
Clarifications regarding access to data (2.3), pregnancy at inclusion 
(5.2), procurement and handling of the study drug (6.1.2), 
randomization process (6.1.3), statistic methods (10).) 
  
 
Version 3 
Feb 27, 2023 
The title is updated. Clarifications regarding collection of samples, 
access to data and data entry into the eCRF and planned publication 
of results. Figure 1 is updated and clarified. The entire statistics 
chapter (9) is updated. WHO trial registration data set and Statistical 
analysis plan is supplemented. Changes from version 2 are marked in 
yellow. 
 
Version 4 
October 6, 2023 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
3 
Addition of sponsor (University of Gothenburg) and project 
statistician. Updated data sharing statement. Changes in relation to 
Version 3 are marked in yellow.  
Version 4.1 
Change from sponsor to correct denomination “research principal” 
for University of Gothenburg. Addition of plasma and thrombocytes 
transfusion on day 2/5, and use of tranexamic acid under “secondary 
endpoint”and Bilirubin analysis . Non-invasive cardiac output 
monitoring added. 
 
Version 4.2 
Addition of protocol and additional ethics approval for exploration 
of thrombocyte function on 30 patients (substudy)  
 
Version 4.3 
Clarification of power calculation / end of study, and regarding 
presentation of AE:s.  
 
Version 4.4 
Addition of assessment of pain scores and opioid equivalents 
(substudy) 
 
Version 4.5 
Addition of background data parameters, adjustment of 
inflammatory parameters planned for analysis. “None” removed 
from severity rating list. Minor linguistic changes.  
 
  
 
 
 
Supplements: 
 
1. World Health Organization Trial Registration Data Set  
2. Statistical Analysis Plan-version 2.0 
3. Patient information- version 4.1 
 
Appendixes:  
Appendix A: Signatures 
Appendix B: Ethics and regulatory review 
Appendix C: Definition of adverse events 
Appendix D: Label 
Appendix E: Protocol thrombocyte pilot study 
Appendix F: Protocol pain pilot study 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
4 
Synopsis 
 
Title: Influence of Argipressin on blood loss during liver resection; a double-blinded, randomized 
placebo-controlled trial (ARG-01). 
 
Principle Investigator  
Kristina Svennerholm, MD, PhD, Dpt of Anesthesia and Intensive Care, Sahlgrenska University 
Hospital  
 
Study centre 
Sahlgrenska University Hospital  
 
Study period 
First patient in: March 2022, last patient out January 2025 
 
Short background 
Hepatic resection is a major surgical intervention with high risk of substantial blood loss. The surgical 
means to reduce blood loss may impair perfusion and induce intestinal congestion. If blood flow to 
the liver can be influenced by pharmacological means, blood loss and transfusion requirements may 
be reduced. Moreover, the inflammatory system is involved in cancer development, and the anti-
inflammatory properties of Argipressin may decrease the inflammatory response after hepatic 
surgery. 
Even though several studies have been made on Argipressin and other pharmacological treatments 
during hepatic surgery, Argipressin has not yet been proven to reduce blood loss in patients treated 
according to our protocol, and the effects of Argipressin on the inflammatory response in this setting 
is not explored. 
 
Hypothesis 
Infusion of Argipressin during hepatic resection surgery reduces blood loss. It may reduce 
transfusion requirements, and mitigate the perioperative inflammatory response compared to 
placebo.  
 
Name and description of study product 
Argipressin (Empressin®) is an endogenous substance, and part of the body’s response to stress and 
trauma. Argipressin affects V1-receptors to produce vasoconstriction, and V2-receptors in the kidney 
to enhance water retention. It is also involved in inflammatory reactions and affects platelets.  
 
Primary objective 
To determine if infusion of Argipressin during hepatic resection surgery reduces blood loss 
compared to placebo. 
 
Secondary objectives 
-To determine if infusion of Argipressin during hepatic resection surgery reduces the need of 
transfusions during and after surgery, compared to placebo. 
-To determine if infusion of Argipressin during hepatic resection surgery mitigates the postoperative 
inflammatory response, compared to placebo. 
-Analyse effects of infusion of Argipressin during hepatic resection surgery on biomarkers of hepatic, 
renal, cardiac and intestinal damage, thrombocyte function and perioperative data and 
hemodynamic measurements. 
 
Primary endpoint: 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
5 
Blood loss (ml) at the end of surgery.  
 
Secondary endpoints: 
Volume of transfused blood during surgery and postoperative day 1, 2 and 5, respectively.  
Inflammatory markers during and after surgery. Markers of hepatic, kidney, cardiac and intestinal 
damage and thrombocyte function will be analysed, and perioperative data as well as 30 day follow 
up data will be recorded.  
 
Study design: 
A single center, double blinded, randomized, parallel group, placebo- controlled trial to investigate 
the effect of Argipressin on blood loss, transfusion requirements and inflammatory response during 
hepatic surgery.  
 
Inclusion criteria 
-Participant planned for hepatic resection (open or laparoscopic, regardless of indication for 
surgery). 
-Age ≥18 years.  
-American Society of Anaesthesiologists (ASA) class I-III. 
-Signed informed consent form.  
 
Exclusion criteria 
-Participant does not understand the given information, and/ or cannot give written informed 
consent. 
-Simultaneous operation of tumor with other localization, or surgery for superficial single hepatic 
tumor less than 2 cm, expected to be of short duration and with minimal blood loss. 
-Terminal kidney failure (estimated preoperative GFR< 15 ml/min)  
-Pregnancy or lactation. 
-Known allergy to Empressin®. 
-Patient included in other interventional study, interacting with the endpoints in the present study, 
or previous randomization in this study. 
-Hyponatremia (S-Na < 130 mmol/L) 
-Patient considered ineligible for other surgical or medical reason. 
-Present infection. 
Patients with systemic inflammatory disease, inflammatory bowel disease or preoperative 
corticosteroid treatment will not be eligible for the subgroups where cytokines and interleukins are 
investigated. 
 
Study medicine/product 
Intravenous infusion of Empressin® 0.8 U/ml, 0.045 U/kg/h (0.056 ml/kg/h). Infusion is started after 
induction of anesthesia, and stopped at the end of surgery. NaCl 9 mg/ml (“normal saline”) given 
with the same infusion rate will be used as placebo. 
 
Statistics 
Calculation of sample size was performed based on data from open and laparoscopic hepatic 
resections performed at Sahlgrenska University Hospital during the period January 2019- October 
2020.  Data will be analysed according to the Statistical Analysis Plan, supplement 2. Adverse Events 
(AE:s) will be registered, and all Serious Adverse Events (SAE:s) will be reported.  
  
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
6 
Table of contents 
 
 
 
 
Synopsis 
4 
 
Abbreviations 
8 
 
 
 
1 
Background 
10 
1.1 
Rational for conducting this study 
11 
1.2 
Hypothesis 
11 
1.3 
Risk/benefit evaluation 
12 
1.4 
Ethics and Regulatory review 
13 
 
 
 
2 
Objectives and Endpoints 
14 
2.1 
Primary objective 
14 
2.2 
Secondary objectives 
14 
2.3 
Primary endpoint 
14 
2.4 
Secondary endpoints 
14 
 
 
 
3 
Study Design 
15 
3.1 
Overall study design 
15 
3.1.1 
Stopping criteria 
18 
3.1.2 
Rational for study design, dose and laboratory analysis 
18 
 
 
 
4 
Patient Population 
20 
4.1 
Inclusion criteria 
20 
4.2 
Exclusion criteria 
20 
4.3 
Subject enrolment 
21 
4.4 
Discontinuation and withdrawal of subjects 
21 
4.5 
Premature termination of the stud 
22 
 
 
 
5 
Methodology 
22 
5.1 
Treatment 
22 
5.1.1 
Labelling 
23 
5.1.2 
Storage, handling and delivery 
23 
5.1.3 
Randomization, Blinding and Study Drug administration 
24 
5.1.4 
Treatment compliance 
25 
5.1.5 
Accountability 
25 
5.2 
Samples and Biobank 
25 
5.3 
Concomitant medication 
26 
 
 
 
6 
Study measurements 
26 
6.1 
Measurements, time points and procedures  
26 
6.1.1 
Preoperative visit 
26 
6.1.2 
Day of surgery 
27 
6.1.3 
Postoperative procedures 
27 
6.1.4 
Follow up 
28 
6.2 
Recording of data 
28 
6.3 
Study variables and laboratory analysis 
29 
6.3.1 
Study variables 
30 
6.3.2 
Blood and urine 
30 
6.3.3 
Safety measurements and variables 
30 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
7 
 
 
 
7 
Safety 
31 
7.1 
Expected adverse reactions  
31 
7.2 
Definitions of Adverse Events (AE) 
32 
7.2.1 
Definition of severity rating  
32 
7.2.2 
Causal relationship 
32 
7.3 
Definitions of Serious Adverse Events 
33 
7.3.1 
Recording and reporting of Adverse Events 
33 
7.3.2 
Follow-up of unresolved Adverse Events 
33 
7.3.3 
Suspected Unexpected Serious Adverse Reaction 
33 
7.3.4 
Reporting of Suspected Unexpected Serious Adverse Reaction 
34 
7.3.5 
Reference safety information 
34 
 
 
 
8 
Study Management 
35 
8.1 
Data Management 
35 
8.2 
Monitoring 
35 
8.3 
Archiving 
36 
8.4 
Quality assurance 
36 
8.4.1 
Audits and Inspections  
36 
8.4.2 
Significant changes 
37 
8.5 
Insurances 
37 
 
 
 
9 
Statistics 
37 
 
 
 
10 
Report and publication 
39 
 
 
 
11 
Study timetable 
39 
11.1 
Definition of “End of study” 
39 
 
 
 
12 
Declaration of interests and funding 
39 
 
 
 
13 
References 
40 
 
 
 
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
8 
Abbreviations 
AE 
Adverse event 
AKI 
Acute Kidney Injury 
Alb 
Albumin 
ALT 
Alanine Transaminase 
AST 
Aspartate Transaminase 
ASA-class 
American Society of Anaesthesiologists classification 
AVP 
C3a 
C5b-9 
CFS 
Arginine Vasopressin 
Complement factor 3a 
Terminal Complement Complex 5b-9 
Clinical Frailty Scale 
CVP 
Central Venous Pressure 
CRP 
C-Reactive Protein 
eCRF 
Electronic Case Report Form 
EC 
ECOG 
Ethics Committee, synonymous to Institutional Review Board and 
Independent Ethics Committee 
Eastern Cooperative Oncology Group Performance Rating Scale 
ECG 
Electrocardiogram 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practice  
HABR 
Hepatic Artery Buffer Response 
Hb 
Haemoglobin 
hs-TNI 
high sensitive -Troponin-I 
ICH 
International Council for Harmonisation of Technical 
Requirements for Pharmaceuticals for Human Use 
ICAM-1 
Intercellular Adhesion Molecule -1 
IFABP 
Intestinal Fatty Acid Binding Protein 
IGFBP7 
Insulin-like growth factor-binding protein 7  
IL-1 IL-6, IL-8, IL-10 
Interleukin -1, -6, -8, -10.  
IMP 
ITT 
Investigational medical product  
Intention To Treat 
MCP-1 
PAD 
Monocyte Chemoattractant Protein -1 
Pathological Anatomical Diagnosis 
PT-INR 
Prothrombine Time- International Normalized Ratio 
PLT 
ROTEM 
Platelet Count 
Rotational Thromboelastometry 
SAE 
SAP 
Serious Adverse Events 
Statistic Analysis Plan 
SDF-1 
SMPA 
Stromal Cell Derived Factor -1 
Swedish Medical Products Agency 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
9 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TIMP-2 
Tissue Inhibitor of Metalloproteinase 2 
TRALI 
Transfusion Induced Lung Injury 
WBC 
vWF 
White Blood Cell Count 
Von Willebrandt Factor 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
10 
Background 
Hepatic resection due to colo-rectal cancer metastasis, primary hepatic or gallbladder 
cancer, or benign conditions, is a major surgical intervention. The surgery entails a high risk 
of perioperative circulatory instability and substantial blood loss. Blood loss and blood 
transfusion is associated with morbidity and mortality after liver surgical treatment of 
malignant disease (1, 2, 3). Standard anaesthesiologic management of these patients aim to 
minimize blood loss by reducing CVP, and to the same end surgical treatment includes 
mechanical occlusion of the hepatic circulation (Pringle manoeuvre) (4).  
Argipressin (also known as Arginin-Vasopressin, AVP or Vasopressin) is an endogenous 
substance, produced in the hypothalamus and released from the posterior pituitary gland as 
part of the body’s response to stress and trauma. Among other effects, Argipressin induces 
vasoconstriction by V1 receptors in smooth muscle (prominent in the splanchnic circulation), 
and water retention by V2 receptors in the kidney’s collecting ducts. Argipressin and its 
analogues are established agents for treatment of vasoplegia, for example in sepsis where 
endogenous levels are low, as well as treatment of esophageal varices and hepatorenal 
syndrome. It may be used during anesthesia for liver transplantation, and our group has 
shown that it decreases portal and hepatic blood flow in patients undergoing hepatic 
resection (5, 6).  
 
Pringle’s manoeuvre, or surgical occlusion of the hepatoduodenal ligament, is used during 
hepatic surgery to limit the blood supply to the liver to minimize blood loss. This method 
impairs venous drainage from mesenteric vessels, and induce stasis of the bowel and 
intermittent hepatic ischemia/ hypoperfusion as well as frequent circulatory instability and 
lactate production (7). When the blood flow through the portal vein is reduced, the flow is 
reciprocally  increased in  the hepatic artery (the Hepatic Artery Buffer Response, HABR) (8). 
Argipressin may redirect blood flow from the splanchnic circulation, and hence decrease 
blood flow through the liver while maintaining oxygenation of the liver parenchyma by 
means of the HABR. This redirection of blood flow may be a way of reducing blood loss 
during hepatic resection. Abbas et al showed a significant reduction of blood loss with the 
use of Terlipressin (an Argipressin-analogoue, with comparatively longer half-life) during 
open hepatic resection, but they did not evaluate effects on inflammatory response or on 
organ perfusion (9). Sims et al administered an Argipressin bolus followed by infusion for 48 
hours to trauma patients with ongoing hemorrhage, and noted decreased transfusion 
requirements in the treatment group compared to placebo (10).  
 
Major surgery such as hepatic resection triggers the inflammatory response (11). The 
inflammatory system has a key function in cancer development, and Argipressin may have 
anti-inflammatory properties (12, 13).  
As for any vasoactive agent, the vasoconstrictive properties of Argipressin imply a risk of 
reduced perfusion of internal organs, such as kidneys and intestines, and there are 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
11 
conflicting results in this area of research. Some studies suggest improved kidney function 
after use of Argipressin analogues during liver transplantation, while others show an oxygen 
supply-demand mismatch in the kidney when used adjacent to cardiac surgery (14, 15, 16). 
The large randomized controlled studies VASST and VANISH on sepsis patients did not 
demonstrate any increased risk of acute kidney injury for the patients treated with 
Argipressin, and the VANISH study showed a reduced need for renal replacement therapy 
(17, 18). The effect of Argipressin on the mesenteric circulation may be beneficial, as when 
used to reduce blood flow to treat esophageal varices. On the other hand, the reduced flow 
might also imply a risk of intestinal hypoperfusion. The same line of reasoning applies to the 
cardiac circulation (19). 
 
1.1 
Rational for conducting this study 
The most common indication for hepatic resection is colo-rectal cancer metastasis, but 
other conditions such as tumours in the biliary system, primary hepatic tumours and benign 
tumours may require surgical treatment. Colo-rectal cancer is a common malignant disease, 
and a large number of patients are affected by the outcome of surgical treatment. Blood 
loss and blood transfusion is shown to influence outcome negatively for patients undergoing 
surgical treatment, and transfusion of blood products may initiate immunological reactions 
(1, 2, 3). The surgical means to reduce blood loss during hepatic surgery may impair 
perfusion and induce intestinal congestion. If blood flow to the liver can be influenced by 
pharmacological means, thus reducing blood flow to the liver while maintaining oxygenation 
through the HABR, blood loss and transfusion requirements may be reduced. Ultimately, 
this could influence morbidity and mortality. The inflammatory system is involved in cancer 
development and is triggered after major surgery. Anti-inflammatory properties of 
Vasopressin may decrease the inflammatory response after hepatic surgery and enhance 
recovery.  
 
The intention of this study is to increase the knowledge of Argipressin to the benefit of 
future patients. Abbas et al studied Terlipressin effects on hepatic surgery patients, albeit 
with a more generous fluid therapy approach compared to the low CVP technique used in 
our centre and showed a significant reduction of blood loss (9). The median blood loss for 
major open resections in our centre was 1250 ml during the period January 2019- October 
2020, and effects of Argipressin has not yet been investigated in the setting of our relatively 
fluid restrictive protocol, with an increasing number of laparoscopic hepatic resections. We 
also want to investigate the potential anti-inflammatory effects of Argipressin in this setting. 
 
1.2 
Hypothesis 
Infusion of Argipressin during hepatic resection reduces blood loss during hepatic surgery. It 
may also reduce transfusion requirements, and mitigate the perioperative inflammatory 
response compared to placebo.  
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
12 
1.3 
Risk/benefit evaluation 
Blood loss and transfusion is shown to influence outcome negatively after surgery for colo-
rectal metastases. Inflammatory reactions are expected after major surgery, and mitigation 
of this response may improve recovery. By potentially influencing these factors, treatment 
with Argipressin may be beneficial for the individual patient, as well as reducing health care 
needs for this large group of patients. Reduced needs of donated blood products would also 
be beneficial in a socioeconomic perspective.  
 
Argipressin is an established pharmacological agent in anaesthesia and intensive care for 
treatment of vasoplegia and circulatory instability, together with norepinephrine or as a 
single agent. Several studies show beneficial effects on kidney function after use of 
Argipressin, for example after liver transplant surgery, and it is recommended in sepsis 
treatment guidelines (5, 14, 20, 21). Sims et al investigated the effects of Argipressin on 
transfusion requirements in trauma patients with severe haemorrhage, and showed 
reduced need of transfusion in the treatment group without any difference in mortality, 
morbidity or complications (10).  
 
As all vasoconstrictive agents, Argipressin may impair organ perfusion, and in extreme cases 
intestinal or digital ischemia may arise. Patients will be closely monitored during the period 
of Argipressin infusion and during the postoperative period, with visual observation of signs 
of ischemia, and laboratory tests. In this study, the infusion of Argipressin will be given only 
during surgery, i. e. during a limited time of a few hours, compared to the VANISH, VASST 
and Sims’ studies where the study drug was infused during several days (10, 17, 18). 
Patients will be euvolemic, and not in septic or haemorrhagic shock. The dose of Argipressin 
will be 0.045 U/kg/h (corresponding to a dose of 3.6 U/h for a patient of 80 kg), which is 
equal to the dose used in the VANISH-trial, and somewhat higher than the dose used in the 
VASST trial, but still lower than the maximal dose in other studies including previous studies 
at our centre (6, 22). The half-life of Argipressin is approximately 10 minutes, and hence no 
circulatory effects of the infusion will be present after the immediate postoperative period. 
The placebo infusion (NaCl 0.056 ml/kg/h) will not have any circulatory or pharmacologic 
effects.  
 
All treatment except for the study drug will be according to clinical routine, and no extra 
visits, X-rays or clinical investigations will be required. The extra amount of blood drawn for 
blood samples in the study is approximately 70 ml, and compared to a normal total blood 
volume of approximately 5000 ml considered negligible in this context. Argipressin is not 
expected to interact with any treatment or medication used in clinical routine. 
Data will be registered in Red Cap®, and will only be accessible to the study nurses, the 
investigators and the monitor before database lock. The study nurses and the investigator 
will not have access to the treatment codes until after database lock. All data will be 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
13 
handled according to Swedish law. The study will not be associated with extra travels or 
visits, and the patient population is prioritized for cancer treatment regardless of the Covid -
19 pandemic. The study will be subject for external monitoring, and reporting of AE:s will be 
performed according to Swedish regulations for clinical trials. The investigators will consider 
the EMA guidance, “Points to consider on implications of Coronavirus disease (COVID-19) on 
methodological aspects of ongoing clinical trials” (EMA/158330/2020 Rev. 1). 
In summary we consider the potential risks associated with infusion of Argipressin during a 
limited time to be minimal, in relation to the inherent risks of major abdominal surgery, and 
corresponding doses of Argipressin have been used during several days in other studies.  
 
1.4 
Ethics and Regulatory review 
The study will be conducted in compliance with the International Council for Harmonisation 
of Technical Requirements for Pharmaceuticals for Human Use (ICH), Good Clinical Practice 
(GCP), applicable national regulatory requirements (Swedish Medical Products Agency 
(SMPA) regulations 2011:19) and in accordance with the ethical principles in the Declaration 
of Helsinki (2013).  
The Swedish Ethical Review Authority (Etikprövningsmyndigheten, EPM) has approved the 
study (Dnr 2021-03557), with addition of University of Gothenburg as research principal on 
Sept 25 2023 (Dnr 2023-05044-02), and administrative amendment (Dnr 2024-02896-02), as 
well as additional approval for the substudy on pain registration (Dnr 2024-06047-02).  The 
study is registered at ClinicalTrials.gov (NTC05293041) and at the EudraCT database 
(EudraCT 2021-001806-32).  
The investigators will ensure that the subjects are given full and adequate oral and written 
information about the nature, purpose, possible risks and benefits of the study, and ensure 
that the subjects are notified that they are free to discontinue from the study at any time. 
Signed and dated informed consent will be obtained before any study specific procedures 
are conducted, and stored in the Study Master File. Each participant will receive a copy of 
the signed Informed Consent Form. The final version of the informed consent form and 
other information provided to subjects is approved by EPM, including the updated version 
with additional laboratory tests regarding thrombocyte function. EPM and the Swedish 
Medical Products Agency will be informed of any significant changes in the study protocol in 
accordance with current requirements.  
All data will be handled in accordance with the EU Directive 2016/679 (GDPR) and the Law 
(2018:218) with additional regulations on the EU data protection regulation. If any part of 
the data is handled by any other organization, inside or outside the EU, appropriate 
agreements and/or other documentation will be established, to ensure that the data 
processing is performed in accordance with the provisions of the General Data Protection 
Regulation (GDPR) and other relevant legislation, before any data transfer takes place.  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
14 
For detailed information regarding ethics and regulatory review, informed consent, data 
protection and audits as well as inspections see Appendix B. 
  
The Ethics review board and the SMPA have been informed about the updates of the 
protocol. 
 
2. Objectives and Endpoints 
2.1 
Primary Objective 
To determine if infusion of Argipressin during hepatic resection surgery reduces blood loss 
compared to placebo. 
 
2.2 
Secondary Objectives 
• To determine if infusion of Argipressin during hepatic resection surgery reduces the need 
of transfusions during and after surgery, compared to placebo. 
• To determine if infusion of Argipressin during hepatic resection surgery mitigates the 
postoperative inflammatory response, compared to placebo.  
2.3 
Primary Endpoint 
Blood loss (ml) at the end of surgery, measured according to the investigator’s instructions, 
by visual assessment of suction devices and gauze, and subtraction of ascites and irrigation 
fluids.  
 
2.4 
Secondary Endpoints 
• Number of patients requiring blood transfusion, as well as amount of blood transfusion 
(ml) at the end of surgery, and at postoperative day 1 and postoperative day 2 or 5, 
respectively, as well as plasma and thrombocytes day 2/5. 
• Levels of WBC, CRP, PLT and Albumin at the end of surgery and postoperative day 1-5.  
• Levels of IL-1 IL-6, IL-8, IL-10, MCP-1, C3a, C5b-9 at the end of surgery and postoperative 
day 1 and 2. 
• ROTEM, vWF activity, factor VIII at the end of surgery and postoperative day 1.  
To evaluate effects of the study drug on liver, kidneys, heart and intestines, tissue 
biomarkers will be part of the study protocol: 
 
• Plasma creatinine will be controlled at postoperative day 1, 2 and 5. AKI graded according 
to KDIGO criteria will be reported.  
• Urine [TIMP-2] x [IGFBP-7] will be controlled after surgery and related to urine-
creatinine. 
• Hs-TNI will be controlled at the end of surgery and at postoperative day 1.  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
15 
• Arterial lactate will be controlled at the end of surgery, at three hours after surgery and 
at postoperative day 1.  
• IFABP will be controlled at three hours after surgery and postoperative day one.  
• ASAT, ALAT, PK-INR and bilirubin will be followed until POD 2 / 5.  
Perioperative data and hemodynamic measurements as listed below will be recorded and 
presented as descriptive data.  
 
• Vasopressor use during surgery, achievement of CVP goal, total urine output and use of 
furosemide at postoperative day 1.  
• Measurements of mean arterial blood pressure (MAP), heart rate, CVP and Cardiac Index 
(if applicable), as well as assessment of capillary refill time in digits at the end of surgery. 
• Total time of surgical hepatic occlusion and radicality of resection, as well as use of TXA. 
• Length of stay in hospital and postoperative complications documented at postoperative 
day 30, including diagnosis verified by PAD. 
A protocol for exploration of coagulation function will be applied on maximum 30 patients 
starting August /September 2024 (appendix E) and results will be presented as a pilot study.  
 
A protocol for exploration of pain scores and opioid consumption was added to the main 
protocol (appendix F). Results will be presented as descriptive data in a pilot study. 
 
3. 
Study Design 
3.1 
Overall study design 
This single centre, double blinded, randomized placebo- controlled trial is performed at 
Sahlgrenska University Hospital. The aims are to investigate the effect of Argipressin on 
blood loss, transfusion requirements and inflammatory response during hepatic surgery. 
Participants will be stratified according to planned surgical technique (open or laparoscopic 
surgery) and planned extent of resection (“large” or ”small”) before randomization to 
treatment with argipressin or placebo during surgery. Markers of hepatic, kidney, cardiac 
and intestinal damage will be evaluated during and after surgery. More extensive testing of 
inflammatory markers will be performed in a limited number of patients (subgroup) in each 
arm.  
 
The study drug infusion will be started after induction of anesthesia and continue until the 
end of surgery. In the rare case of additional surgical procedure after the hepatic resection, 
such as (but not limited to) abdominal wall hernia repair, the study medication might be 
stopped after the resection phase. All other treatment will be according to clinical routine, 
including use of vasopressor (norepinephrine) if required to achieve adequate MAP. Blood 
loss will be assessed at completion of surgery, and given transfusions recorded at “End of 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
16 
surgery” and “postop day 1”. At “end of hospitalization“ (day 2 and 5 respectively) total 
transfusion requirements (erythrocytes, plasma and thrombocytes) will be recorded. Blood 
and urine samples will be obtained before and during surgery (timepoints: Day of surgery; 
“Before anesthesia”, “After induction”, “End of surgery”), as well as postoperatively 
(timepoints: “End of surgery +3h”, “Post op day 1-5”). Assessments at postoperative day 5 
will pertain only to patients operated with open technique, since patients operated with 
laparoscopic technique are expected to be discharged from hospital on postoperative day 2. 
Perioperative data and hemodynamic measurements will be registered during surgery.  
 
Throughout the study, the treating physician will be clinically responsible for the patient. 
This includes interpretation of study laboratory results that are accessible in the patient 
chart during the hospital stay, as well as treatment of surgical or medical conditions and 
consultation of other specialists if needed. Tests obtained outside of clinical routine, where 
results are not accessible for the treating physician (only to the study team), will not lead to 
further investigation (i. e. Nephrocheck®). No further study measurements or samples will 
be obtained after the fifth postoperative day. Data from the surgical follow up at 30 days 
will be obtained from the SweLiv registry and recorded in the eCRF. Adverse reactions and 
adverse events are registered in the eCRF throughout the entire study, i. e. until maximum 
postoperative day 5, and followed until resolution. 
 
Overall study design and activities are shown in Figure 1 and Table 1 below. 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
17 
Fig 1. Flow Chart ARG-01 (ITT adjusted to modified ITT (mITT)). 
 
ARG-01 Flow Diagram 
Assessed for eligibility (n=  ) 
Excluded  (n=   ) 
¨   Not meeting inclusion criteria (n=  ) 
¨   Declined to participate (n=  ) 
¨   Other reasons (n=  ) 
Discontinued intervention (give reasons) (n=  )  
Lost to follow-up (give reasons) (n=  ) 
Allocated to intervention: active treatment (n=  ), placebo (n=  ) 
¨ Received allocated intervention: treatment (n=  ), placebo (n=.  ) 
¨ Did not receive allocated intervention (give reasons): treatment (n=  ), placebo (n=.  ) 
Included (n=…, max 272) 
Open resection (n= ..) 
Laparoscopic resection (n= ..) 
“large” 
“small” 
“small” 
Randomization 1:1 (max n=272, excluded during surgery n=…) 
mITT population (evaluable patients) n=248  
30 day follow up (analysed n=…) 
Enrollment 
Stratification 
Intervention 
Data Collection 
Eligible for inflammatory subgroup, n=44  
Eligible for inflammatory subgroup, n=44  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
18 
 
Table 1 - Overview of the study activities 
 
Enrolm
ent 
Allocation 
Inter 
vention 
 
Post  
operativ
e  
care 
→ 
Close -out 
TIMEPOINT 
Pre op 
visit 
 
Day of 
surgery -
Before 
anesthesia 
Day of 
Surgery-
After 
induction  
Day of 
Surgery-
End of 
surgery 
Day of 
Surgery- 
End of 
Surgery 
+3h 
Post 
op 
day 1 
5 am 
Post op 
day 1  
10 am 
 
Post 
op 
day 2 
 
Post op 
day 5* 
 
30 day 
follow up 
ENROLMENT: 
 
 
 
 
 
 
 
 
 
 
Eligibility screen 
X 
 
 
 
 
 
 
 
 
 
Informed consent  
X 
 
 
 
 
 
 
 
 
 
Demographic data 
X 
 
 
 
 
 
 
 
 
 
Allocation 
 
X 
 
 
 
 
 
 
 
 
INTERVENTION: 
 
 
 
 
 
 
 
 
 
 
Study drug 
 
 
I-------------- 
-----------I 
 
 
 
 
 
 
assessment of AEs 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
ASSESSMENTS: 
 
 
 
 
 
 
 
 
 
 
Blood loss 
 
 
 
X 
 
 
 
 
 
 
Blood transfusion 
(ml) 
 
 
 
X 
 
 
X 
X 
X 
 
Norepinephrine** 
 
 
 
X 
 
 
 
 
 
 
Use of other 
inotropic drugs  
 
 
 
X 
 
 
 
 
 
 
CVP-goal achieved 
 
 
 
X 
 
 
 
 
 
 
Total diuresis  
 
 
 
 
 
 
X 
 
 
 
Furosemide total 
dose 
 
 
 
 
 
 
X 
 
 
 
Hemodynamics^ 
 
 
X 
X 
 
 
 
 
 
 
Surgical data^^ 
 
 
 
X 
 
 
 
 
 
 
Postoperative 
data^^^  
 
 
 
 
 
 
 
X 
X 
X 
Clinical Frailty 
Scale 
X 
 
 
 
 
 
 
 
 
 
LABORATORY 
TESTS: 
 
 
 
 
 
 
 
 
 
 
Blood samples• 
 
X 
 
X 
 
X  
  
X 
X 
 
Cytokines 
+Interleukins•• 
 
X 
 
X 
 
 
X 
X 
 
 
[TIMP-2 xIGFBP7], 
U-creatinine 
 
 
X 
 
X 
 
 
 
 
 
hs-TNI 
 
         X 
 
X 
 
X 
 
 
 
 
Arterial lactate,  
glc, Na  
X° 
X 
 
X   
X 
X 
 
 
 
 
                  IFABP 
 
X 
 
 
X  
 
X••• 
 
 
 
TEG, fVIII, vW 
 
 
 
X 
 
 
 
 
 
 
AST, ALT, PT-INR, 
bilirubin 
X 
 
 
 
 
X 
 
X 
X 
 
 
*Patients having open surgery, 4-6 days postoperative, closest possible weekday;  
**Total dose of norepinephrine during surgery (cg), divided by minutes of surgery and weight of patient;  
^Mean Arterial Blood Pressure, Heart Rate (before induction), Central Venous Pressure and Cardiac Index (after insertion) and 
thereafter every 30 min during the resection phase. Capillary refill time; hourly during surgery 
^^Performed surgical procedure, Duration of surgery, total Pringle time, Use of Tranexamic Acid 
^^^complications (SweLiv Registry), length of stay in hospital, radicality of resection, pain scores and opioid consumption, 
diagnosis verified by PAD 
•WBC, CRP, PLT, Albumin, Hemoglobin, p-Creatinine 
••cytokines / interleukins: IL-1 IL-6, IL-8, IL-10, MCP-1, C3a, C5b-9.  
°only S-Na 
••• for ROTEM, factor VIII and vonWillebrand tests, samples are taken at 5 am if possible, but until 10 am if needed 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
19 
3.1.1 
Stopping criteria 
The only general stopping criteria is suspected hypersensitivity to the study drug or to any of 
the excipients. In case of unexpected serious events jeopardizing the safety of the subject, 
the study may be stopped by the physician in charge, and the randomization code broken.  
Any data recorded in Red Cap® will be kept, but no further recordings will be made. The 
time of and reason for study drug termination will be recorded. Any saved blood samples 
collected until then will be discarded, but data already entered into the eCRF will be 
included in the study analysis when appropriate.  
 
3.1.2 
Rational for study design, dose and laboratory analyses 
Design 
Participants will be stratified according to planned surgical technique and planned size of 
resection, since open and larger resections have a higher expected blood loss. 
Randomization will be performed by a computerized randomization tool in Red Cap®, at a 
1:1 ratio. From each allocation arm, 44 (total n=88) patients will be selected for extended 
testing of cytokines and interleukins. These tests are costly and require immediate 
centrifugation and freezing and will therefore not be performed in all the study participants.  
 
Study drug infusion and dose  
The study drug infusion will be started after induction of anaesthesia and collection of 
baseline blood and -urine samples. The study drug infusion (Empressin® 0.8 U/ml or NaCl 
9mg/ml (placebo)) is run at a constant speed of 0.056 ml/kg/h until the end of surgery. This 
corresponds to a dose of Empressin® of 0.045 U/kg/h, or 3.6 U/h for an 80 kg patient 
(Empressin® 0.8 U/ml, 0.056 ml/kg/h= 4.5 ml/h = 3.6 U/h for 80 kg). Empressin® has a half-
life of 10 minutes in the circulation, and steady state in plasma is reached after 30 minutes 
of infusion. Starting the infusion at the beginning of surgery will give the infusion time to 
reach steady state and potentially divert blood away from the mesenteric circulation before 
start of the resection of liver parenchyma.  
 
The dose of Argipressin (Vasopressin) in previous large RCTs varies between 0.03- 0.075 
U/kg/h (10, 17, 18). In the Surviving Sepsis Campaign guidelines, the recommended dose is 
0.03 U/min (1.8 U/h), which is also suggested in FASS, in both cases for use during 48 hours 
(20). The dose of Argipressin used in this study is well established in our hospital clinical 
practice, and lower than the dose used in previous studies at our center (6, 22). 
 
Choice of laboratory analyses  
Inflammatory markers are expected to rise after major surgery. CRP, WBC, PLT and Albumin 
are controlled postoperatively according to clinical routine, and are also part of the study 
protocol outcome measurements for all included subjects. The analyses of interleukins and 
cytokines (IL-1 IL-6, IL-8, IL-10, MCP-1, C3a, C5b-9) were chosen according to our pilot 
study to represent different stages of the inflammatory cascade and is performed in a 
subgroup of 44 patients in each arm.  
 
Plasma creatinine is controlled in clinical practice as a marker of kidney dysfunction, and is 
used in the definition of AKI according to the KDIGO criteria. Urine [TIMP-2] x [IGFBP-7] 
(Nephrocheck®) is suggested (although not validated) as a marker of early tubular damage, 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
20 
and urine-creatinine will be analysed at the same timepoints to enable comparison of 
Nephrocheck® values. 
 
hs-TNI is a specific marker of cardiac ischemia. Hs-TNI is followed until post op day 1; any 
increase after that will not likely be due to the study drug infusion.  
 
Arterial lactate will be controlled frequently according to clinical practice, together with 
plasma glucose levels (since the glucose level itself might influence lactate values). IFABP is 
suggested as a marker of intestinal mucosal damage (23). In our pilot study, IFABP returned 
to baseline at Postoperative day 1, and will not be followed after that timepoint. Serum-Na 
will be controlled due to Argipressin’s potential to cause water retention. 
 
AST, ALT, PT-INR, bilirubin and Haemoglobin are controlled according to clinical practice. 
The results will be recorded in the eCRF and presented as descriptive data.  
 
The measurement timepoints were chosen to cover the peak increase of the various 
laboratory tests. Some of the measurements are also considered safety parameters (plasma 
creatinine, hs-TNI, arterial lactate).  
 
See appendix E for evaluation of coagulation function, and appendix F for evaluation of pain 
scores and opioid consumption.  
 
4. Patient Population 
All patients > 18 years, male and female, scheduled for hepatic resection at Sahlgrenska 
University Hospital due to primary malignant disease, metastasis or benign tumour will be 
assessed for eligibility. The surgery schedule is reviewed together with study nurses and 
surgical coordinator to make sure all eligible patients are considered.  
 
In each arm (treatment/ placebo, stratified for open or laparoscopic resection), 44 patients 
(total n= 88) will be selected for extended testing of inflammatory markers. This selection 
will be based inflammatory status and logistic factors. The patient will be marked as eligible 
for the inflammatory subgroup in the randomisation part of Red Cap®, to ensure adequate 
distribution of the subgroup patients.  
 
Participants will have to fulfil the following inclusion and exclusion criteria: 
 
4.1 
Inclusion criteria 
1. Participant planned for hepatic resection (open or laparoscopic, regardless of indication 
for surgery). 
2. Age ≥18 years.  
3. ASA class I-III. 
4. Signed informed consent form.  
4.2 
Exclusion criteria 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
21 
1. Participant does not understand the given information, and/ or cannot give written 
informed consent. 
2. Simultaneous operation of tumor with other localization, or surgery for superficial single 
hepatic tumor less than 2 cm, expected to be of short duration and with minimal blood 
loss. 
3. Terminal kidney failure (estimated preoperative GFR< 15 ml/min)  
4. Pregnancy or lactation (Patients declare any possibility of pregnancy at the preoperative 
assessment, and if appropriate a pregnancy test will be taken). 
5. Known allergy to Empressin®. 
6. Patient included in other interventional study, interacting with the endpoints in the 
present study, or previous randomization in this study. 
7. Hyponatremia (S-Na < 130 mmol/L) 
8. Patient considered ineligible for other surgical or medical reason. 
9. Present infection (defined as active treatment with antibiotics, prophylactic antibiotics is 
not an exclusion criteria). 
Patients with systemic inflammatory disease, inflammatory bowel disease or preoperative 
corticosteroid treatment will not be eligible for the subgroups where cytokines and 
interleukins are investigated. 
 
4.3 
Subject enrolment 
The investigator will keep a screening list of patients who were considered for enrolment 
but not included, and record the reason for exclusion. The identity of the patients on the list 
will not be available to the rest of the research group. Immediately after inclusion of a 
participant fulfilling the inclusion/exclusion criteria, a Signed Informed Consent will be 
obtained before any study-specific procedures are carried out. Information is given, and 
consent form obtained by the study staff physicians or specifically trained physicians at the 
preoperative anaesthesia consultation department. Furthermore, a “subject number” will 
be allocated to each subject.  
 
If a potential participant requires some extra time to consider participation, or for some 
reason is not approached at the preoperative visit, the study team may contact him or her 
by phone call (approved by head of department). The phone call aims to obtain an 
indication of willingness to participate in the study, so that the potential participant may be 
added to RedCap® and obtain a subject number for logistic purposes. Written consent is still 
obtained before surgery and any study specific interventions. The subject number will 
follow on all patient records, eCRFs, urine- and blood samples etc, except for blood samples 
sent directly to the department of Clinical Chemistry for analysis. Those samples will be 
labelled with the patient’s social security number, and recorded in the hospital clinical 
charts. The results will then be transferred to the eCRF under the subject number. 
 
4.4 
Discontinuation and withdrawal of subjects 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
22 
Subjects are free to discontinue their participation in the study at any time without 
prejudice to further treatment. If participation is discontinued, subjects will be asked about 
the reason(s) for the discontinuation and the presence of any AE. The subjects may be 
withdrawn from the study at the discretion of the investigators due to safety concerns, 
incorrect enrolment or perioperative change of surgical procedure (for example aborted 
surgery due to spread disease). After discussion in the study team, including statistician, 
patients converted from laparoscopic to open surgery generally stays in the study. Due to 
eCRF configuration, data could initially only be entered until postoperative day 2 for 
patients planned for laparoscopic surgery- this is now adjusted and data is entered until 
postoperative day 5 for these patients. In case of discontinuation, no further data will be 
registered in the eCRF except follow up of AEs and SAEs and 30-day mortality. Any saved 
blood samples collected until then will be discarded, but data already entered into the eCRF 
will be included in the study analysis.  
 
Discontinued subjects will not be replaced, but inclusion will continue until 248 evaluable 
participants are enrolled (to a maximum 272 patients). The discontinued patients will be 
followed up and treated as long as needed by the treating physician, according to clinical 
routine, including treatment of SAEs and AEs.  
 
4.5 
Premature termination of the study 
The Sponsor or the Investigators may decide to stop the complete study or part of the study 
at any time. If the study is prematurely terminated or suspended, the Investigators should 
promptly inform the previously included patients. Furthermore, the Investigators should 
promptly inform the Ethical Review Authority and provide a detailed written explanation. 
The Regulatory Authority should be informed according to national regulations.  
 
No interim analysis is planned. The sponsor and the study group will review all Adverse 
Events, and Serious Adverse Events will be assessed for causality. This phase IV study is 
considered low risk, and no Data Safety Monitoring Board has been appointed. 
 
5. 
Methodology 
5.1 
Treatment 
Argipressin is the active substance in Empressin®. Patients will receive either continuous 
infusion of Empressin® 0.8 U/ml, or NaCl 9 mg/ml (placebo) at a constant rate of 0.056 
ml/kg/h during surgery. 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
23 
Table 2. Composition of the product 
Study Product  
Concentration, dosage, administration 
Manufacturer 
Empressin® 20 U/ml 
Size of ampoule: 2 ml  
(2 ml of Empressin® is mixed in 48 
ml of NaCL 9 mg/ml, to a 
concentration of 0.8 U/ml).  
Intravenous infusion of Empressin® 0.8 U/ml, 
0.056 ml/kg/h (The solution is administered in a 
50 ml syringe, by an infusion pump, in a central 
venous catheter). Infusion is started after 
induction of anesthesia, and stopped at the end 
of surgery.  
AOP Orphan Pharmaceuticals AG 
Färögatan 33, 31 TR 
16454 Kista, Sweden 
e-mail: office.se@aoporphan.com 
phone: +46 0705786100 
NaCl 9 mg/ml (“normal saline”) = 
placebo 
Intravenous infusion of NaCl 9 mg/ml, 0.056 
ml/kg/h (The solution is administered in a 50 ml 
syringe, by an infusion pump in a central venous 
catheter). Infusion is started after induction of 
anesthesia, and stopped at the end of surgery.  
 
5.1.1 Labelling 
The study drug will be labelled with the Study Code (ARG-01), the EudraCT-number, “Study 
Drug”, the subject number, route of administration, “for clinical study use only”, name, 
address and telephone number to the investigator (appendix D). The number to the 
manufacturer and the batch number will be available in the drug preparation room, but not 
on the label of the syringe as to not jeopardize the blinding. The nurse preparing the syringe 
will sign it with date and signature.  
 
5.1.2 Storage, handling and delivery 
Commercially available Empressin® ampoules will be procured through the normal channels 
of distribution, i.e. hospital pharmacy at Sahlgrenska University hospital (or other hospital 
pharmacy, depending on study centre). The ampoules contain concentrated Empressin® 
which is very potent, and needs to be diluted before infusion. The Empressin® ampoules will 
be kept locked up at the drug preparation room in the anaesthesia department (“on the 
shelf”). After randomisation on the day of surgery, the assisting nurse will use one ampoule 
from the shelf for preparation of the study drug (if the patient is in the treatment group). 
The infusion of Empressin® needs to be prepared directly before use according to 
manufacturer’s instructions, and hence it cannot be prepared by the hospital pharmacy in 
advance. The study nurse in cooperation with the OR staff will be responsible to keep the 
store refilled. The boxes with Empressin®-ampoules as well as NaCl-ampules used 
specifically for the study will be labelled with the study name, and the telephone number to 
the manufacturer, and to the principal investigator.  
The labelling of the infusion syringe is performed when the content of an ampoule is mixed 
with saline in the syringe (Appendix D). The content of the infusion of Empressin® does not 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
24 
differ from the infusion content described in the IMPD (or FASS). The ampoules are labelled 
by the manufacturer, and this label is not changed or hidden during the study. The used 
ampoules are kept locked in the drug preparation room as to not interfere with the blinding, 
until assessed by the monitor.  
Empressin® will be handled and prepared according to the instructions from the 
manufacturer in FASS. Should the date of expiry be passed (unmixed ampoules of 
Empressin® is durable for 3 years), it is the responsibility of the study nurse to alert the PI so 
that additional ampoules can be provided.  
The placebo infusion consists of normal saline (NaCl 9 mg/ml) will be provided by the 
Anesthesia department at Sahlgrenska University Hospital. Any remaining infusion of study 
drug at the end of surgery will be disconnected from the patient and the syringe saved, after 
notation of the administered volume. The syringe will be discarded after inspection by the 
monitor.  
It is the investigator’s responsibility to establish a system for handling the study medicine to 
ensure that it is correctly received and recorded and only dispensed to patients in 
accordance with this protocol and the written manufacturer instruction in FASS. The empty 
ampoules of Empressin® and NaCl will be labelled with the subject number and saved in a 
dedicated box in the medical preparation room, and will only be discarded after inspection 
by the monitor.  
 
5.1.3 Randomization, Blinding and Study Drug administration 
Randomization in RedCap® and preparation of the study drug infusion syringe will be 
performed by an assisting nurse with access only to the randomization tool in Red Cap®. A 
list of assisting nurses with delegation to use the randomization tool in Red Cap® will be 
made. The syringe, labelled “Study drug”, will be handed to the anesthesia nurse, who will 
be blinded to its content (both solutions are colorless and transparent), as well as the study 
staff and all healthcare professionals involved in the care of the patient. The assisting, 
unblinded, nurse will not be involved in the care of the patient.  
 
The randomization tool in Red Cap® will generate information regarding weather active 
treatment or placebo will be given to the patient, as well as a randomization number. 
Allocation ratio will be 1:1. The randomization number will be noted on the anesthesia chart 
and in the medical record (Melior), and linked to an envelope with information about which 
treatment has been given. The envelopes are kept locked in, and are used only in case 
unblinding is needed due to any unexpected serious medical event jeopardizing the safety 
of the study participant. The attending physician is responsible for decisions regarding 
unblinding after discussion with the primary investigator or sponsor. Unblinding must be 
documented and reported to the investigator.  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
25 
Treatment codes will not be broken for the planned analyses of data until all decisions on 
the evaluability of the data from each individual patient have been made and documented 
by the monitors at the end of the study (database lock). 
5.1.4 Treatment compliance 
As study treatment will be administered intravenously by hospital staff during surgery, and 
all samples will be obtained during hospitalization in conjunction with surgery, compliance is 
expected to be 100%. 
 
5.1.5 Accountability 
The study nurse will be responsible for collection of samples, to check that start and 
termination of the study drug is done at the correct timepoints, and ensure collection of 
perioperative data. Correct study drug administration is controlled by the monitor.  
 
The study product provided for this study is for use only as directed in the protocol. All 
unused products will be accounted for and returned to the PI at the termination of the 
study. At the end of the study, it must be possible to reconcile delivery records with records 
of usage and returned batches. 
 
5.2 
Samples and Biobank 
Haemoglobin, WBC, CRP, PLT, Albumin, plasma and urine-creatinine and hs-TNI, as well as 
AST, ALT, bilirubin, PK-INR, vWF and factor VII will be analysed directly at the Department of 
Clinical Chemistry at Sahlgrenska University Hospital. When handled at the Department of 
Clinical Chemistry, the samples will be part of each centre’s biobank. Analysis results are 
filed in the patient’s hospital chart and then recorded in the eCRF under the “subject 
number”.  
 
Arterial lactate, glucose and S-Na will be obtained by point of care blood gas analysis, as well 
as ROTEM analysis. Samples will be discarded after analysis. Analysis results are filed in the 
patient’s hospital chart and then recorded in the eCRF under the “subject number”. Urine 
[TIMP-2] x [IGFBP-7] will be analysed by point of care use of Nephrocheck®, and the result 
will be recorded directly in the eCRF. Samples for IFABP will be centrifugated immediately 
and kept at -80°C until the end of the study, when batch analysis will be performed at the 
Study section at the Department of Clinical Chemistry at Sahlgrenska University Hospital.  
 
Plasma samples for interleukins and cytokines (IL-1 IL-6, IL-8, IL-10, MCP-1, C3a, C5b-9) will 
only be collected from patients included in the inflammatory subgroup. They will be handled 
by the research group/ study nurse, centrifugated immediately and stored at -80°C until 
batch analysis. These samples will be part of Sahlgrenska Biobank 809, Västra Götaland 
Region. From the serum drawn at each measurement point for the subgroup, one 500 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
26 
microliter sample will be saved in case of future interest of supplemental analysis, although 
maximum for ten years. All samples will be discarded after thawing and analysis. 
 
All stored samples will be handled according to current law (Swedish Code of Statutes 
2002:297). The responsible investigator at each site keeps full tractability of collected 
biological samples from the subjects while in storage at the centre. Likewise, the sample 
receiver keeps full tractability of the samples while in storage and during use until used. The 
amount of blood drawn for study purposes, in addition to clinical routine samples, is 62.5 
ml.  
 
5.3 
Concomitant medication 
Concomitant medication during the study will be recorded in the eCRF (temporary 
omittance of medication in relation to surgery will be considered routine practice and not 
documented). Participants are allowed to continue with their regular medications during the 
study.  
6. 
Study measurements 
6.1 
Measurements, time points and procedures  
 
6.1.1 
Preoperative visit 
Screening 
Written information about the study will be sent by e-mail or mail to each patient when 
summoned for the preoperative anesthesia visit, where screening for eligibility will take 
place. All patients, ASA class I-III, planned for elective hepatic surgery will be eligible for 
inclusion. Eligible patients will be given oral and written information about the study, and 
asked to provide a written consent, signed both by the patient and by appointed physicians 
at the preoperative center (a list of delegated physicians will be established). If the patient 
was not approached at the preoperative visit, screening and enrolment may also take place 
at admission to the surgical ward the day before surgery (with oral and written information 
provided by the research group, as well as the written consent form). In case information 
was not sent to the patient before the preoperative visit, written and oral information may 
be provided at the visit, by appointed physicians, and for logistic reasons an oral preliminary 
willingness to participate may be assessed by phone call to enable registration in RedCap®. 
This rare procedure is approved by the head of department. A signed written consent will be 
obtained when the patient is admitted for surgery, and before any study -specific 
procedures. After inclusion, the patient will be assigned a subject number. All patient data 
processed by the sponsor will be filed under this pseudonym, and the subject number will 
follow the patient throughout the study. ASA class IV patients (patients with significant life -
threatening disease, such as recent cardiac infarction or major cardiac failure) will not be 
included in the study.  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
27 
 
Before the preoperative visit, routine laboratory tests will be taken. This data is not specific 
for the study, and permission to include these results in the eCRF will be requested in the 
informed consent form. Demographic data, medical history and medications will also be 
recorded.  
 
For the blood and urine- samples obtained during and after surgery, set times will be used 
for printed labels (preoperative samples; 8:00 am, end of surgery samples; 3:00 pm, end of 
surgery +3h samples; 6:00 pm, postoperative samples; 5:00 am). This routine makes it easier 
to distinguish the study samples in the chart. Samples at 10:00 am are not registered in 
LabBest, and no printed label is needed. The study nurse will note in the work sheet the 
actual time that samples were obtained, and a time span of ±1 hour is acceptable.  
 
6.1.2 Day of surgery 
Before anesthesia  
Randomization in RedCap® and preparation of the study drug infusion syringe will be 
performed by an assisting (unblinded) nurse with limited access to the eCRF program (only 
the randomization module). The syringe, labelled “Study drug” (Appendix D), will be handed 
to the anesthesia nurse, who thus will be blinded to its content (both solutions are colorless 
and transparent). The assisting nurse is not involved in the care of the patient. 
 
Before induction of anesthesia, an arterial catheter will be inserted, and baseline blood 
samples obtained. Epidural catheter or intrathechal morphine for open surgery patients is 
placed before anesthesia at the discretion of the treating anesthesiologist.  
 
After induction  
After induction of anesthesia according to clinical routine, a central venous catheter and a 
urinary catheter will be inserted, and baseline urine samples will be obtained. A cardiac 
output monitor (Picco®, Pulsioflex®, HemSphere /FlowTrac® sensor, or other monitor) will 
be inserted at the discretion of the anesthesiologist (primarily for open surgery patients). 
Norepinephrine infusion (or other vasoactive drugs, such as nitroglycerine or dopamine) 
may be used as needed. 
 
After collection of all baseline samples, the study drug or placebo is started in the central 
venous catheter, in a dedicated lumen, at a continuous rate of 0.056 ml/kg/h (0.045 U/kg/h, 
corresponding to 3.6 U/h for an 80-kg patient), and run until the end of surgery. The 
anesthesia nurse will alert the assisting nurse (who was responsible for randomization and 
preparation of the study drug) if an additional syringe will be needed in case off prolonged 
surgery. A maximum weight of 100 kg will be used for infusion rate calculation- obese 
patients will hence receive a slightly lower dose/kg to avoid excessively high doses.  
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
28 
Surgical procedure  
Hepatic resection is carried out in different stages. In the first phase of surgery, the 
abdomen is dissected to access the liver (dissection phase), and then the resection of liver 
parenchyma ensues (resection phase).  
 
The risk of blood loss is greatest during the resection phase, where liver parenchyma is 
divided, and occlusion of the hepatoduodenal ligament is applied intermittently by the 
surgeon to control blood loss. During the study, use of surgical occlusion techniques will be 
applied according to the preference of the surgeon, after discussion among the surgeons on 
a standardized routine. The resection area is also susceptible to the pressure in the central 
venous system, why anesthesiologic management aims to keep venous pressure low. 
Hemodynamic values, including CVP, will be assessed during surgery.  
 
End of surgery 
The study drug/placebo infusion will be given at a constant rate until the end of surgery, 
when it is tapered out by reduction with 50%, after 10 minutes further reduction with 50%, 
and after another 10 minutes discontinued. Norepinephrine may be used to counterbalance 
any fall in blood pressure. In the rare case of additional procedure after the resection phase, 
such as hernia repair, the study drug may be stopped after the resection phase.  
 
Blood loss will be assessed by recording of the levels in suction devices used during surgery, 
counting of soaked gauze pieces, and deduction of ascites and irrigation fluid according to 
instructions given by the investigators. Utmost care will be taken to clear the abdomen of 
excess irrigation fluids during laparoscopic surgery, and amount of used irrigation fluid will 
be noted.  
 
Samples will be obtained, as well as recordings of hemodynamic and perioperative data, 
such as unexpected surgical events. At the end of surgery, anesthesia is discontinued, the 
patient is extubated and transported to the postoperative care unit.  
 
IFABP, Nephrocheck®, urine-creatinine and an arterial blood gas will be collected at 3 hours 
after conclusion of surgery, at the postoperative ward.  
 
6.1.3 Postoperative procedures 
Postoperative day 1 
Routine blood samples are taken at approximately 5 am. The study nurse will obtain the 
tests that require immediate handling (centrifugation and freezing) in the morning, at 
approximately 10 am. Total volume of blood transfusion will be recorded, as well as urinary 
output and use of diuretics. If the arterial line is removed, a venous blood gas will be 
obtained.  
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
29 
Postoperative day 2 
The patients treated with laparoscopic surgery are usually discharged from hospital at 2 
days after surgery. Blood samples will be taken from all patients at this timepoint, both in 
the laparoscopic group as well as in the open surgery group.  
 
Samples for analysis of interleukins and cytokines will be obtained in a subgroup of patients 
in each arm. These samples require immediate handling, and will be obtained postoperative 
day 1 and 2.  
 
Postoperative day 5 
The open surgery group is usually discharged from hospital at 5 days after surgery. Blood 
samples will be taken at postoperative day 5 (or earlier if patient is discharged before 
postoperative day 5). Total transfusion requirements (erythrocytes, plasma, thrombocytes) 
will be assessed at postoperative day 5 (or postoperative day 2, if the patient had 
laparoscopic surgery). Additional transfusions after this timepoint are not considered 
related to the study drug, and hence not registered in the eCRF.  
 
6.1.4 
Follow up 
No extra visits or tests after postoperative day 2 (laparoscopic group) or day 5 (open surgery 
group) will be added due to the study. Patients will be followed up by the surgical team 
according to clinical routine at 30 days after surgery. Usually, this follow-up is made by 
phone call, and postoperative complications will be registered in the SweLiv registry. Data 
will be obtained from the registry and noted in the eCRF, including the final diagnosis 
verified by Pathologic Anatomic Diagnosis (PAD).  
 
6.2 
Recording of data 
An electronic Case Registration Form (eCRF), Red Cap®, will be used for data collection. The 
investigators ensure the accuracy, completeness and timeliness of the data recorded, and 
will sign the completed eCRF after revision by the monitor. The complete Trial Master File, 
as well as source documents, will be archived for at least 15 years after the study is 
completed (or longer, if required by new Swedish regulations). Metadata will be posted in 
the Swedish National Data Service (SND), and after study closure and publication of results 
pseudonymized patient data may be available on reasonable request.  
The treatment code will not be broken until the database has been cleaned, approved and 
locked by the sponsor, and all decisions on the evaluability of the data from each individual 
subject have been made and documented. 
 
6.3 
Study variables and laboratory analysis 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
30 
All study data will be noted and recorded in the eCRF (Table 1). Some of the laboratory 
measurements are also safety parameters, and will be used both for assessment of the 
patient in clinical praxis, and in the study analysis.  
 
6.3.1 
Study variables 
Background data 
Sex, age, medical history, medication (including treatment with chemotherapy), Clinical 
Frailty Scale, Eastern Cooperative Oncology Group performance status scale (ECOG), weight 
and height will be recorded, as well as indication for surgery. 
 
Blood loss  
Blood loss will be measured at the end of surgery by reading of amount of blood in suction 
devices, soaked gauze pieces and surgical dressings, according to instructions from the 
investigators. Utmost care will be taken to clear the abdomen of excess irrigation fluids 
during laparoscopic surgery, and amount of used irrigation fluid will be noted and 
subtracted. Volume of transfused blood will be recorded at the end of surgery, at 
postoperative day 1, and at postoperative day 2 and 5, respectively.  
 
Descriptive data  
As shown in Table 1, anaesthesiologic data (achievement of CVP goal, vasoactive 
medications, urinary output), hemodynamic data (heart rate, MAP, CVP and CI) and surgical 
data (performed surgical procedure, duration of surgery, time of surgical occlusion, 
radicality of resection, postoperative complications and length of stay) will be recorded.  
 
6.3.2 Blood and urine 
The total volume of blood needed for samples not included in routine management is 62.5 
ml, with additional 25 ml for the patients included in the thrombocyte pilot. 
  
Plasma  
CRP, Albumin, hs-TNI, Creatinine, AST, ALT, bilirubin, PT-INR, vWF and factor VIII will be 
analysed in plasma, as well as C3a and C5b-9. Cytokine samples will be centrifugated 
immediately and stored at -80C for batch analysis. 
 
Serum  
IFABP and interleukins (IL-1 IL-6, IL-8, IL-10, MCP-1) will be analysed in serum. Samples will 
be centrifugated immediately and stored at -80C for batch analysis.  
 
Whole blood  
Haemoglobin, WBC and PLT will be analysed in whole blood samples, as well as arterial 
lactate, glucose and Na (analysed by point of care blood gas analysis).   
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
31 
Urine  
Samples of urine will be taken twice for analysis of [TIMP-2] x [IGFBP-7] and urine-
creatinine.  
 
6.3.3 
Safety measurements and variables 
The study trial will take place in hospital, and patients will be closely monitored prior to and 
after surgery according to clinical routine.  
hs-TNI is analysed as part of the study, as well as plasma creatinine and arterial lactate; 
indicators of cardiac, renal and intestinal damage. Markers of inflammation and infection 
(WBC, CRP) are analysed both as part of the study and according to clinical routine. AST, 
ALT, PK-INR, bilirubin and PLT are analysed in clinical routine management and will be 
recorded in the eCRF. Results will be presented as descriptive/ explorative data.  
 
Laboratory results indicating organ damage or need for surgical or medical treatment will be 
handled by the treating physician. This may include ECG and hs-TNI series if indicated, as 
well as consultation of other relevant specialists. Should complications to surgery arise, 
patients will be treated by the surgical team as long as required. No additional safety 
parameters due to the study will be assessed after postoperative day 2 (laparoscopic group) 
or postoperative day 5 (open surgery group). 
 
All study related procedures will be performed according to current local and international 
safety recommendations to keep the risk for each participant as low as possible. In addition 
to the regular safety precautions, all participants will be observed for eventual AE as 
described above.  
7. 
Safety 
It is of the utmost importance that all staff involved in the study is familiar with the content 
of this section. The Principal Investigator is responsible for ensuring that procedures and 
expertise are available to handle medical emergencies during the study.  
 
The term AE is used to include both serious and non-serious AEs. Detailed information on 
definitions and reporting rules are seen below in Appendix C (Definitions of Adverse 
Events). 
 
All interventions of the study protocol will be performed according to local and international 
safety and procedural recommendations to assure the safety of the patient and to keep any 
risk as low as possible.  
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
32 
Safety surveillance and registration of Adverse Events (AE) and adverse reactions will be 
performed during the entire study. In case of SUSAR, the investigators will be alerted within 
24 hours or the next working day, and decide if the study code is to be broken and potential 
causality investigated. Beyond the tests defined in the data collection protocol, no 
additional biochemical monitoring is considered necessary for this study. In case any of 
these tests indicate need for treatment, the treating physician will be responsible for 
assessment, treatment and follow up. Test results not available to the treating physician will 
be regarded as study samples only and not basis for any clinical treatment.  
 
7.1 
Expected adverse reactions  
Pre-existing conditions prior to study start will not be registered as adverse reactions. The 
expected complication rate after hepatic resection varies between 4.1- 47.7 % (24). 
Common complications are hepatic failure, bile leakage, AKI, postoperative infection and 
more; such events will be noted in the eCRF, but considered part of the expected 
postoperative course, and not reason for unblinding. Also, expected adverse reactions to 
anaesthesia, such as hypotension, may be noted, but not considered an AE. 
 
All vasoconstrictive drugs, including Argipressin, has the potential to affect perfusion of vital 
inner organs such as intestines and kidneys, as well as peripheral perfusion (skin and digits). 
The risk of hypoperfusion increases with higher doses, in combination with other 
vasopressors and in unstable, hypovolemic patients. The side effects Argipressin listed as 
“common” (>1/100) in FASS includes arrythmia, myocardial ischemia, peripheral 
vasoconstriction and digital ischemia, bowel hypoperfusion and stomach cramps. These 
conditions will be supervised with routine perioperative monitoring (ECG), per protocol 
assessment of digital capillary refill time, and by part of the laboratory results in this study.  
 
Laboratory results outside of the normal range are considered AE:s if: 
Hs-TNI: outside reference range 
Plasma Creatinine: criteria for AKI fulfilled, i e baseline value x 1.5 or +27 micromoles/L 
INR: > 1.4 
AST and ALT: > baseline value x 20  
 
Non-serious AE:s coded as investigations and referring to laboratory values alone will be 
presented in tables, and not primarily in the AE table. Results from tests included in the 
thrombocyte analysis protocol are taken only for research purposes and will not be 
regarded as adverse events.  
  
7.2 
Definitions of Adverse Events (AE) 
An AE is the development of an undesirable medical condition or the deterioration of a pre-
existing medical condition following or during exposure to a pharmaceutical product, 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
33 
whether or not considered causally related to the product. An undesirable medical 
condition can be symptoms (e.g., nausea, chest pain), signs (e.g., tachycardia, enlarged liver) 
or the abnormal results of an investigation (e.g., laboratory findings, electrocardiogram). In 
clinical studies, an AE can include an undesirable medical condition occurring at any time, 
from the date of signed consent, including run-in or washout periods, even if no study 
treatment has been administered, to the final follow-up visit (i.e postoperative day 2 
(laparoscopic group) or postoperative day 5 (open surgery group)).  
An AE will be followed up for as long as it is considered to be medically relevant. 
It is important to distinguish between Serious Adverse Events (SAEs) and Severe AEs. 
Severity is a measure of intensity whereas seriousness is defined by the criteria listed below. 
An AE of severe intensity need not necessarily be considered serious. 
 
7.2.1 
Definition of severity rating  
A definition for the grading of severity of AEs is provided below in Table 3. 
 
Table 3 - Severity rating of an Adverse Event 
 
1 
Mild 
Transient symptoms; awareness of sign or symptom, but easily 
tolerated.  
No interference with the subject’s daily activities. 
2 
Moderate 
Marked symptoms; discomfort sufficient to cause interference 
with normal activities. 
Moderate interference with the subject’s daily activities. 
3 
Severe 
Considerable interference with the subject’s daily activities; 
unacceptable, incapacitating.  
Inability to perform normal activities. 
 
 
7.2.2 
Causal relationship 
The following terms and definitions are used when assessing the causal relationship 
between each AE and the relevant study product (Table 4). 
 
Table 4 - Casual relationship 
 
1 
Definite 
There is no doubt that the incident is related. 
2 
Probable 
Good reason and sufficient documentation to assume a 
causal relationship. 
3 
Possible 
A causal relationship is conceivable and cannot be 
dismissed. 
4 
Unlikely 
The event is most likely related to etiology other than 
the trial product. 
5 
Not related 
The event is not related to the study product. 
6 
Unknown/Unclassifiable A report suggesting an adverse event reaction, which 
cannot be judged because information is 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
34 
insufficient or contradictory and which cannot be 
supplemented. 
 
 
7.3 
Definitions of Serious Adverse Events 
All SAEs must be collected, and an assessment of causality should be performed. An SAE is 
an event that results in one of the following: 
 
• Results in death 
• Is immediate life-threatening 
• Requires in-patient hospitalisation or prolongation of existing hospitalization,  
• Results in persistent or significant disability or incapacity, 
• Is a congenital abnormality or birth defect, 
• Is an important medical event that may jeopardize the subject or may require medical 
intervention to prevent one of the outcomes listed above 
7.3.1 
Recording and reporting of Adverse Events 
All AEs will be collected throughout the study. It is the responsibility of the investigator to 
record and assess all AEs and SAEs until discharge from hospital (maximum postoperative 
day 5). The investigator have to alert the Principal Investigator to all SAEs within 24 hours 
after gaining knowledge about the AE/SAE (or on the next business day), and the Principal 
Investigator will then report the SAE to the sponsor. A supplementary report will follow with 
necessary information for a risk-benefit assessment. 
 
7.3.2 
Follow-up of unresolved Adverse Events 
Any AEs that are unresolved at the end of the study are followed up by the treating 
physician (or study nurse, if delegated) for as long as medically indicated, but without 
further recording in the eCRF. A final outcome assessment will be made by the physicians in 
the research group. All AEs will be summarized and listed in the Clinical Study Report. SAE:s 
will also be described in all narratives/publications. 
 
7.3.3 
Suspected Unexpected Serious Adverse Reaction 
A Suspected Unexpected Serious Adverse Reaction (SUSAR) is serious, according to the 
above criteria and is an untoward and unintended response to an investigational medical 
product (IMP). The definition implies a reasonable possibility of a causal relationship 
between the event and the IMP. A serious adverse reaction, which is related to a non-IMP, is 
not a SUSAR and is not reported as such.  
 
7.3.4 
Reporting of Suspected Unexpected Serious Adverse Reaction 
The sponsor is responsible for the immediate reporting of any serious adverse reaction that 
is suspected and unexpected to the European Database EudraVigilance and to the EC. Fatal 
and life-threatening events must be reported as soon as possible and no later than 7 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
35 
calendar days after they have come to the sponsor's knowledge. A detailed written follow-
up report with all relevant information must be submitted within an additional 8 days. For 
non-fatal and non-life-threatening SUSARs 15 days do apply. The causality of SAEs will be 
assessed. The Sponsor is responsible for SUSARs to be electronically reported and registered 
in the EudraVigilance database. 
 
7.3.5 
Reference safety information 
The current reference safety information contained in the Product résumé (FASS) applies 
and constitutes the basis of the assessment if the adverse reaction is unexpected or not. The 
sponsor is responsible for the annual safety reporting including a summary of 
all SAEs and SUSARs that must be submitted to the SMPA and the EC as long as the study 
is ongoing.  
 
The sponsor will report to the SMPA and EC (via CTIS), within 3 months after the study is 
completed, that the trial is ended as defined in the study protocol (Declaration of End of 
Trial Notification). After 12 months, a summary report will be registered in the EudraCT 
database. 
The SMPA is requested to assist with the registrations in the EudraVigilance database and 
EudraCT database.  
8. 
Study Management 
8.1 
Data Management 
Study data will be collected using an electronic Case Report Form (eCRF; Red Cap®). All data 
handling activities will be described in the Data Management Plan. Clean File/database lock 
will be documented and dated. The reason for any excluded data or protocol deviations will 
be described in the study report. 
 
8.2 
Monitoring 
The study will be monitored by an independent monitor before the study begins, during the 
study conduct, and after the study has been completed, so as to ensure that the study is 
carried out according to the protocol and that data is collected, documented, and reported 
according to ICH-GCP and applicable ethical and regulatory requirements. Monitoring is 
performed as per the study’s monitoring plan and is intended to ensure that the subject’s 
rights, safety, and well-being are met as well as data in the eCRF are complete, correct, and 
consistent with the source data.  
 
The monitor will have regular contacts with the study staff to verify informed consents of 
participating subjects, to confirm that facilities remain acceptable, that the investigational 
team is adhering to the protocol, that data are being accurately recorded in the eCRFs, and 
that all investigations are responsibly carried out according to the study protocol. The 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
36 
monitor will also ensure source data verification (comparison of the data in the eCRF with 
the hospital/practice and/or other records at the investigational site). 
 
The Head of Department will allow the monitor transparency to the patient's medical 
records and other source documents and will provide subject confidentiality. The monitor 
must sign a confidentiality agreement.  
 
All patient source data such as demographic data, medical history, clinical examinations and 
vital signs-readings and measurements analysis results from the hospital laboratories, will 
be stored in the patient files according to routines at the study sites. 
  
8.3 
Archiving 
eCRF documentation and physical documentation including subject consents, study 
documents and other source data will be retained for at least 15 years after finalization of 
the study (or longer if required by Swedish regulations).  
Information about the patients involved in the current study, the consent date, name of the 
study and name of the medical test product must be recorded, saved and stored according 
to national regulations in the hospital’s electronic medical records. The Swedish National 
Data Service (SND)will be used as data repository after study closure and publication of 
results. 
 
8.4 Quality assurance 
The sponsor has the overall responsibility for the implementation of the clinical study. In the 
present study the sponsor will delegate all or part of their duties to the Principal 
Investigator at the Sahlgrenska University Hospital. The Principal Investigator will ensure 
that there are written instructions for the study personnel, for the monitoring process, 
audits and inspections, that the personnel involved in the clinical trial has adequate 
competence and relevant training for their duties and that the subjects through insurance 
or otherwise have guaranteed adequate financial protection. The responsible investigators 
are responsible for the medical welfare of the study subjects, but may delegate 
responsibility for clinical treatment to the surgery team. 
  
8.4.1 
Audits and Inspections  
Audits or inspections may be performed, including source data verification, in order to 
achieve a high quality of the study. The investigators will permit study-related monitoring, 
audits, EC review, and regulatory inspection(s), providing direct access to source 
data/documents. The sponsor will allow transparency into the patient’s medical records and 
other source documents and ensure subject confidentiality. 
 
8.4.2 
Significant changes 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
37 
Significant changes in the protocol must be approved by the SMPA before they are 
implemented. The common Substantial Amendment Notification Form will be used. A 
substantial change is, for example, change of the main purpose, primary or secondary 
variables, method to measure the primary endpoint, change of investigational medicinal 
products or dosage. 
 
8.5 
Insurances 
All participants of the study, as any other patient in the general Swedish health care, will be 
covered by the general patient insurance and pharmaceutical insurance. 
9. 
Statistics 
The complete Statistical Analysis Plan (SAP) is attached as supplement 2.  This single centre, 
double-blinded, randomized, placebo-controlled trial is performed at Sahlgrenska University 
Hospital. The aims are to investigate the effect of Argipressin on blood loss, transfusion 
requirements and inflammatory response during liver resection. Participants will be 
stratified according to planned surgical technique (open or laparoscopic surgery) and 
planned extent of resection (“large” or ”small”) before randomization to treatment with 
argipressin or placebo during surgery. Markers of hepatic, kidney, cardiac and intestinal 
damage will be evaluated during and after surgery. More extensive testing of inflammatory 
markers will be performed in a limited number of patients (subgroup) in each arm. 
 
Analysing models 
All analyses will be performed using SAS software version 9.4 or later (SAS Institute Inc., 
Cary, NC, USA). 
Descriptively, continuous variables will be described by mean, SD, median, interquartile 
range, and range as appropriate, and categorical variables by number and percentage. 
For test between two groups Fisher’s exact test will be used for dichotomous variables, 
Mantel-Haenszel Chi-square trend test for ordered categorical variables, Chi-square test for 
non-ordered categorical variables, and two-sample t-test or Mann-Whitney U-test for 
continuous variables as appropriate based on their distribution. 
Analysis of normally distributed outcome variables will be performed using general linear 
model adjusted for randomization strata (laparoscopic, open small and open large 
surgeries), and those that are lognormally distributed generalized linear model will be used 
with lognormal distribution with the same adjustment. In case of not fulfilling model 
assumptions non-parametric unadjusted Mann-Whitney U-test will be used for continuous 
outcome variables. Dichotomous variables will be analysed using binary logistic regression 
adjusted for randomization strata as above. Number of complications per follow-up time 
will be analysed using Poisson regression including adjustment for randomization strata. 
Time-to-event data, such as length of stay in hospital, will be graphically described using 
Kaplan-Meier technique and analysed using Cox regression model, with the same 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
38 
adjustment. Assumption of proportional hazard will be checked by studying interactions 
with time in study. From these analyses, difference in least square means, relative risk (RR), 
odds-ratio (OR), and hazard ratio (HR) with 95% CI between the treatment groups and 
associated p-values will be the main measures presented. 
 
The secondary variables that will be included in the confirmatory fixed sequential testing 
per the order below following the confirmation of the primary analysis, with 0.05 
significance level, will be: 
• The proportion of patients receiving blood transfusion 
• The volume of blood transfusions during surgery and hospitalization 
 
All other secondary endpoints will be evaluated in exploratory manner, and hence not 
adjusted for multiplicity. All exploratory tests will be cautiously considered, considering the 
magnitude and clinical relevance of the results.  
Tests for interleukin and cytokine levels (IL-1b IL-6, IL-8, IL-10, MCP-1, C3a, C5b-9) will only 
be analysed in a subgroup of 44 patients in each parallel group (total n=88). The results will 
be presented as explorative data.  
 
Tests for coagulation function will be analysed in a subgroup of maximum 30 patients and 
will be presented as descriptive data in a pilot study.  
 
Pain scores and opioid consumption will be presented as descriptive data.  
 
Sample size 
Calculation of sample size was performed based on data from open and laparoscopic liver 
resections performed at Sahlgrenska University Hospital during the period Jan 2019-Oct 
2020. When applying log-transformation on the blood volume variable normal distribution 
was obtained. The sample size calculation was performed using two-sided t-test on the log-
transformed variable that will correspond to the selected method for the primary analysis, 
i.e. generalized linear model with lognormal distribution. To be able to find at least 35% 
reduction in the mean blood loss in the treatment arm compared to the placebo arm (962 
ml vs 625 ml, respectively), i.e. a difference of at least 0.43 in the log-scale assuming SD of 
1.17, with a level of significance of 5%, and a power of 80%, 118 patients are needed to be 
included in each arm. Assuming a dropout rate of 5%, 248 patients in total will need to be 
included, 124 patients in each arm. A limited number of patients will be discovered fulfilling 
the exclusion criteria after the randomization and first after they have started the surgery. 
Since the investigational product is given from the start of the surgery these patients will be 
part of the Safety population and their safety outcome regarding 30-day survival will be 
collected. Their surgery will be immediately stopped, and they will be excluded from the 
study and the ITT population from all efficacy analyses. To account for these dropouts 248 
ITT evaluable patients will be included, but not more than 272 randomized patients in total. 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
39 
Hence, the study will be stopped either when 272 patients are randomized (including the 
“open/close drop outs”) or when 248 evaluable patients are included- whichever occurs 
first. With the expected inclusion rate, these criteria will be met in January 2025, and the 
study will be closed for inclusion at the latest on January 31, 2025.   
 
For the subgroup analysis 44 patients in the argipressin and placebo group respectively, will 
be included (total n= 88). The number of patients selected for extended inflammatory 
testing is based on a pilot study (unpublished data) performed at Sahlgrenska University 
Hospital. 
 
The SAP is updated regarding analysis of ROTEM, von Willebrand factor and factor VIII, as 
well as description of pain scores and opioid consumption, and background variables 
including CFS ratings, ECOG and preoperative chemotherapy.  
 
Randomization 
Participants will be stratified according to planned surgical technique (open or laparoscopic 
surgery) and planned extent of resection (“large” or ”small”) before randomization to 
treatment with argipressin or placebo during surgery. “Small resection” = wedge resections 
with maximum 4 resections, or segmental resections, maximum 2 segments. “Large 
resection” = More than 2 segments if anatomical resections, or resections including more 
than 4 segments (wedge or segmental resections, including right or left lobe resections and 
extended resections). 
 
Safety 
All adverse events (AE) from the first visit onwards will be collected in the study. Treatment 
emergent AEs are those that have started on or after the first dose of study drug provided in 
the study, and will be summarized. AEs occurring prior to the provided study intervention 
will also be tabulated. The AEs will be collected continuously during the study and will be 
coded using Medical dictionary for regulatory activities (MedDRA) to standardized system 
organ class (SOC) and preferred term (PT) before summarized. Laboratory values outside of 
the normal reference limit will be presented in the tables displaying all laboratory results, 
not in the AE table.  
 
10. 
Report and publication 
The main results of the study analyses and physiological measurements will be evaluated 
and reported after all parts of the study data having been collected, compiled and 
evaluated. The investigators will only have access to blinded data until after termination of 
the study and data base lock. There will be a clinical study report, based on the main results 
including safety data, regardless of the results and without restrictions. The extent of the 
clinical study report will be adjusted to Swedish regulations. The results of the trial may be 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
40 
published by the investigators in an international scientific journal and presented at 
international meetings. Authorship will be granted depending on contribution to the study, 
according to the ICMJE guidelines.  
 
11. 
Study timetable 
First subject in: February 2022 
Last subject finalized: February 2025 
 
11.1 
Definition of “End of study” 
The end of the entire study is defined as “the last performed investigation in the last 
subject”. In the present study this will be when data from the 30 day follow up is collected 
for the last patient included. 
 
12. 
Declaration of interests and funding 
This work was supported by the Department of Anaesthesia and Intensive Care, Sahlgrenska 
University Hospital, and the following grants: Gothenburg University, and the Sahlgrenska 
University Hospital (ALF-LUA), Gothenburg Medical Society (GLS-974156, GLS-961705), 
Sahlgrenska University Funds (SU-961353), Anna-Lisa Bror Björnsson Foundation, Tore 
Nilson’s Foundation, and The Foundation for Transplantation and Cancer Research. 
 
This is an investigator-initiated trial, and the authors have no conflicts of interest. The 
funders have no role in study design, analysis, preparation of manuscript or publication 
procedure.  
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
41 
13. 
References 
1. 
Katz SC, Shia J, Liau KH, Gonen M, Ruo L, Jarnagin WR, et al. Operative blood loss 
independently predicts recurrence and survival after resection of hepatocellular carcinoma. 
Ann Surg. 2009;249(4):617-23. 
2. 
Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, Dematteo RP, et al. 
Influence of transfusions on perioperative and long-term outcome in patients following 
hepatic resection for colorectal metastases. Ann Surg. 2003;237(6):860-9; discussion 9-70. 
3. 
Margonis GA, Kim Y, Samaha M, Buettner S, Sasaki K, Gani F, et al. Blood loss 
and outcomes after resection of colorectal liver metastases. J Surg Res. 2016;202(2):473-80. 
4. 
Wang CC, Iyer SG, Low JK, Lin CY, Wang SH, Lu SN, et al. Perioperative factors 
affecting long-term outcomes of 473 consecutive patients undergoing hepatectomy for 
hepatocellular carcinoma. Ann Surg Oncol. 2009;16(7):1832-42. 
5. 
Wagener G, Gubitosa G, Renz J, Kinkhabwala M, Brentjens T, Guarrera JV, et al. 
Vasopressin decreases portal vein pressure and flow in the native liver during liver 
transplantation. Liver Transpl. 2008;14(11):1664-70. 
6. 
Wisen E, Svennerholm K, Sand Bown L, Houltz E, Rizell M, Lundin S, et al. 
Vasopressin and nitroglycerin decrease portal and hepatic venous pressure and hepato-
splanchnic blood flow. Acta Anaesthesiol Scand. 2018. 
7. 
Pietsch UC, Herrmann ML, Uhlmann D, Busch T, Hokema F, Kaisers UX, et al. 
Blood lactate and pyruvate levels in the perioperative period of liver resection with Pringle 
maneuver. Clin Hemorheol Microcirc. 2010;44(4):269-81. 
8. 
Lautt WW. Regulatory processes interacting to maintain hepatic blood flow 
constancy: Vascular compliance, hepatic arterial buffer response, hepatorenal reflex, liver 
regeneration, escape from vasoconstriction. Hepatol Res. 2007;37(11):891-903. 
9. 
Abbas MS, Mohamed KS, Ibraheim OA, Taha AM, Ibraheem TM, Fadel BA, et al. 
Effects of terlipressin infusion on blood loss and transfusion needs during liver resection: A 
randomised trial. Acta Anaesthesiol Scand. 2019;63(1):34-9. 
10. 
Sims CA, Holena D, Kim P, Pascual J, Smith B, Martin N, et al. Effect of Low-Dose 
Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients 
With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 
2019;154(11):994-1003. 
11. 
Schwarz C, Fitschek F, Bar-Or D, Klaus DA, Tudor B, Fleischmann E, et al. 
Inflammatory response and oxidative stress during liver resection. PLoS One. 
2017;12(10):e0185685. 
12. 
Evans C, Dalgleish AG, Kumar D. Review article: immune suppression and 
colorectal cancer. Aliment Pharmacol Ther. 2006;24(8):1163-77. 
13. 
Russell JA, Walley KR. Vasopressin and its immune effects in septic shock. J 
Innate Immun. 2010;2(5):446-60. 
14. 
Mukhtar A, Mahmoud I, Obayah G, Hasanin A, Aboul-Fetouh F, Dabous H, et al. 
Intraoperative terlipressin therapy reduces the incidence of postoperative acute kidney injury 
after living donor liver transplantation. J Cardiothorac Vasc Anesth. 2015;29(3):678-83. 
15. 
Bragadottir G, Redfors B, Nygren A, Sellgren J, Ricksten SE. Low-dose vasopressin 
increases glomerular filtration rate, but impairs renal oxygenation in post-cardiac surgery 
patients. Acta Anaesthesiol Scand. 2009;53(8):1052-9. 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
42 
16. 
Fayed N, Refaat EK, Yassein TE, Alwaraqy M. Effect of perioperative terlipressin 
infusion on systemic, hepatic, and renal hemodynamics during living donor liver 
transplantation. J Crit Care. 2013;28(5):775-82. 
17. 
Russell JA, Walley KR, Singer J, Gordon AC, Hebert PC, Cooper DJ, et al. 
Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 
2008;358(9):877-87. 
18. 
Gordon AC, Mason AJ, Thirunavukkarasu N, Perkins GD, Cecconi M, Cepkova M, 
et al. Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic 
Shock: The VANISH Randomized Clinical Trial. JAMA. 2016;316(5):509-18. 
19. 
Writing Committee for the VSI, Devereaux PJ, Biccard BM, Sigamani A, Xavier D, 
Chan MTV, et al. Association of Postoperative High-Sensitivity Troponin Levels With 
Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. 
JAMA. 2017;317(16):1642-51. 
20. 
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving 
Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. 
Intensive Care Med. 2017;43(3):304-77. 
21. 
Mukhtar A, Salah M, Aboulfetouh F, Obayah G, Samy M, Hassanien A, et al. The 
use of terlipressin during living donor liver transplantation: Effects on systemic and splanchnic 
hemodynamics and renal function. Crit Care Med. 2011;39(6):1329-34. 
22. 
Bown LS, Ricksten SE, Houltz E, Einarsson H, Sondergaard S, Rizell M, et al. 
Vasopressin-induced changes in splanchnic blood flow and hepatic and portal venous 
pressures in liver resection. Acta Anaesthesiol Scand. 2016;60(5):607-15. 
23. 
Derikx JP, Schellekens DH, Acosta S. Serological markers for human intestinal 
ischemia: A systematic review. Best Pract Res Clin Gastroenterol. 2017;31(1):69-74. 
24. 
Ishii M, Mizuguchi T, Harada K, Ota S, Meguro M, Ueki T, et al. Comprehensive 
review of post-liver resection surgical complications and a new universal classification and 
grading system. World J Hepatol. 2014;6(10):745-51. 
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
43 
Appendix A - Signatures 
 
 
SPONSOR’S AND INVESTIGATOR’S SIGNATURES  
 
 
 
I hereby certify that the study will be conducted in accordance with the Study Protocol 
and applicable regulations, SMPA regulation 2011:19, ICH-GCP and latest version of the 
Declaration of Helsinki (2013): 
 
 
 
 
 
 
 
 
 
 
 
 
 
Kristina Svennerholm 
Department of Anaesthesia and Intensive Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
Date  
 
 
 
 
 
 
 
 
 
 
 
 
 
Peter Dahm 
Head of the Department of Anaesthesia and Intensive 
Care 
Sahlgrenska University Hospital 
413 45 Gothenburg, Sweden 
 
 
Date   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
44 
Appendix B - Ethics and regulatory review 
 
The final study protocol, including the final version of the Written Informed Consent Form and 
other information given to subjects (as advertisements) must be approved or given a 
favourable opinion by an EC before enrolment of any subject into the study.  
Before enrolment of any subject into the study, the final study protocol, including the final 
version of the Informed Consent Form, is approved by the national regulatory authority or a 
notification to the national regulatory authority is done, according to local regulations. 
It is the responsibility of the Principal Investigator to apply to the EC in writing. The application 
document should:  
• contain the name and address of the EC, 
• clearly identify, by title and date, the protocol and other documents submitted for 
review, and 
• be dated. 
In addition, the Principal Investigator should request the EC to provide: 
• their approval/opinion in a dated document identifying the Principal Investigator’s 
application, 
• EC composition for the meeting when the approval was given, and 
• a statement confirming that the EC is organised and operates according to GCP and 
applicable laws and regulations. 
The Principal Investigator is responsible for informing the EC of any modifications and 
amendments to the protocol as per local requirements. 
Progress reports and notifications of serious and unexpected adverse drug reactions will be 
provided to the EC according to local regulations and guidelines. 
The Principle Investigator should file all correspondence with the EC in the appropriate form. 
The Principle Investigator is also responsible for obtaining approvals from scientific bodies (eg, 
to use radiolabelled substances) if necessary for the study. 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
45 
SUBJECT INFORMATION AND WRITTEN INFORMED CONSENT FORM 
The Principle Investigator will ensure that the subject is given full and adequate oral and 
written information about the nature, purpose, possible risk and benefit of the study. Subjects 
must also be notified that they are free to discontinue from the study at any time. The subject 
should be given the opportunity to ask questions and allowed time to consider the information 
provided. 
The subject’s signed and dated informed consent must be obtained before conducting any 
procedure specifically for the study.  
The Principal Investigator must store the original, signed Informed Consent Form in the 
Investigator’s Study File. A copy of the signed Informed Consent Form must be given to the 
subject. 
If a protocol amendment requires a change to the Informed Consent Form, the EC must 
approve modifications that lead to a revised Informed Consent Form before the revised form 
is used. 
The content of the informed consent form complies with relevant integrity and data 
protection legislation. In the subject information and the informed consent form, the subject 
will be given complete information about how collection, use and publication of their study 
data will take place. The subject information and the informed consent form will explain how 
study data are stored to maintain confidentiality in accordance with national data legislation 
(please describe how data is stored and which data security measures are taken). All 
information processed by the sponsor will be pseudonymized and identified with <<Subject 
number>>.  
The informed consent form will also explain that for verification of the data, authorized 
representatives of the sponsor, as well as relevant authority, may require access to parts of 
medical records or study records that are relevant to the study, including the subject’s 
medical history. 
 
Subject data protection 
The Informed Consent Form will incorporate (or, in some cases, be accompanied by a separate 
document incorporating) wording that complies with relevant data protection and privacy 
legislation. 
Extra precautions are taken to preserve confidentiality and prevent genetic or other study data 
being linked to the identity of the subject. In exceptional circumstances, however, certain 
individuals might see both the genetic and/or other study data as well as the personal 
identifiers of a subject. For example, in the case of a medical emergency or an investigator 
might know a subject’s identity and also have access to his or her data. Also, Regulatory 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
46 
authorities may require access to the relevant files, though the subject’s medical information 
and the genetic files would remain physically separate. 
Audits and inspections 
Authorized representatives of the Sponsor, a regulatory authority, or an EC may perform audits 
or inspections at the centre, including source data verification. The purpose of an audit or 
inspection is to systematically and independently examine all study-related activities and 
documents, to determine whether these activities were conducted, and data were recorded, 
analysed, and accurately reported according to the protocol, GCP, guidelines of the ICH, and 
any applicable regulatory requirements. 
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
47 
Appendix C - Definitions of Adverse Events  
Definitions: 
Adverse Events 
Serious Adverse Events 
Definitions of severity rating 
Causal relationship 
Action taken 
Reporting in CRF 
Adverse Events based on signs and symptoms 
Follow up and outcome assessment 
         Suspected Unexpected Serious Adverse Reaction (SUSAR) 
Further guidance on Serious Adverse Events: 
Life threatening 
Hospitalisation 
Important medical event or medical intervention 
A guide to interpreting the causality QUESTION 
Other significant Adverse Events 
Overdose 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
48 
DEFINITIONS OF ADVERSE EVENTS AND PROCEDURES IN CASE OF PREGNANCY 
It is of the utmost importance that all staff involved in the study is familiar with the content of 
this section. The Principal Investigator is responsible for ensuring this.  
Adverse Events 
An AE is the development of an undesirable medical condition or the deterioration of a pre-
existing medical condition following or during exposure to a pharmaceutical product, whether 
or not considered causally related to the product. An undesirable medical condition can be 
symptoms (e.g., nausea, chest pain), signs (e.g., tachycardia, enlarged liver) or the abnormal 
results of an investigation (e.g., laboratory findings, electrocardiogram). In clinical studies, an 
AE can include an undesirable medical condition occurring at any time, from the date of signed 
consent, including run-in or washout periods, even if no study treatment has been 
administered, to the final follow-up visit.  
An AE will be followed up for as long as it is considered to be medically relevant. 
It is important to distinguish between SAEs and severe AEs. Severity is a measure of intensity 
whereas seriousness is defined by the criteria listed below. An AE of severe intensity need not 
necessarily be considered serious. 
Serious Adverse Events 
It is important to distinguish between SAEs and severe AEs. Severity is a measure of intensity 
whereas seriousness is defined by the criteria listed below. An AE of severe intensity need not 
necessarily be considered serious. For example, nausea which persists for several hours may 
be considered severe nausea, but not an SAE. On the other hand, a stroke, which results in only 
a limited degree of disability may be considered a mild stroke but would be a SAE. 
A medical emergency usually constitutes an SAE and is to be reported as such. 
A SAE is an AE occurring during any study phase (i.e. run-in, pre-entry, screening, treatment, 
wash-out, follow-up), and at any dose of the investigational product, comparator or placebo, 
that fulfils one or more of the following criteria: 
• results in death, 
• is immediately life-threatening, 
• requires in-patient hospitalisation or prolongation of existing hospitalisation,  
• results in persistent or significant disability or incapacity, 
• is a congenital abnormality or birth defect, 
• is an important medical event that may jeopardise the subject or may require medical 
intervention to prevent one of the outcomes listed above.  
Definitions of severity rating 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
49 
 
1 
Mild 
Transient symptoms; awareness of sign or symptom, but easily 
tolerated.  
No interference with the subject’s daily activities. 
2 
Moderate 
Marked symptoms; discomfort sufficient to cause interference with 
normal activities. 
Moderate interference with the subject’s daily activities. 
3 
Severe 
Considerable interference with the subject’s daily activities; 
unacceptable, incapacitating.  
Inability to perform normal activities. 
 
Causal relationship 
The causality of (S)AEs (ie, their relationship to study treatment and/or the investigational 
procedure) will be assessed by the investigator(s), who in completing the relevant case report 
form must answer “yes” or “no” to the question “Do you consider that there is a reasonable 
possibility that the event may have been caused by the drug/the investigational procedure?”.  
The following terms and definitions are used when assessing the causal relationship between 
each AE and the relevant trial product(s): 
 
1 
Definite 
There is no doubt that the incident is related. 
2 
Probable 
Good reason and sufficient documentation to assume a 
causal relationship. 
3 
Possible 
A causal relationship is conceivable and cannot be 
dismissed. 
4 
Unlikely 
The event is most likely related to aetiology other than the 
trial product. 
5 
Not related 
The event is not related to the study product. 
6 
Unknown/Unclassifiable A report suggesting an adverse event reaction, which 
cannot be judged because information is 
insufficient or contradictory and which cannot be 
supplemented. 
 
Causal relationship in cases where the disease under study has deteriorated due to lack of 
effect will be classified as no reasonable possibility. 
For SAEs causal relationship will also be assessed for additional study drug and/or other 
medication and/or study procedure. Note that for SAEs that could be associated with any study 
procedure the causal relationship is implied as “yes”. 
Action taken: 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
50 
• None 
• Dose of study drug changed 
• Study drug temporarily stopped 
• Study drug stopped 
Reporting in the Case Report Form  
The following variables will be recorded in the CRF for each AE: description of the AE, the date 
and time when the AE started and stopped, maximum intensity, whether the AE is serious or 
not, causality rating (yes or no; if yes specify), action taken with regard to investigational 
product, AE caused subject to discontinue study and outcome. 
Adverse Events based on signs and symptoms 
All AEs spontaneously reported by the subject or reported in response to the open question 
from the study personnel: “Have you had any health problems since the previous visit?”, or 
revealed by observation will be collected and recorded in the CRF. When collecting AEs the 
recording of diagnoses is preferred (when possible) to recording a list of signs and symptoms. 
However, if a diagnosis is known and there are other signs or symptoms that are not generally 
part of the diagnosis, the diagnosis and each sign or symptom will be recorded separately. 
Follow-up - Outcome assessment 
Any AEs that are unresolved at the patient’s last AE assessment in the study are followed up 
by the investigators for as long as medically indicated, but without further recording in the CRF. 
The following terms and definitions are used in assessing the final outcome of an AE: 
1. Recovered - The subject has fully recovered, or by medical or surgical treatment the 
condition has returned to the level observed at the first trial-related activity after the 
subject signed the informed consent. 
 
2. Recovering - This term is only applicable if the subject has completed the trial or has died 
from another AE. The condition is improving and the subject is expected to recover from 
the event. 
 
3. Recovered with sequelae - The subject has recovered from the condition, but with lasting 
effect due to a disease, injury, treatment or procedure. If a sequele meets an SAE criterion, 
the AE must be reported as an SAE. 
 
4. Not recovered - The condition of the subject has not improved and the symptoms are 
unchanged, or the outcome is not known at the time of reporting. 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
51 
5. Fatal - This term is only applicable if the subject died from a condition related to the 
reported AE. Outcomes of other reported AEs in a subject before he/she died should be 
assessed as “recovered”, “recovering”, “recovered with sequelae” or “not recovered”. An 
AE with fatal outcome must be reported as an SAE. 
 
6. Unknown - This term is only applicable if the subject is lost to follow-up. 
Suspected Unexpected Serious Adverse Reaction 
For studies in countries implementing the EU Clinical Trials Directive, informing ECs and 
Regulatory Authorities will be performed by the sponsor. 
In the case of research with a medical product there may be a causal link to the administered 
product. If it concerns an unexpected serious reaction, then this is a SUSAR. 
Definition of a SUSAR: 
1. The event must be serious, that is to say irrespective of the dose the event is: 
• fatal, and/or 
• life-threatening for the research subject, and/or 
• makes hospital admission or an extension of the admission necessary, and/or 
• causes persistent or significant invalidity or work disability, and/or 
• manifests itself in a congenital abnormality or malformation. 
2. There must be a certain degree of probability that the event is harmful, and an 
undesirable, reaction to the medicinal product being investigated, regardless of the 
administered dosage. In other words, there is an adverse reaction. 
3. The adverse reaction must be unexpected. That is to say, the nature and severity of the 
adverse reaction are not in agreement with the product information as recorded in: 
• for an authorised medicinal product: the SPC text (Summary of Product Characteristics: 
in the Netherlands this is the IB1 text). In the case of an international multicentre 
research with an authorised product, the sponsor may choose an SPC. If there is, in 
comparison to the authorisation, a different administration form, indication, patient 
group or dose, then the summary of the product information is supplemented with the 
relevant supplemental information for the concerned study. 
• for an unauthorised medicinal product: the Investigator’s Brochure/Product résumé. 
Reporting of SUSAR 
SUSARs within the study that are life threatening or have had fatal consequences must be 
reported, at the latest, within 7 days after the sponsor has become aware of them. All relevant 
information on the aftermath of this must be reported within a time period of a further 8 
days. Other reports of SUSARs must be made within 15 days after the sponsor has become 
aware of them.  

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
52 
The Clinical Study Serious Adverse Event Report Form will be used together with other relevant 
supporting documentation (e.g. ECG, laboratory results, autopsy report) and relevant CRF 
modules. All SUSARs have to be electronically registered in the EudraVigilance database. 
FURTHER GUIDELINES ON THE DEFINITION OF A SERIOUS ADVERSE EVENT 
Life threatening 
‘Life threatening’ means that the subject was at immediate risk of death from the AE as it 
occurred or it is suspected that use or continued use of the product would result in the 
subject’s death. ‘Life threatening’ does not mean that if an AE had occurred in a more severe 
form it might have caused death (eg, hepatitis that resolved without hepatic failure). 
Hospitalisation 
Out-patient treatment in an emergency room is not in itself a SAE, although the reasons for it 
may be (eg, bronchospasm, laryngeal oedema). Hospital admissions and/or surgical operations 
planned before or during a study are not considered AEs if the illness or disease existed before 
the subject was enrolled in the study, provided that it did not deteriorate in an unexpected 
way during the study. 
Important medical event or medical intervention 
Medical and scientific judgement should be exercised in deciding whether a case is serious in 
situations where important medical events may not be immediately life threatening or result 
in death, hospitalisation, disability or incapacity but may jeopardize the subject or may require 
medical intervention to prevent one or more outcomes listed in the definition of serious. These 
should usually be considered as serious. 
Examples of such events are: 
• Angioedema not severe enough to require intubation but requiring iv hydrocortisone 
treatment. 
• Hepatotoxicity caused by paracetamol (acetaminophen) overdose requiring treatment 
with N-acetylcysteine. 
• Intensive treatment in an emergency room or at home for allergic bronchospasm. 
• Blood dyscrasias (eg, neutropenia or anaemia requiring blood transfusion, etc) or 
convulsions that do not result in hospitalisation. 
• Development of drug dependency or drug abuse. 
A guide to interpreting the causality QUESTION 
The following factors should be considered when deciding if there is a “reasonable possibility” that an AE may 
have been caused by the drug. 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
53 
• Time Course. Exposure to suspect drug. Has the subject actually received the suspect 
drug? Did the AE occur in a reasonable temporal relationship to the administration of the 
suspect drug? 
• Consistency with known drug profile. Was the AE consistent with the previous knowledge 
of the suspect drug (pharmacology and toxicology) or drugs of the same pharmacological 
class? OR could the AE be anticipated from its pharmacological properties? 
• Dechallenge experience. Did the AE resolve or improve on stopping or reducing the dose 
of the suspect drug? 
• No alternative cause. The AE cannot be reasonably explained by aetiology such as the 
underlying disease, other drugs, other host or environmental factors. 
• Rechallenge experience. Did the AE reoccur if the suspected drug was reintroduced after 
having been stopped? A re-challenge would not normally be recommended or 
supported. 
• Laboratory tests. A specific laboratory investigation (if performed) has confirmed the 
relationship? 
A “reasonable possibility” could be considered to exist for an AE where one or more of these 
factors exist. In contrast, there would not be a “reasonable possibility” of causality if none of 
the above criteria apply or where there is evidence of exposure and a reasonable time course 
but any dechallenge (if performed) is negative or ambiguous or there is another more likely 
cause of the AE. 
In difficult cases, other factors could be considered such as: 
• Is this a recognised feature of overdose of the drug? 
• Is there a known mechanism? 
Ambiguous cases should be considered as being a “reasonable possibility” of a causal 
relationship unless further evidence becomes available to refute this. Causal relationship in 
cases where the disease under study has deteriorated due to lack of effect should be classified 
as no reasonable possibility. 
Overdose 
An overdose with associated AEs is recorded as the AE diagnosis/symptoms on the relevant. 
 
 
 
 
 
 
 
 
 
 

ARG-01: EudraCT No. 2021001806-32 
Date: 250228 Version 4.5 
54 
Appendix D - Marking of syringes  
 
ARG-01 
STUDY DRUG 
Empressin® 0.8U/ml /placebo 
 
 
EudraCT No. 2021001806-32 
Contacts: 
Subject number:  
 
Kristina Svennerholm, AnOpIva 
Sahlgrenska, tel 0708117993 
Ellinor Wisén, AnOpIva Sahlgrenska 
tel: 0702457661 
For clinical study use only 
For intravenous use