Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: An Open-label Randomized Control Trial
Phase: NA
Conditions: Liver Cirrhosis
Sponsor: Post Graduate Institute of Medical Education and Research, Chandigarh

                                                                 Title page  
 
Title: Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: An open-
label randomized control trial 
NCT Number: NA 
Unique protocol ID: INT/IEC2018/2076 
Dated: 1.08.2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study Protocol:  
Title: Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: An 
open-label randomized control trial 
 
INTRODUCTION 
 
Cirrhosis of liver is the culmination point of long-standing chronic liver disease 
hallmarked by the cardinal features of liver fibrosis and portal hypertension. The prognosis of 
patients with cirrhosis is punctuated by the onset of complications which denote the stage of 
decompensation characterized by ascites, hepatic encephalopathy (HE) and variceal bleeding1. 
Onset of decompensation heralds concomitant complications like renal dysfunction, immune 
dysregulation, pulmonary and cardiac dysfunction as well as bacterial infections including 
spontaneous bacterial peritonitis accounting for significant morbidity and mortality2. 
The role of human gut microbiota in health and disease has recieved considerable 
attention.. The gut microbiome consists of over 1014 microorganisms, including bacteria, 
fungi, viruses and archaea, which co-exist in a symbiotic relationship.3A majority comprises 
anaerobic bacteria. A healthy gut microbiome enhances metabolism, resilience to infection and 
inflammation, and resistance to cancer and autoimmunity. The microbiome may mediate these 
effects by secretion of factors that modulate intestinal permeability, the mucus layer, epithelial 
cell function, innate and adaptive immunity and intestinal motility. A disruption of this 
microbial symbiosis is intestinal dysbiosis, which adversely affects these functions and is 
implicated in the pathogenesis of disease. The gut is connected to the liver by the portal tract, 
and hence qualitative and quantitative changes in the gut microbiome play a pivotal role in the 
pathogenesis of alcoholic liver disease, as well as other liver diseases.3 
Patients with cirrhosis have been demonstarated to have significant changes in their gut 
microbiota characterized by alteration in the intestinal microbiome (gut dysbiosis) as well as 
small intestinal bacterial overgrowth (SIBO) 3, 4. In a study with patients with cirrhosis from 
China it has been reported that  the proportion of phylum Bacteroidetes was decreased, and 
those of  Proteobacteria and Fusobacteriawere highly enriched in the faeces of these patients.5 
On the other hand a study from the United States has shown higher prevalanceAlcaligeneceae, 

Enterobacteriaceae, and Fusobacteriaceae while those belonging to Ruminococcaceae and 
Lachnospiraceae were found in a lower proportion.6 In this perspective a proposed index called 
cirrhosis dysbiosis ratio (CDR)8 of the amounts of beneficial autochthonous taxa 
(Lachnospiraceae + Ruminococaceae + Veillonellaceae + ClostridialesIncertaeSedis XIV) and 
potentially pathogenic taxa (Enterobacteriaceae + Bacteroidaceae) has been found to core-relate 
inversely with model of end-stage liver disease (MELD) score and 30 day mortality thus 
suggesting an integral role of gut dysbiosis in the prognostic outcome of cirrhosis.8 
Gut dysbiosis has been closely linked to the complications associated with 
decompensated cirrhosis. Several studies have documented the alteration of  gutmicrobiota in   
patients with hepatic encephalopathy.  Liu et al found an overgrowth of potentially pathogenic 
Escherichia coli (E. coli) and Staphylococcus spp. in the feces of patients with liver cirrhosis 
(70%–80% related to HBV or HCV) and MHE.9 Another study showed that patients with 
cirrhosis and HE had a higher abundance of fecal Enterobacteriaceae, and Alcaligenaceae 
compared with control subjects.7 
Therapeutic modalities that restore normal gut flora and stabilize the gut liver axis are 
being extensively studied in the management of cirrhosis and its complications. Antibiotics, 
probiotics and long chain fatty acid supplementation are being evaluated as methods to restore 
gut eubiosis and consequently limit progressive liver damage. 
Fecal Microbiota Transplantation (FMT) involves the infusion of intestinal 
microorganisms by the  transfer of stool from a healthy individual into a diseased individual  
for restoration of normal intestinal flora.10Methods to infuse stool include a nasogastric tube or 
gastroscopy, or into the colon through a colonoscope or rectal catheter.11 The ultimate goal of 
FMT is to replace aberrant native microbiota with a stable community of donor 
microorganisms. The treatment is based on the premise that an imbalance in the community of 
microorganisms residing in the gastrointestinal tract (i.e., dysbiosis) is associated with specific 
disease states. FMT has been well-established as a treatment modality to stably modify the gut 
microbiome and has been shown to be safe and efficacious in several disease states resulting 
from gut dysbiosis including Clostriumdifficile infection and inflammatory bowel disease.12, 13 
With this background it is hypothesized that in patients with advanced cirrhosis FMT 
may reduce the progression to chronic liver failure including jaundice, accumulation of fluid 

within the abdominal cavity, bleeding, encephalopathy and the development of infection and 
organ dysfunction. A trial is proposed to determine whether a FMT from a healthy donor to a 
patient with advanced cirrhosis is both feasible and safe and to assess its impact on overall 
survival and prognosis. 
 
 
 
2. REVIEW OF LITERATURE 
Microbiota refers to the bacteria, archaea, microeukaryotes, fungi and viruses that share 
the human body space, so as to function in a commensal, symbiotic, or pathogenic relationship 
with the host. The human microbiota is estimated to contain 10-100 trillion microbial cells.14 
Microbiome refers to the collective genomes of all the above-mentioned microorganisms. 
The microbiome is commonly used interchangeably with microbiota – even though this usage 
is incorrect.15 The gut microbiota is composed of 100 trillion bacteria of diverse taxonomy . 
The microbiome has 150-fold more genes than the human genome of which over 99% of the 
genes are bacterial which is why we study that what is predominant.15 
Disruption of the healthy microbiota in both composition and functionality is dysbiosis – 
in which pathogenic species predominate leading to various disease conditions. The term 
pathogenic species in this context could be better utilized to an increase in numbers and 
functionality of those that promote/participate in deleterious functional metabolic outcomes that 
affect the host adversely rather thanjust the numbers of pathogenic species per say – for 
example pathogenic species such as E.coli and K.pneumonia are all normal components of the 
gut microbiota in healthy state (probably in lesser numbers) – however, in the presence of a 
modifying factor, say for example alcohol or high fat diet – their number and functions are 
adversely modified to promote adverse metabolism/metabolic product accumulation in the host.  
Multiple studies have shown association of gut dysbiosis with cirrhosis and its 
complications. In a study from Wang et al FMT exerted protective effects in hepatic 
encephalopathy (HE) in rats, and improved the cognitive function with improvement of overall 

the liver function indexes.16 FMT may cure HE by altering the intestinal permeability and 
improving the TLR response of the liver. This study was the index study to establish a rat 
model of hepatic encephalopathy and then prospectively carried on the FMT. The results 
unequivocally hinted that FMT can serve as a kind of new method for the treatment of hepatic 
encephalopathy. 
The first human report of utility of FMT in HE was shown by Kao et al where dramatic 
clinical improvements, both subjectively and objectively, following serial FMT were 
observed.17 This case study demonstrated that serial FMT can result in cognitive improvement 
in mild HE. 
Bajaj et al demonstrated the first trial that showed that FMT from a rationally selected 
donor reduced hospitalizations, improved cognition, and dysbiosis in cirrhosis with recurrent 
HE.18 In this study a specified beneficial population of bacterial community from a stool bank 
was used. 
The following table summarizes the some of the other major studies demonstrating the 
utility of FMT in cirrhosis 
Authors 
Methodology 
Hallmarks of the study 
Chen et 
al.2011 
 
Controls vs. patients 
with alcoholic and 
hepatitis B cirrhosis 
First major study of stool microbiome in cirrhosis. Showed that 
fecal microbiome in cirrhoticsis distinct, including increase in 
bacteroidetes (Bacteroidaceae) and proteobacteria and reductions 
in 
autochthonous 
taxa, 
such 
as 
Lachnospiraceae. 
Streptococcaceaeand 
positively 
correlated 
with 
cirrhosis 
severity. 
Bajaj et 
al. 
2012  
 
Controls vs. all etiology 
OHE and no OHE 
cirrhosis. 
 
First study of stool microbiome in cirrhotics with and without 
Overt Hepatic Encephalopathy (OHE) that looked at correlation- 
networkanalysis 
between 
microbiome, 
endotoxemia 
and 
cognition. HE was associated with reduced abundance 
ofLachnospiraceae 
and 
ruminococcaceae 
and 
increased 

Enterobacteriaceae. 
Increased 
inflammation 
andendotoxemiawere noted in HE groups.. 
Mutlu et 
al. 
2012 
Healthy 
controls 
vs. 
alcohol cirrhosis 
Study of sigmoidal mucosa microbiome that showed lower 
median abundance of Bacteroidetes and increased median 
abundance of proteobacteria in alcoholic cirrhotics 
Bajaj 
et 
al. 
2012 
 
Controls vs. all etiology 
OHE 
and 
no-OHE 
cirrhosis. 
 
First major study to compare changes in sigmoid mucosal 
microbiome in all etiology with stool microbiota in cirrhotics 
with and without OHE. Mucosal microbiota analysis revealed 
increased enterococcus and Veillonella abundance in OHE. 
Roseburia was reduced in OHE and, along with other 
autochthonous microbes, showing positive co-relation with 
cognition and reduced inflammation in all groups. Enterococcus 
and 
Veillonella 
associated 
with 
poor 
cognition 
and 
inflammation. 
Bajaj 
et 
al. 
2014 
 
Cirrhotics followed as 
outpatient(compensated 
and decompensated) and 
during 
inpatient 
decompensation. 
First major study of cirrhosis stool microbiome comparing 
cirrhosis in compensated and decompensated state. Increased 
porphyromonadaceae, Bacterioidaceae, and Enterobacteriaceae 
with 
reduced 
Veillonellaceae, 
Ruminococcaceae, 
and 
Clostridiales XIV (Firmicutes) noted in compensated cirrhosis. 
Decompensation resulted in increased Enterobacteriaceae, 
Enterococcaceae, 
and 
Staphylococcaceae 
and 
reduced 
Bacterioidaceae. MELD score correlated negatively with 
Firmicutes and positively with Enterobacteriaceae. Introduction 
of CDR concept. 
Bajaj 
et 
al. 
Controls vs. all etiology 
cirrhosis studied before 
First major study looking at the influence of PPI use on stool 
microbiota in cirrhosis. Streptococcaceae abundance was 

2014  
 
and after administration 
of PPI. 
 
relatively increased in controls and cirrhotics after 14 days of 
PPI. First study that hypothesized oral microbiota could migrate 
distally secondary to change in intestinal protective mechanisms 
Kakiyama 
et al. 
2014  
 
Controls vs. all etiology 
cirrhosis. 
Subgroups 
examined before and 
after rifaximin therapy. 
 
First major study of role of BAs in gut microbiome modulation 
in cirrhosis. Showed increased Bacterioidaceae and reduced 
Veillonellaceae, Lachnospiraceae, and Ruminococcaceae in 
advanced 
cirrhosis. 
CDCA 
positively 
correlated 
with 
Enterobacteriaceae, while DCA positively correlated with 
Ruminococcaceae. Post rifaximin, early cirrhotics had reduced 
Veillonellaceae 
Qin et al. 
2014 
 
Controls vs. all etiology 
cirrhosis 
followed over time. 
 
Major study that cataloged human microbiome genes in cirrhotic 
stool samples. Increased Veillonella, Streptococcus, Clostridium, 
and Prevotella, with reduced bacteroides in cirrhosis. 
Bajaj 
et 
al. 
2015 
 
Controls vs. all etiology 
cirrhosis 
with and without DM 
Major study that compared stool and sigmoid mucosa microbiota 
in cirrhotics with and without DM. The study showed no change 
to 
in 
decompensated 
diabetic 
cirrhotics. 
Increased 
Enterococcaceae-relative abundance, reduced Bacteroidaceae, 
and increased Lactobacillaceae and Enterococcaceae were noted 
in compensated diabetic cirrhotics at the end of the study period. 
Chen  et 
al. 2015  
Controls vs. all etiology 
cirrhosis with ACLF 
Study evaluated stool microbiome of cirrhotics with ACLF. 
ACLF was associated with increased relative abundance of 
Pasteurellaceae, Streptococcaceae, and Enterococcaceae with 
decreased 
Bacterioidaceae, 
Lachnospiraceae, 
and 
Ruminococcaceae. 
OHE 
was 
associated 
with 
reduced 
Lachnospiraceae. On networkcorrelation analysis, strong linkage 

of Lachnospiraceae and Ruminococcacea 
Bajaj 
et 
al. 
2015  
 
 
Controls vs. all etiology 
cirrhosis 
with 
and 
without OHE. 
 
First major study that to explored stool and salivary microbiota 
in detail in all etiology cirrhotics and further explored the 
changes 
with 
decompensation. 
Significantly 
increased 
Enterobacteriaceae 
and 
Enterococcaceae, 
with 
reduced 
Lachnospiraceae, 
Ruminococcacea, 
and 
ClostridialesIncertaeSedis XIV noted in the saliva from 
compensated cirrhotics. Similar microbiota was noted to be 
prominent in cirrhotics with prior OHE. Streptococcaceae in the 
saliva was significantly higher in the stool for both groups. 
Ahluwalia 
et al. 
2016  
 
Controls vs. alletiology 
cirrhosis 
withand 
without OHE. 
 
Study looked at stool microbiota of cirrhotics with OHE. OHE 
patients had higher relative abundanceof autochthonous bacteria 
with 
higher 
abundance 
of 
Enterococcaceae, 
Staphylococcaceae,Porphyromonadaceae, and Lactobacillaceae. 
MR 
spectroscopy 
showed 
autochthonous 
taxa 
correlatednegatively and Enterobacteriaceae correlated positively 
with disease. 
 
Methodologies for FMT  
Initially, patients identified their own donors selected from family or friends. 
Subsequently, some institutions offered the option of an anonymous donor(s). This shifts the 
burden of donor identification from the patient, creates a pool of tested healthy donors with a 
track record of cure, and also avoids donors with shared genetic or environmental 
susceptibilities to the recipient. An approach of using highly filtered human microbiota mixed 
with a cryoprotectant and then frozen for storage at −80 °C until required for use. This 
processing removes the fecal smell and reduces the volume of the filtrate. Use of such a 

standardized, purified tissue has been shown to have equivalent clinical efficacy in treatment of 
C difficle infections. 19 
Multiple routes of administration has been tried in FMT including naso-duodenal, 
transcolonoscopic, or enema based.A systematic review of FMT for C difficle suggested a lower 
success rate for upper gut administration (76 %), as compared with colonoscopy (89 %) and 
enema (95 %) administration.11 
A recent analysis had similar findings, with a trend toward higher CDI resolution rates 
with lower GI, rather than upper GI, administration (91 % vs. 82 %) although no head-to-head 
comparison has yet been performed – however, in liver diseases, the routes are not defined, but 
duodeno-jejunal region has been shown to have maximal dysbiosis.20 
 
 
 
 
 
 
 
 3. AIMS AND OBJECTIVES 
         Research question 
Does FMT improve liver functions, prevent complications, reduce levels of pro-
inflammatory cytokines and lead to an improvement in prognostic scores (CTP, MELD, 
MELD Na) and short-term survival in patients with DC? 
Study Hypothesis:  

In patients with DC, FMT may improve liver functions, prevent complications, reduce 
levels of pro-inflammatory cytokines and lead to an improvement in prognostic scores 
(CTP, MELD, MELD Na) and 180-day survival. 
Aim:   
To determine the role of FMT in improving liver function, prognostic scores, and short 
term mortality and reducing complications in patients with DC 
     Objectives: 
Primary Objective: To assess the difference in 180-day mortality between the FMT group 
and the SOC group. 
Secondary Objective 
1. To assess and compare the changes in liver function in both groups based upon  
 CTP score at 28 days, 90 days and 180 days  
 MELD Score at 28 days, 90 days and 180 days  
 MELD Na Score at 28 days, 90 days and 180 days 
2. To compare the complications in both groups in a follow-up period of 180 days 
3. Changes in inflammatory markers (IL-1b, IL-6) in both groups at 28 days 
 
 
4. METHODOLOGY 
 
Study design: This will be an institute based prospective pilot study carried out in Postgraduate 
Institute of Medical Education and Research, Chandigarh from July 2018 to June 2020. 
 
Study period: 15 months (from August 2018 to November 2019) 
 
 
Recruitment Period: 10 months (August 2018 to May 2019) 
 
 
Sample Size: 20 consecutive patients satisfying the selection criteria in each arm  

 
Study population 
 
All patients with decompensated cirrhosis who will be admitted to the Department of Hepatology 
in Medical Ward Unit or Liver ICU of Postgraduate Institute of Medical Education and Research 
(PGIMER) or will be attending the outpatient department of PGIMER during the period from 
August 2018 till May 2019 will be screened for eligibility for enrollment after ethical approval 
from the institute ethics committee. An informed consent will be taken from all the participants. 
Those patients who satisfy the inclusion and exclusion criteria and provide a valid informed 
consent will be enrolled in the study. 
 
Inclusion Criteria 
1. 18-75 years 
2. Confirmed advanced cirrhosis of any aetiology with a MELD score between 12 and 21. 
The diagnosis of liver cirrhosis will be based on clinical, radiological, or histological 
criteria 
3. Patients must be deemed to have capacity to consent to study. 
Exclusion Criteria  
1. Ongoing bacterial infection requiring antibiotic treatment. 
2. Current or history of significant alcohol consumption for a period of more than 2  
consecutive months within 6 months prior to screening (significant alcohol consumption 
is defined as more than 20 g/day in females and more than 30 g/day in males, on 
average). 
3. Treatment with antibiotics or probiotics in the preceding  14 days 
4. History of recent spontaneous bacterial peritonitis , gastrointestinal bleeding or overt 
hepatic encephalopathy (14 days) 
5. Previous Liver Transplantation 
6. Hepatocellular Carcinoma  
7. Human Immunodeficiency Virus (HIV) infection 
8. Active or serious medical disease with likely life expectancy less than 5 years 
9. Active substance abuse including inhaled or injection drugs in the year prior to screening. 
10. Pregnancy, planned pregnancy, potential for pregnancy and unwillingness to use effective 
birth control during the trial, breast feeding 

11. History of severe (anaphylactic) food allergy 
12. History of gastroparesis or altered gastric motility  
13. Psychiatric disorder 
14. Inflammatory bowel disease (IBD) 
15. Coeliac disease 
16. Immunosuppression e.g. more than two weeks treatment with corticosteroids within 8 
weeks of active treatment with tacrolimus, mycophenylate, azathioprine 
17. Any other condition which, in the opinion of the investigator, would impede compliance 
or hinder completion of the study 
Randomization of patients 
 
Patients with decompensated cirrhosis who will be enrolled in the study after 
satisfying the selection criteria will be randomized  into two groups 1:1 ratio using a random 
number generator 
 
Group 1(Experimental Arm): Patients with decompensated cirrhosis who will 
receive Fecal MicrobiotaTransplantation via nasojejunal tube as well as traditional treatment 
for decompensated cirrhosis. 
 
Group 1(Standard of Care Arm): Patients with decompensated cirrhosis who will 
receive standard medical treatment for decompensated cirrhosis. 
Pre FMT  
 
Participants randomized to the FMT arm will be given pretreatment antibiotics to 
decrease the host bacterial load, lower diversity, and enable a colonic colonizationof the 
donor microbiota.Lactulose and rifaximin  will becontinued for all patients as per indication. 
A 5-day broad-spectrum coverage regimen will be  used (metronidazole 500 mg orally three 
timesdaily, ciprofloxacin 500 mg orally twice-daily, andamoxicillin 500 mg orally three 
times daily) prior to admisnistration of FMT. All antibiotics will be discontinued at least 12 
hours before FMTto ensure that these agents would not impact theinstilled 
microbiota.Participants in the SOC arm will not receive antibiotic pretreatment or FMT,but 
follow-up will be identical on days 7, 30 and 90 post FMT.postrandomization 
DonorSelection Criteria: 

 
Family members will be interviewed and screened for eligibility for being a FMT 
donor since pooled stool donor facility is not available at our institute.  The subjects will be  
screened for routine laboratory tests, hemogram, fasting blood sugar, liver function tests, 
lipid profile, stool routine and microscopy for cysts, parasites, ova stool for occult blood, 
stool cultures, HBsAg, anti HCV, HIV 1 and 2, Clostridium difficile and VDRL. A written 
informed consent will be taken from the donor to donate fresh stool sample on day of FMT. 
Donors will be  excluded if they had abnormal bowel motions, abdominal complaints, 
extensive travel history or predisposing factors for potentially transmittable diseases, 
occasional or chronic alcohol intake, and history of substance abuse or fail to provide 
consent. Subjects will  also excluded if they are less than 18 or more than 60 years of age, 
had primary or secondary immunosuppressed state, had enteric infections within last 2 
months, history of inflammatory bowel disease, prior abdominal surgery, pancreatic disease, 
gastrointestinal neoplasms in the past, metabolic syndrome, systemic autoimmunity, atopic 
diseases or on treatment for the same, food and respiratory allergies, chronic neurologic 
disorders, neuro-developmental disorders, have had antibiotics within the last 2 months. 
Donors will be advised to eat food based on recommended daily allowance as calculated by 
dietician and not permitted to eat street foods or attend public functions or eat at family 
functions or parties. They will not be allowed social consumption of alcohol or tobacco 
during a period of one week.  
 
Preparation of Donor Stool 
 
Donors will be advised to collect and submit fresh stool sample  on the day of FMT 
after arriving at the hospital in sterile plastic collection containers. All stool samples will be 
obtained 6 hours before the procedure. Stool specimen (preferably Bristol Stool Type 4 or 5) 
with a weight of ∼30 g (about ~ 2 cm3) will be considered adequate. 100 mL of sterile 
normal saline will be added to the stool sample and homogenized with a blender (Morphy 
Richards ® HBCP Hand Blender @https://www.amazon.in/Morphy-Richards-HBCP-400-
Watt-Blender/dp/B0073QIN6C) for 2-4 minutes in pulses of 30 seconds with 10 seconds 
wait in between each pulse. The homogenous suspension will be then filtered through sterile 

gauze pieces, 3-4 times until the filtrate was devoid of roughage. Personnel involved in stool 
specimen preparation will be required to wear eye shield, masks and fluid resistant gowns. 
The FMT Procedure 
In the Fecal Microbiota Transplantation procedure 100 ml volume of strained and 
filtered stool will be delivered through a nasojejunal tube.The recipient patient will be kept 
nil per oral for at least 4 hours prior to the stool instillation. 100 mL of freshly prepared stool 
suspension will be given. IV antibiotics will be continued as per treating physician’s 
decision in the event of active sepsis based on culture and sensitivity. The duodenal tube will 
be flushed with normal saline (30mL) after the stool instillation. The patient will be allowed 
to consume liquid diet two hours after the procedure. All patients will continue on salt 
restriction, diuretics, and 1.5g/kg per day of plant and egg based protein and weight based 
recommended calorie intake as prescribed by the dietician. Intravenous albumin will be 
continued as indicated during hospitalized period. While rifaximinand other non-absorbable 
antibiotics will be withheld, disaccharides will be  permitted to have 2-3 soft stools per day. 
 
 Follow Up post FMT 
 
Follow up of patients will be done at  at 7, 30 ,90 and 180 days post FMT. During 
follow up patients will be evaluated for clinical parameters, routine biochemical monitoring 
and inflammatory markers for determining status of disease status.  
Clinical and Laboratory Assessment 
 
 
All patients will undergo a detailed clinical evaluation including history and physical 
examination, and routine biochemical and imaging evaluation. Investigations for etiology of 
cirrhosis will be performed as required on a case by case basis. Patients will be worked up for 
chronic liver disease with proper history, clinical examination and investigations which will 
include viral markers (HbsAg, Anti-HCV, Total anti-Hbc, AIH markers (ANA/SMA/LKM), 
serum ceruloplasmin, iron profile, celiac work up, NAFLD work up and radiological 
investigations for cirrhosis and as otherwise indicate 
Management post FMT  

 
All patients (experimental arm as well standard of care arm) will be managed by 
standard medical management in the department of Hepatology, PGIMER. Antibiotics will 
be given as per protocol and subsequently upgraded according to culture and sensitivity 
reports. Acute kidney injury will be managed with intravenous 20% human albumin with 
vasoactive agents if needed and dialysis when indicated. Patients with hepatic 
encephalopathy will be treated with lactulose and rifaximin. Diuretics will be given for 
ascites if not precluded by renal failure or hepatic encephalopathy. Inotropes will be given 
for hypotension and endotracheal intubation with mechanical ventilation will be done for 
respiratory failure as well as for airway protection for advanced HE. 
Assessment of Pro-inflammatory Cytokines 
 
Cytokines (,interleukin [IL]1b, and IL6  will be measured in plasma derived from 
cirrhoticpatients using specific enzyme-linked immunosorbent assaykits (RayBiotech, Inc, 
Norcross, GA) according to the manufacturer’s protocol. The plate will be read at 450 nm. 
Absorbance will be converted to picograms per milliliter using a standardcurve prepared with 
recombinant human IL1b, IL6. Measures will be taken at base line and 28 days  post FMT. 
 
 
4. STATISTICAL ANALYSIS 
The results will be expressed as mean ± standard deviation (SD) or median with range. 
Comparisons between groups will be performed using student’s t-test or the Mann–Whitney U 
test. For categorical data chi-square test or Fisher’s exact test will be applied. A value of P < 0.05 
will be taken as significant. The results will be analyzed at baseline and at day 7, 30 and 90 of 
the study. The in hospital survival curves will be made by the Kaplan-Meier method and 
compared with the log-rank test. All statistical tests will be done by Microsoft Excel and SSPSS 
Software version 18. 
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ANNEXURE 1 
ETHICAL CONSIDERATION 
According to guideline setup by ICMR (2000) and Helsinki declaration (modified 2008) the 
following will be adhered to in all patients/ volunteers involved in the study. 
1. 
All the possible treatment options will be given and none will be withheld. 
 
2. 
Patients will be enrolled in the study with their knowledge, and study will be done 
by utilizing known investigation modalities, regarding which proper information will be 
provided to the patients. 
 
3. 
Patient will be informed about all the major and minor risk factors and the 
remedies thereof and a refusal to participate in this study will not interfere with patient-doctor 
relationship. 
 
4. 
Patient will be given the option of quitting from the study at any point during the 
study if he or she so desires and no element of compulsion will be exerted. 
 
5. 
Confidentiality of data collected from contribution source or individual will be 
maintained. 
 
6. 
Written informed consent will be obtained from all the patients included in the 
study after informing them about the aims and method of the study and the institutional 
affiliation of the researcher. 
 
7. 
In the cases where the patients are legally incompetent minors or are not eligible 
for giving consent due to poor neurological status, consent of the close relative available will be 
taken. 
 

8. 
There will be no difference in the management of the patients and all the patients 
will be treated by standard protocol of the Department of Hepatology, PGIMER, Chandigarh in 
the best interest of the patient. 
 
9. 
In publication of the results of this study all efforts would be made to preserve the 
accuracy of both the positive and negative results of this study. 
 
10. 
At conclusion of study every patient entered in to this study will be assured of 
access to the best proven prophylactic, diagnostic and therapeutic methods identified by this 
study. 
 
This study titled has been planned with due ethical justification and the study will be 
completed in accordance with the ICMR guidelines. 
 
ANNEXURE  
PATIENT CONSENT FORM 
 
Fecal Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: An open-
label randomized control trial 
 
Name of the participant: ____________________________________________ 
 
Name of the Investigator: DrAkash Roy 
 
Name of the Institution: PGIMER, Chandigarh 
 
Documentation of the informed consent 
 
Consent for Fecal Microbiota Transplantation (FMT) 
 
1. I ________________________________ or _______________________________ for 
 
(Patient name) 
 
(Legal guardian) 
 
 
__________________________ 
 
(Patient name) 
 
 
authorize the performance of FMT to be administered by 
 

 
Dr. _____________________________ and/or his assistants or designees. 
 
 
2. I understand that FMT may be performed through a nasoduodenal tube inserted via the nose 
into the first part of the small intestine. FMT is administered to treat decompensated cirrhosis. 
FMT consists of introducing normal bacterial flora contained in stool collected from a healthy 
donor into the diseased gut where the flora is missing. 
 
3. The nature, purpose, risks and benefits of this procedure has been discussed with me. I 
understand that the donor will be screened for a possible history of exposure to a 
communicable infectious agents through a detailed health questionnaire, and also undergo 
blood and feces testing for occult infectious pathogens as some infectious diseases may be 
silent or clinically undetectable. 
 
I have discussed all alternative treatments for decompensated cirrhosis with my 
physician, and understand the risk and benefits of the alternative treatments. I understand that my 
condition could improve, worsen or stay the same with each of the alternative treatment options, 
including FMT. I understand that individuals who are severely ill with FMT have a high risk of 
dying from their illness, regardless of what treatment is used. I understand that at the current time 
the cumulative experience with FMT is limited and that FMT is therefore considered 
investigational. 
 
In choosing to proceed with FMT I understand that a solution of donor stool will be infused into 
the beginning of my small intestinal tract via a hollow tube inserted through the nose  
 
4. The risks of FMT procedure has been discussed in detail with me. I understand that 
complications may arise as a result of FMT. Complications may include but are not limited to: 
 
·Transmission of infectious organisms contained in stool (bacteria, viruses, fungi, parasites)  
·Allergic reactions to constituents (antigens) contained in the donor stool 
·Mechanical complication related to the insertion and presence of the tube, such as potential 
perforation of the lining of the esophagus, stomach, or duodenum, or aspiration of stool 
into the lungs (for the nasoduodenal tube) 

 
I understand that the outline above is not a complete list of potential complications, and that 
unforeseen risks that have not been discussed with me may exist. 
 
5. I understand that the above risks, as well as other complications, may require additional 
procedures or operations and that these issues have been discussed with me. I give my consent 
to undergo additional procedures which my physician deems necessary. 
 
6. I am aware that the practice of medicine is not an exact science. I acknowledge that no 
guarantee or promise can be made by my physician as to the outcome of my treatment. 
 
7. I acknowledge that the entire content of this form has been explained to me, and that I 
understand the contents. 
I have had the opportunity to ask questions, and all of my questions have been answered to my 
satisfaction. 
 
 
Signature: ________________________________ 
 
 
Date _____________ 
 
 
Time _____________ 
 
(Patient or legal guardian) 
 
Signature: ________________________________ 
 
Date _____________ 
 
Time ____________ 
 
(Stool donor) 
 
 
Provider’s Acknowledgement: 
 
I confirm that I have fully explained to the above patient or legal representative the nature and purpose of Fecal 
Microbiota Transplantation and the possible risks and benefits of FMT and treatment alternatives. 
 
Printed name: 
____________________________ 
 
(Provider) 
 
Signature: ___________________________ 
(Provider) 
 
Date: ___________ 
 
Time: ___________ 
 
 
Interpreter’s Acknowledgement (when applicable): 

 
I confirm that consent to proceed with FMT, as explained above, has been given by this patient or legal guardian. 
 
Printed name: ____________________________ 
 
(Interpreter) 
 
Signature: ___________________________ 
(Interpreter) 

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ANNEXURE  
INFORMED CONSENT FORM-DONOR 
 
 
I ,...........................................................EXERCISING MY FREE POWER OF CHOICE 
HEREBY 
 
GIVE MY CONSENT TO BE INCLUDED AS A FECAL DONOR IN THE STUDY of 
“Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: An open-
label randomized control trial 
” I have been informed to my satisfaction by the attending physician the purpose of the study 
and the nature of the test to be done. 
 
I have been informed that there will be no payment for participation in this study. My 
patient’s identity shall be kept confidential and in case the data is published, identity shall not 
be revealed. I also understand that participation in the study is entirely voluntary and I am / 
my patient is free to opt out of the study at any point of time without having to give reasons 
for doing so and this will not jeopardize my patient receiving treatment in the future. I have 
read the foregoing information, or it has been read to me. I have had the opportunity to ask 
questions about it and my questions that I have asked have been answered to my satisfaction. 
I consent voluntarily to participate in this research. 
 
 
 
 
 
 
 
 
 
 

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ANNEXURE- II 
PATIENT INFORMATION FORM 
TITLE: - Single Session of Fecal Microbiota Transplantation in Decompensated Cirrhosis: 
An open-label randomized control trial 
 
Name of Participant: .................................................................................. 
You are invited to take part in this research study. The information in this document is meant 
to help you decide whether or not to take part. Please feel free to ask if you have any queries 
or concerns. 

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What is the purpose of research? 
The purpose of this research is to assess how fecal microbiota transplantation from a healthy 
donor to a patient with decompensated cirrhosis affects their overall prognosis, by means of 
assessing parameters of prognosis commonly used in patients of liver disease, as well as their 
survival at 3 months so that this could aid in the future management of similar patients with 
fecal microbiota transplantation so that the overall mortality and morbidity could be 
benefitted. 
Possible benefits to other people 
The results of the research may provide benefits to the society in terms of advancement of 
medical knowledge and/or therapeutic benefit to future patients. 
The alternatives you have 
If you do not wish to participate, you still will get the standard treatment for your condition. 
Compensation: Nil 
Reimbursement: You will not be paid to participate in this research study. 
What should you do in case of injury or a medical problem during this research study? 
Your safety is the prime concern of the research. If you are injured or have a medical 
problem as a result of being in this study, you should contact one of the people listed at the 
end of the consent form. You will be provided the required care/treatment. 
How will your decision to not participate in the study affect you? 
Your decision not to participate in this research study will not affect your medical care or 
your relationship with the investigator or the institution. Your doctor will still take care of 
you and you will not lose any benefits to which you are entitled. 
Can you decide to stop participating in the study once you start? 
The participation in this research is purely voluntary and you have the right to withdraw 
from this study at any time during the course of the study without giving any reasons. 
However, its advisable that you talk to the research team prior to stopping the treatment. You 
may be advised about how best to stop the treatment safely. If you withdraw, you may be 
asked to undergo some additional tests to which you may or may not agree. Though advisable 
that you give the investigators the reason for withdrawing, it is not mandatory. 

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Can the investigator take you off the study? 
You may be taken off the study without your consent if you do not follow instructions of 
the investigators or the research team or if the investigator thinks that further participation 
may cause you harm. 
Right to new information 
If the research team gets any new information during this research study that may affect 
your decision to continue participating in the study, or may raise some doubts, you will be 
told about that information. 
Confidentiality of the information obtained from you 
You have the right to confidentiality regarding the privacy of your medical 
information (personal details, results of physical examinations, investigations, and your 
medical history). By signing this document, you will be allowing the research team 
investigators, other study personnel, sponsors, institutional ethics committee and any person 
or agency required by law like the Drug Controller General of India to view your data, if 
required. The results of clinical tests and therapy performed as part of this research may be 
included in your medical record. The information from this study, if published in scientific 
journals or presented at scientific meetings, will not reveal your identity. 
Contact Persons: 
 
 
Principal Investigator: 
 
 
 
 
Guide: 
 
 
Akash Roy 
 
 
Prof RK Dhiman 
 
 
Senior Resident 
 
 
Professor and Head 
 
 
Department of  Hepatology 
 
 
Department of Hepatology 
 
 
PGIMER Chandigarh 
 
 
PGIMER Chandigarh 
 
 
Ph no:+91 9774056722 
 
 
Ph no: 
 
 
Email id: royakash12@gmail.com 
 
 
Email id: rkpsdhiman@hotmail.com 

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