Implications of Fecal Microbiota Transplantation in Modulating the Effects of Liver Cirrhosis
Phase: PHASE3
Conditions: Liver Cirrhosis
Sponsor: Cristian Ichim

STUDY PROTOCOL 
 
Official Title: Implications of Fecal Microbiota Transplantation in Modulating the Effects of 
Liver Cirrhosis 
 
NCT Number: NCT06478602 
Unique Protocol ID: No. 3505/15.02.2023 
Protocol Date: 10.04.2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1. Background 
 
Liver cirrhosis is associated with profound alterations of the intestinal microbiota, which 
contribute to systemic inflammation, disease progression and complications such as hepatic 
encephalopathy. The gut–liver axis plays a crucial role in the pathophysiology of cirrhosis, as 
microbial imbalance may promote endotoxemia, immune dysregulation and worsening liver 
function. 
 
Fecal microbiota transplantation (FMT) has emerged as a promising therapeutic approach 
aimed at restoring microbial diversity and intestinal homeostasis. By transferring intestinal 
microbiota from a healthy donor to a patient, FMT may improve gut barrier integrity, reduce 
inflammation and potentially improve clinical outcomes in patients with liver disease. 
 
Several studies have suggested that modulation of gut microbiota may improve hepatic 
encephalopathy and liver-related outcomes. However, evidence regarding its impact on liver 
fibrosis and cirrhosis progression remains limited. The present study investigates the potential 
clinical benefits of fecal microbiota transplantation in patients with alcohol-associated liver 
cirrhosis. 
 
2. Study Objective 
 
The objective of this study is to evaluate the clinical effects of fecal microbiota 
transplantation on liver fibrosis and hepatic encephalopathy in patients diagnosed with 
alcohol-associated liver cirrhosis. 
 
3. Study Design 
 
This study is designed as a prospective clinical investigation conducted over a three-year 
period between 2023 and 2025. 
 
A total of 19 participants with alcohol-associated liver cirrhosis are included in the study and 
divided into two groups: 
 
FMT group: 6 patients receiving fecal microbiota transplantation. 
 
Control group: 13 patients receiving standard medical therapy for liver cirrhosis. 

 
Participants are recruited from adult patients admitted primarily to the Gastroenterology 
Department of the County Clinical Emergency Hospital of Sibiu. 
 
4. Study Population 
 
Eligible participants are adult patients diagnosed with liver cirrhosis according to standard 
international diagnostic criteria based on clinical, laboratory and imaging evaluations. 
 
Although gender is not a predefined selection criterion, all enrolled participants are male, 
which contributes to greater cohort homogeneity and reduces potential variability related to 
sex differences. 
 
Some patients presenting characteristics of metabolic dysfunction associated with alcohol-
related liver disease (MetALD) may be included, reflecting real-world clinical practice. 
However, none of the enrolled participants meet the diagnostic criteria for metabolic 
syndrome according to the NCEP ATP III guidelines. 
 
5. Eligibility Criteria 
Inclusion Criteria 
 
Participants must meet the following criteria: 
 
Age ≥ 18 years 
 
Diagnosis of alcohol-associated liver cirrhosis 
 
Documented abstinence from alcohol at study enrollment 
 
Ability and willingness to provide written informed consent 
 
Exclusion Criteria 
 

Participants are excluded if they present: 
 
Cirrhosis of non-alcoholic etiology 
 
Uncertain or unconfirmed diagnosis of liver cirrhosis 
 
Age below 18 years 
 
Concomitant malignancies 
 
Major trauma 
 
Hemodynamic or respiratory instability 
 
Acute or chronic infections including HIV, tuberculosis, cytomegalovirus, multidrug-resistant 
Enterobacteriaceae, parasitic or fungal infections 
 
Severe immunodeficiency 
 
Comatose state or severely impaired consciousness 
 
Refusal or inability to provide informed consent 
 
6. Study Procedures 
 
All participants undergo baseline clinical and paraclinical evaluation including: 
 
clinical examination 
 
laboratory tests 
 

stool sample collection 
 
abdominal ultrasound 
 
liver elastography 
 
Participants assigned to the FMT group undergo colonoscopy with fecal microbiota 
transplantation using stool obtained from a screened healthy donor. 
 
Following the transplantation procedure, participants undergo a follow-up evaluation 
approximately one month (approximately 30 days) after the intervention. 
 
The follow-up visit includes: 
 
clinical examination 
 
laboratory investigations 
 
abdominal ultrasound 
 
liver elastography 
 
Patients included in the FMT group must not have received antibiotic therapy during the three 
months preceding transplantation. 
 
7. Control Group Management 
 
Patients assigned to the control group receive standard medical therapy for liver cirrhosis, 
which may include: 
 
normocaloric diet 
 

normoproteic diet 
 
normolipidic and normoglucidic dietary regimen 
 
beta-blockers 
 
hepatoprotective agents 
 
diuretics 
 
Baseline clinical and laboratory assessments are performed at study entry. 
 
A follow-up evaluation is conducted approximately one month (approximately 30 days) after 
the baseline assessment. 
 
Alcohol consumption is prohibited throughout the study period. 
 
8. Donor Selection and Screening 
 
Fecal donors are selected from healthy volunteers, including both relatives of patients and 
unrelated individuals. 
 
Preference is given to young donors without significant comorbidities. All donors provide 
written informed consent and undergo extensive screening procedures. 
 
Screening includes: 
 
medical questionnaire assessing epidemiological risk factors 
 
complete blood count 
 
biochemical and coagulation tests 

 
screening for HIV infection 
 
screening for viral hepatitis 
 
stool examination for occult blood 
 
microbiological and parasitological stool analysis 
 
These measures are implemented to minimize the risk of infectious transmission to recipients 
with liver cirrhosis. 
 
9. Preparation of Fecal Material 
 
On the day of transplantation, fecal material is prepared according to a standardized protocol. 
 
A minimum of 70 g of stool is mixed with 250 mL of sterile 0.9% sodium chloride solution in 
a sterile container and homogenized for approximately three minutes. 
 
The mixture is filtered through sterile gauze layers to remove particulate material. The filtrate 
is transported to the hospital and used for transplantation within approximately six hours after 
preparation to ensure microbial viability. 
 
10. Fecal Microbiota Transplantation Procedure 
 
FMT is performed via colonoscopy following standard bowel preparation with polyethylene 
glycol solutions. 
 
Sedation and analgesia are administered according to routine clinical protocols. 
 
Following transplantation, patients are instructed to avoid defecation for approximately two 
hours in order to improve transplant retention. 
 

11. Outcome Measures 
Primary Outcome 
 
Liver fibrosis assessed by measurement of liver stiffness (kPa) using transient elastography 
(FibroScan). 
 
Secondary Outcome 
 
Hepatic encephalopathy assessed using the EncephalApp Stroop Test. 
 
Clinical staging of encephalopathy is performed according to the West Haven classification.