High-dose hydroxocobalamin in end-stage liver disease and liver transplantation

  • Sujit Vijay SakpalEmail author
  • Hannah Reedstrom
  • Cody Ness
  • Tobin Klinkhammer
  • Hector Saucedo-Crespo
  • Christopher Auvenshine
  • Robert N. Santella
  • Jeffery Steers
Therapy in Practice


Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.



Sujit Vijay Sakpal, MD, FICS: study conception of design; drafting of manuscript; critical revision; review, analysis and interpretation of scientific literature. Hannah Reedstrom, PharmD: drafting of manuscript; review, analysis and interpretation of scientific literature. Cody Ness, BS: drafting of manuscript; review, analysis and interpretation of scientific literature. Tobin Klinkhammer, PharmD: drafting of manuscript; review, analysis and interpretation of scientific literature. Hector Saucedo-Crespo, MD: drafting of manuscript; review, analysis and interpretation of scientific literature. Christopher Auvenshine, DO, FACOS: drafting of manuscript; review, analysis and interpretation of scientific literature. Robert N. Santella, MD, FACP: drafting of manuscript; critical revision. Jeffery Steers, MD, FACS: drafting of manuscript; critical revision.

Compliance with Ethical Standards

Conflict of interest

The authors of this manuscript disclose no relevant, real or apparent financial interest or affiliation with content discussed in this article.

Informed consent and ethical approval

Written consent was obtained from the patients or the person authorized to be their healthcare proxy or to have power of attorney, as per the authors’ Institutional Review Board approval to collect, analyze and present multivariate clinical outcomes in potential abdominal solid-organ transplant candidates and transplant recipients.


No outside funding was utilized for this project.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver SurgerySioux FallsUSA
  2. 2.Department of SurgeryUniversity of South Dakota-Sanford School of MedicineSioux FallsUSA
  3. 3.Department of Internal MedicineUniversity of South Dakota-Sanford School of MedicineSioux FallsUSA
  4. 4.Department of PharmacyAvera McKennan Hospital & University Health CenterSioux FallsUSA

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