- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01140399
REWORD-HF REverse WOrsening Renal Function in Decompensated Heart Failure (REWORD-HF)
Impact of Different Therapeutic Approaches in Patients With Cardiorenal Syndrome in the Setting of Acute Decompensated Congestive Heart Failure (ADCHF)
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Acute decompensated congestive heart failure (ADCHF), the most common single cause of hospitalization over 65 years, results in 4-8% in-hospital mortality and 30-38% incidence of readmissions within 3 months after discharge. While fluid accumulation remains the main factor causing hospitalization, impaired cardiac output in ADHF causes renal arterial underfilling and increased venous pressure, reducing the glomerular filtration rate and causing acute kidney injury.
Aggressive therapy is required to alleviate volume overload during hospital admission and achievement of a dry weight is capital in preventing rehospitalisation. Currently diuretics are considered the standard of care for volume overload in ADHF, yet any patients, especially those with advanced HF become soon resistant to standard doses of loop diuretics, so escalating doses and the association of thiazides are often required to achieve effective diuresis, an approach that will progressively worsen renal function, causing the cardiorenal syndrome.
When diuretic resistance develops and symptoms persists, mechanical fluid removal via ultrafiltration should be considered. Ultrafiltration is an alternative method of sodium and water removal, that filters plasma water directly across a semipermeable membrane in response to a transmembrane pressure gradient, resulting in an ultrafiltrate that is isoosmotic compared with plasma water, In view of the limits of traditional therapies for the treatment of congestion and concomitant progressive renal dysfunction in ADHF patients, there is a compelling need for additional studies to individuate the better method for fluid removal in volume-overloaded patients and guide management decisions to reduce associated morbidity.
The main objectives of the present project are to evaluate whether in patients with acute decompensated congestive heart failure and the cardiorenal syndrome, i.e. a state in which therapy directed to improve CHF symptoms is limited by further worsening renal function, fluid removal by ultrafiltration is superior to different pharmacological approaches in acutely relieving congestion and preventing further deterioration in renal function and whether it results in longer admission-free survival 90 days after enrolment
Study Type
Enrollment (Actual)
Phase
- Phase 4
Contacts and Locations
Study Locations
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Ancona, Italy, 60020
- Ospedali Riuniti di Ancona Cardiology Presidio Lancisi
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Bergamo, Italy, 24128
- Ospedali Riuniti di Bergamo - Cardiovascular Medicine
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Bologna, Italy, 40138
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi - Cardiology Unit
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Bologna, Italy, 40138
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi - Nefrology,Dialysis and Hypertension Unit
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Como, Italy, 22100
- Azienda Ospedaliera Sant'Anna - Cardiology
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Cosenza, Italy, 87100
- Ospedale SS Annunziata Cardiology
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Cremona, Italy, 26100
- Azienda Istituti Ospitalieri di Cremona Cardiology
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Milano, Italy, 20138
- Centro Cardiologico Monzino, I.R.C.C.S. Cardiology Intensive Care
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Milano, Italy, 20162
- Azienda Ospedaliera Niguarda - Heart Failure and Heart Transplant Program
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Piacenza, Italy, 29100
- Ospedale Guglielmo da Saliceto Cardiology Department
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Verona, Italy, 37126
- AO Verona Ospedale Civile Maggiore Cardiology Unit
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Bari
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Cassano Murge, Bari, Italy
- Fondazione S. Maugeri. IRCCS Istituto di Cassano Murge
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Milano
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Legnano, Milano, Italy, 20025
- Ospedale Civile di Legnano Cardiology
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Rozzano, Milano, Italy, 20089
- Istituto Clinico Humanitas - IRCCS Clinical Cardiology Cardiovascular Department
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Monza Brianza
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Monza, Monza Brianza, Italy, 20052
- Azienda Ospedaliera S. Gerardo Heart Failure and Cardiomyopathy Clinic
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Monza, Monza Brianza, Italy, 20052
- Gruppo Policlinico di Monza Clinical Cardiology and Heart Failure Unit - Cardiology Department
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion criteria
On admission (screening)
- Informed consent
- Age 18-80 years
- NYHA class III - IV
- Signs of pulmonary (pulmonary rales, and interstitial oedema or pleural effusion on chest Xray) and/or systemic congestion (pitting ankle oedema and enlarged liver or ascites and neck vein distension ≥ 7 cm) and weight gain ≥ 2 kg during the previous week
- Glomerular filtration rate ≥ 30 ml/min
BNP increased >400 pg/ml (diagnostic cut-off for ADCHF), as confirmatory diagnostic test)
24 hours after admission (randomization)
- Persistent signs of pulmonary (pulmonary rales, interstitial oedema or pleural effusion on chest Xray) and/or systemic congestion (ankle oedema, enlarged liver or ascites, neck vein distension ≥ 7 cm)
- Serum creatinine or urine output criteria indicative of modified RIFLE (AKI: risk) class at least 1 (increase x 1.5 in serum creatinine or decrease > 25% in GFR or urine output < 0.5 ml/Kg/h for more than 6 hours) 29-30 during diuretic infusion
Exclusion criteria
- Chronic kidney disease stage 4-5 (GFR < 30 ml/min)
- Acute coronary syndromes
- Systolic blood pressure <90 mm Hg/need for intravenous inotropes
- Hematocrit > 45%
- Unattainable venous access
- Contraindications to anticoagulation by heparin
- Systemic infection
- Heart transplant
Study Plan
How is the study designed?
Design Details
- Primary Purpose: TREATMENT
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
ACTIVE_COMPARATOR: Infusional drug treatment
Diuretics or diuretics plus fixed low dose dopamine infusion
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Patients randomized to pharmacological treatment receive
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EXPERIMENTAL: Ultrafiltration
Device: Ultrafiltration appliance Sessions of 8 h UF are conducted on 2 subsequent days in the first 48 hours after randomization; a third session is performed on day 3 in case of persistent congestion
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All loop diuretics will be discontinued. Rate of fluid removal will be based on the extent of fluid overload as assessed by increase in body weight vs the patient's known dry weight
Criteria for achievement of target UF goals are removal of > 50% and <70% of fluid excess based on the estimated increase in body weight Diuretic infusion is allowed provided that a minimum of 3 hours after the end of the UF session have elapsed, at a maximum cumulative dose of 100 mg furosemide, till start of the next UF session The use of inotropic agents is prohibited |
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Changes in a composite clinical-lab score
Time Frame: Baseline and 96 h after randomization,precisely:48 h after end of the last UF session in the intervention arm;24 h after end of 72 h infusional drug treatment in the control arm
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Changes in a score derived by summing up changes in dyspnea, weight loss, glomerular filtration rate (GFR), brain natriuretic peptide (BNP)
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Baseline and 96 h after randomization,precisely:48 h after end of the last UF session in the intervention arm;24 h after end of 72 h infusional drug treatment in the control arm
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Changes in the dyspnea Likert scale
Time Frame: Measured at day 4, at day 10, at day 90 vs baseline
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Measured at day 4, at day 10, at day 90 vs baseline
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Changes in modified RIFLE (AKIN) stage
Time Frame: Measured at day 4 vs baseline
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Measured at day 4 vs baseline
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Length of stay during index admission
Time Frame: Measured at average day 10
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Measured at average day 10
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Occurrence of major adverse events
Time Frame: Measured at day 90
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All cause mortality, hospital readmission and unscheduled office and emergency department visits for ADCHF
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Measured at day 90
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Days spent alive and out of hospital (DAOH) within 90 days
Time Frame: Measured at day 90
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Sum of days spent alive and out of hospital
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Measured at day 90
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BNP changes
Time Frame: Measured at day 0, at day 4, at 10 and day 90
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Changes in BNP at specified times VS baseline
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Measured at day 0, at day 4, at 10 and day 90
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Changes in neutrophil gelatinase associated lipocalin (NGAL)
Time Frame: Measured at day -1, at day 0 and day 4
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Changes in NGAL at specified times VS screening
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Measured at day -1, at day 0 and day 4
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Changes in Cystatin C (CysC)
Time Frame: Measured at day 0, day 4, day 10 and day 90
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Changes in Cystatin C (CysC) at specified times VS baseline
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Measured at day 0, day 4, day 10 and day 90
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Treatment-related adverse events
Time Frame: Measured at day 4
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Bleeding, thrombosis, clotting, infection
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Measured at day 4
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Adverse changes in blood pressure, heart rate and rhythm
Time Frame: Measured at day 4
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Hypotension (< 90 mmHg), tachycardia (> 110 bpm) arrhythmias
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Measured at day 4
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Adverse changes in lab parameters
Time Frame: Measured at day 4
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Hyper-Azotemia (>180 mg/dl), hyper-kaliemia (6.5 mEq/l), hemoconcentration (hematocrit >45%)
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Measured at day 4
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Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Study Chair: Antonio Santoro, MD, Department of Nephrology, Dialysis and Hypertension, Sant'Orsola Malpighi Hospital, Bologna, Italy
Publications and helpful links
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ACTUAL)
Study Completion (ACTUAL)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ESTIMATE)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Heart Diseases
- Cardiovascular Diseases
- Kidney Diseases
- Urologic Diseases
- Renal Insufficiency
- Heart Failure
- Cardio-Renal Syndrome
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Autonomic Agents
- Peripheral Nervous System Agents
- Protective Agents
- Natriuretic Agents
- Cardiotonic Agents
- Membrane Transport Modulators
- Dopamine Agents
- Diuretics
- Sympathomimetics
- Sodium Potassium Chloride Symporter Inhibitors
- Furosemide
- Dopamine
Other Study ID Numbers
- EudraCT code 2009-014
- FO001
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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