Evaluation of the Efficacy of an inTerdialytic "Ethanol 40% v/v - enoxapaRin 1000 U/mL" Lock solutioN to Prevent Tunnelled Catheter Infections in Chronic Hemodialysis Patients (ETERNITY)

Evaluation of the Efficacy of an inTerdialytic "Ethanol 40% v/v - enoxapaRin 1000 U/mL" Lock solutioN to Prevent Tunnelled Catheter Infections in Chronic Hemodialysis Patients: a mulTi-centre, Randomized, Single Blind, Parallel Group studY (ETERNITY)

The purpose of this study is to assessed the efficacy of a combined solution of ethanol (4%) and low molecular weight heparins LMWH in preventing tunnelled dialysis catheter infection in chronic hemodialysis patients

Study Overview

• Status: Recruiting
• Conditions: Tunnelled Hemodialysis Catheter Infection
• Intervention / Treatment: Drug: Ethanol; Drug: enoxaparin

Detailed Description

In France, a central venous catheter is used in 20 to 30% of chronic hemodialysis patients as the vascular access device. In this patient population the recommended device is a tunnelled dialysis catheter (TC). TC-related infections (TCI) and TC dysfunctions are two major complications and are associated with increased antibiotic consumption, hospital stays, health costs and mortality. Strategies to prevent TCI should target endoluminal biofilm formation, which is the major cause of long-term catheter colonization.

Unfractionated heparin (UFH), 5000 U/mL, is the standard interdialytic lock solution for the prevention of TC thrombosis. A lower-UFH concentration (1000U/mL) is associated with similar catheter patency. However, UFH has no antibiofilm properties. Antibiotic locks decrease the rate of TCI including TC- related bloodstream infections (TCBSI) and exit-site infection (ESI). The widespread use of antibiotic lock solutions raises concerns, however, because of side effects and the risk for the development of antimicrobial-resistant microorganisms.

Ethanol is an inexpensive antiseptic agent with activity against a broad range of bacteria and fungi commonly involved in TCI. It acts by non-specific protein denaturation and thus is less likely to promote antimicrobial resistance. Ethanol concentration of 40% v/v is highly effective in eradicating biofilm and has no significant impact on the integrity of silicone and polyurethane TCs or on their mechanical properties. A small randomized controlled trial performed in chronic hemodialysis patients with TC suggests that once-weekly instillation of an interdialytic ethanol lock is effective in preventing TCBSI. However, ethanol has no anticoagulant properties and may induce TC dysfunctions when used alone.

Experimental data provide evidence that a combined solution of ethanol and injectable anticoagulant is a promising lock solution for preventing both TC infections and dysfunctions. UFH, at whatever concentration, cannot be mixed with ethanol 40% v/v because of precipitation. ERA-EDTA recommends using low molecular weight heparins (LMWHs) for blood circuit anticoagulation during dialysis sessions. Like UFH, LMWHs have no antibiofilm properties. In contrast, LMWHs can be mixed in ethanol 40% v/v with enoxaparin having the highest solubility, up to 1300 U/mL. Our group demonstrated that ethanol 40% v/v - enoxaparin 400 U/mL is stable, compatible with TC materials and exhibits antibiofilm and anticoagulant properties in vitro (patent). No clinical studies have previously assessed the efficacy of a combined solution of ethanol and LMWH in preventing TCI in chronic hemodialysis patients.

Screening Patients eligible to participate in the study will be identified by a clinical research assistant in each study centre at the beginning of the study and then weekly. Data recorded in the medical records will be used.

Enrolment Eligible patients, previously identified during the screening procedure, will be recruited during a routine hemodialysis session by an investigator from centres participating in this study Randomization Enrolled patients will be randomly assigned in a 1:1 ratio either to the intervention group (Ethenox) or to the control group (reference solution: UFH 5000 U/mL or citrate 4% w/v depending on which solution is generally used). Random allocation will be performed by minimization using a computer algorithm. Minimization strata will be the study centre, the incident or prevalent nature of the TC and in the prevalent group the existence or not of a previous infection of the TC in place.

Single blind procedure The study will be performed single blind for the patients and the analysts. The recognisable smell of ethanol and the need to prepare the Ethenox lock solution rule out blinding of the healthcare staff.

Treatment Study treatment (Ethenox in the intervention group or reference solutions in the control group: UFH 5000 U/mL or citrate 4% w/v according to usual practice) will be used by the hemodialysis nurse as TC lock solution after each hemodialysis session with all successive TCs used during the study.

All the centres participating in the study will use similar hygiene protocols for TC placement and maintenance in accordance with the guidelines drawn up by the Haute Autorité de Santé and the Société Française d'Hygiène Hospitalière. Audits will be conducted during the study to ensure compliance with guidelines.

Study assessments Bacteriological sampling will be performed in accordance with guidelines for TCI.

A monthly blood sample will be taken as part of the routine care given to the patients.

Data will be collected weekly in an electronic case report form (e-CRF) except endpoint data for adjudication and serious adverse events, which will be recorded continuously.

• Study Type: Interventional
• Enrollment (Estimated): 400
• Phase: Phase 3

Contacts and Locations

• Study Contact: Name: Patrick LACARIN; Phone Number: 04 73 75 10 81; Email: placarin@chu-clermontferrand.fr

Study Locations

• France
  • Clermont-Ferrand, France, 63003
    • Recruiting
    • CHU Clermont-Ferrand
    • Principal Investigator: Julien ANIORT
    • Contact: Patrick LACARIN; Phone Number: 0473751081; Email: placarin@chu-clermontferrand.fr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• end-stage renal disease
• chronic hemodialysis/hemodiafiltration at least three times a week
• functional TC inserted for at least two weeks
• Social security cover
• Written informed consent

Exclusion Criteria:

-

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Single Group Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention group; Enrolled patients will be randomly assigned in a 1:1 ratio either to the intervention group (Ethenox) or to the control group (reference solution: UFH 5000 U/mL or citrate 4% w/v depending on which solution is generally used).	Drug: Ethanol; An ethanol 40 % v/v - enoxaparin 1000 U/mL (Ethenox) interdialytic lock solution
Other: control group; Enrolled patients will be randomly assigned in a 1:1 ratio either to the intervention group (Ethenox) or to the control group (reference solution: UFH 5000 U/mL or citrate 4% w/v depending on which solution is generally used).	Drug: enoxaparin; An ethanol 40 % v/v - enoxaparin 1000 U/mL (Ethenox) interdialytic lock solution

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to first TC infection (TCI)	TCI is a composite endpoint defined by the occurrence of at least one of the three following events: Definitive TC-related bloodstream infection (definitive TCBSI) or Probable TC-related bloodstream infection (probable TCBSI) or TC exit-site infection (ESI). TCI diagnosis and its type (definitive or probable TCBSI or ESI) will be assessed by an endpoint adjudication committee (EAC) according to predefined criteria	at 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to first definitive or probable TCBSI	TCI prevention criteria	at 1 year
Time to first ESI	TCI prevention criteria	at 1 year
Incidence rate of definitive or probable TCBSI	TCI prevention criteria	at 1 year
Incidence rate of ESI	TCI prevention criteria	at 1 year
prevalence of colonizations of removed TCs for each TC removed		at 1 year
Incidence rate of TC dysfunctions		at 1 year
Dialysis dose measured by the dialysis machine		at 1 year
time to TC removal		at 1 year
Time to first systemic antibiotic treatment for TCI		at 1 year
Total duration ( type of antibiotic treatment)		at 1 year
Time to first hospitalization for TCI		at 1 year
Total duration of hospital stays for TCI		at 1 year
Total number of TCs replaced during the study		at 1 year
Incidence rate of breaches in TC integrity (TC leakage or disruption)		at 1 year
Incidence rate of clinical adverse events related to ethanol exposure	Incidence rate of clinical adverse events related to ethanol exposure (tiredness, ethanol taste, headaches, dizziness, nausea, light-headedness, and increase in serum aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase or alkaline phosphatase).	at 1 year
Incidence rate of type II heparin-induced thrombocytopenia.		at 1 year
Incidence rate of hemorrhages	bleeding or suspected bleeding, qualified as major if associated with a decrease in hemoglobin levels of more than 2g/dL or the need to transfuse at least two units of red blood cells	at 1 year

Collaborators and Investigators

• Sponsor: University Hospital, Clermont-Ferrand
• Collaborators: Ministry of Health, France; University Hospital, Toulouse; Hôpital Edouard Herriot; Calydial; University Hospital of Saint-Etienne; Centre hospitalier de Perpignan; CH du Puy en Velay, Hôpital Emile Roux; Centre hospitalier de Chambéry; Nouvel Hôpital Civil, 1 place de l'Hôpital 67091 Strasbourg cedex; Hôpital Lapeyronie; Centre de dialyse d'Alès; Centre de néphrologie Polyclinique Médipôle Saint-Roch, Rue Ambroise Croizat; CHU Hôpital Maison Blanche, 45 Rue Cognacq-Jay 51092 REIMS Cedex
• Investigators: Principal Investigator: Julien ANIORT, University Hospital, Clermont-Ferrand

Publications and helpful links

General Publications

• Aniort J, Piraud A, Adda M, Perreira B, Bouiller M, Fourcade J, Guerraoui A, Kalbacher E, Krumel T, Moragues HL, Thibaudin D, Vela CG, Vernin G, Weclawiak H, Bernard L, Heng AE, Souweine B. Evaluation of the efficacy of an interdialytic "ethanol 40% v/v - enoxaparin 1000 U/mL" lock solution to prevent tunnelled catheter infections in chronic hemodialysis patients: a multi-centre, randomized, single blind, parallel group study. BMC Nephrol. 2019 Apr 30;20(1):149. doi: 10.1186/s12882-019-1338-6.

Study record dates

Study Major Dates

• Study Start (Actual): February 9, 2018
• Primary Completion (Estimated): December 1, 2026
• Study Completion (Estimated): December 1, 2027

Study Registration Dates

• First Submitted: March 7, 2017
• First Submitted That Met QC Criteria: March 13, 2017
• First Posted (Actual): March 17, 2017

Study Record Updates

• Last Update Posted (Actual): December 8, 2023
• Last Update Submitted That Met QC Criteria: December 7, 2023
• Last Verified: May 1, 2023

More Information

Terms related to this study

• Keywords: Hemodialysis; hemodiafiltration; tunnelled dialysis catheter; interdialytic lock solution; preventing tunnelled catheter infection
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Infections; Communicable Diseases; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents, Local; Anti-Infective Agents; Central Nervous System Depressants; Fibrinolytic Agents; Fibrin Modulating Agents; Anticoagulants; Ethanol; Enoxaparin
• Other Study ID Numbers: CHU-0307; 2016-A00180-51 (Other Identifier: 2016-A00180-51)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No