- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04153487
Role of Ascorbic Acid Infusion in Critically Ill Patients With Transfusion Related Acute Lung Injury (ASTRALI)
TRALI was defined as "acute noncardiogenic pulmonary edema typically occurs ≤ 6 hours following transfusion of plasma-containing blood products, such as packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate." In critically ill patients, TRALI remains the leading cause of transfusion-related fatalities and is accompanied by a very significant morbidity and mortality. Survival in such patients is as low as 53% compared with 83% in acute lung injury (ALI) controls.
The incidence of TRALi is likely underreported. In densely populated developing countries, incidence has not decreased due to lack of male-only strategy for plasma donation.
TRALI is associated with systemic inflammation characterized by low anti-inflammatory cytokine as interleukin (IL)-10, increased pro-inflammatory cytokine as IL-8. Regulation of inflammation should include avoidance of overproduction of inflammatory mediators. So, it can be dampened not only by increasing IL-10 but also by decreasing IL-1β release. C-reactive protein (CRP) is an acute phase protein which is up-regulated during infections and inflammation. CRP was recently identified as a novel first hit in TRALI.
Till now, there is no established treatment for TRALI beyond supportive care and monitoring. Recently, potential therapies have been reviewed, and it was concluded that the most promising therapeutic strategies are IL-10 therapy, downregulation of CRP levels, targeting reactive oxygen species (ROS) or blocking IL-8 receptors. So, antioxidants (such as high dose vitamins), were recommended for future studies as potentially effective treatment.
Vitamin C hypovitaminosis is observed in 70% of critically ill despite receiving recommended daily doses.
The aim of this study is to investigate the role of intravenous vitamin C (ascorbic acid) as a targeted therapy for transfusion related acute lung injury (TRALI) in critically ill patients in terms of IL-8, IL-10, CRP, SOD, malondialdehyde (MDA), vasopressor use, duration of mechanical ventilation, ICU length of stay, 7-days mortality and 28-days mortality.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
- Ethical committee approval will be obtained from Ethics committee of Faculty of Pharmacy, Damanhour University.
- The minimum required sample size is estimated to be 40 patients for each group.
- Full written informed consent will be taken from all patients or their next of kin to participate in this study.
All patients will be subjected directly at time of enrollment to the following;
- Complete history taking and demographic data
- The potential recipient risk factors for TRALI.
- The initial cause of ICU admission and the blood products received.
- Complete physical examination including chest auscultations.
- Vital signs
- Routine laboratory investigations
- Brain natriuretic peptide level
- Troponin T
- Hypoxic index
- Acute Physiology and Chronic Health Evaluation version II (APACHE II) score.
- Sequential Organ Failure Assessment (SOFA) score.
- Kidney Disease Improving Global Outcomes (KDIGO) criteria.
- Child Pugh score.
- Chest radiography and transthoracic echocardiography.
- Samples will be drawn to measure the initial values of ascorbate level, plasma IL-8, IL-10, IL-1β, SOD, MDA and serum CRP.
Eighty patients with confirmed TRALI (n=80) will be enrolled from critical care units (tertiary hospitals). Then, in addition to their supportive and standard care, they will be randomized (computer sheet) into two groups:
- ASTRALI (AScorbic acid in TRALI) group (n=40) will receive 2.5 gm vitamin C intravenously every 6 hrs for 96 hrs from diagnosis.
- Control group (n=40) will receive placebo in similar regimen.
- All patients will be followed up and treated during the study time. All relevant routine investigations, supportive measures, medications and ventilatory data will be recorded.
- All possible adverse events will be monitored, recorded and managed directly. Hyperoxaluria, microscopic calcium-oxalate crystallization or oxalate nephropathy will be monitored, recorded and managed directly.
- After 96 hrs, resampling for ascorbate level and the same biomarkers will be done.
- Measuring the study secondary outcomes will include vasopressor use, duration of mechanical ventilation, ICU length of stay, 7-days mortality and 28-days mortality.
- Statistical tests appropriate to the study design will be conducted to evaluate the significance of the results.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
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Beheira, Egypt, 22511
- Damanhour University
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
Adult (18 - 64 years) critically ill patients diagnosed with transfusion related acute lung injury (TRALI), at the time of enrollment or maximum 6 hours before, according to the National Heart, Lung and Blood Institute (NHLBI) Working Group definitions and or the Canadian Consensus Conference criteria (29, 30) as the following criteria;
- No evidence of ALI prior to transfusion.
- Onset of ALI ≤ 6 hours following cessation of transfusion.
- Hypoxemia, defined as the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ≤ 300 mmHg or oxygen saturation ≤ 90% on room air.
- Radiographic evidence of bilateral infiltrates.
- No evidence of left atrial hypertension.
Exclusion Criteria:
- Pregnancy or breastfeeding.
- Hypernatremia or known hypersensitivity to the study drug.
- Parenteral nutrition (total/partial) containing vitamin C.
- Active renal stone or history of urolithiasis.
- Acute Kidney Injury.
- Glucose 6 phosphate dehydrogenase deficiency, iron and copper storage diseases.
- Immunocompromised patients (cancer or patients on immunosuppressive drugs).
- Moribund patient not expected to survive 24 hours .
- Home mechanical ventilation (via tracheotomy or noninvasive) except for Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure (CPAP/BIPAP) used only for sleep-disordered breathing .
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: ASTRALI Group
ASTRALI (AScorbic acid in TRALI) group (n=40)
|
Intermittent Intravenous Infusion of Ascorbic Acid (Vitamin C) 2.5 gm / 6 hours for 96 hours
Other Names:
|
Placebo Comparator: Control Group
Control group (n=40)
|
Placebo saline / 6 hours for 96 hours
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Interleukin-8 (IL-8)
Time Frame: 96 hrs
|
Plasma level of IL-8
|
96 hrs
|
Interleukin-10 (IL-10)
Time Frame: 96 hrs
|
Plasma Level of IL-10
|
96 hrs
|
C-reactive protein (CRP)
Time Frame: 96 hrs
|
Serum level of CRP
|
96 hrs
|
Superoxide Dismutase (SOD)
Time Frame: 96 hrs
|
Plasma Level of SOD
|
96 hrs
|
Malondialdehyde (MDA)
Time Frame: 96 hrs
|
Plasma level of MDA
|
96 hrs
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Vasopressor use (days)
Time Frame: up to 28 days
|
Duration of circulatory support
|
up to 28 days
|
Duration of Mechanical Ventilation (days)
Time Frame: up to 28 days
|
Duration of ventilatory support
|
up to 28 days
|
ICU length of stay (days)
Time Frame: Up to 28 days
|
Length of stay in ICU
|
Up to 28 days
|
7-days Mortality
Time Frame: 7 days
|
All cause mortality
|
7 days
|
28-days Mortality
Time Frame: 28 days
|
All cause mortality
|
28 days
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Study Director: Gamal A Omran, PHD, Professor of Biochemistry, Damanhour University.
- Study Director: Mohamed M Megahed, MD, Professor of Critical Care Medicine, Alexandria University.
- Study Chair: Tamer N Zakhary, MD, Ass. Professor of Critical Care Medicine, Alexandria University.
- Study Chair: Amira B Kassem, PHD, Lecturer of Clinical Pharmacy, Damanhour University.
- Principal Investigator: Islam E Ahmed, PharmD, Clinical Pharmacy Specialist, Damanhour University.
Publications and helpful links
General Publications
- Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996 Jul;22(7):707-10. doi: 10.1007/BF01709751. No abstract available.
- Pepys MB, Hirschfield GM. C-reactive protein: a critical update. J Clin Invest. 2003 Jun;111(12):1805-12. doi: 10.1172/JCI18921. No abstract available. Erratum In: J Clin Invest. 2003 Jul;112(2):299.
- Fowler AA 3rd, Truwit JD, Hite RD, Morris PE, DeWilde C, Priday A, Fisher B, Thacker LR 2nd, Natarajan R, Brophy DF, Sculthorpe R, Nanchal R, Syed A, Sturgill J, Martin GS, Sevransky J, Kashiouris M, Hamman S, Egan KF, Hastings A, Spencer W, Tench S, Mehkri O, Bindas J, Duggal A, Graf J, Zellner S, Yanny L, McPolin C, Hollrith T, Kramer D, Ojielo C, Damm T, Cassity E, Wieliczko A, Halquist M. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019 Oct 1;322(13):1261-1270. doi: 10.1001/jama.2019.11825. Erratum In: JAMA. 2020 Jan 28;323(4):379.
- Long CL, Maull KI, Krishnan RS, Laws HL, Geiger JW, Borghesi L, Franks W, Lawson TC, Sauberlich HE. Ascorbic acid dynamics in the seriously ill and injured. J Surg Res. 2003 Feb;109(2):144-8. doi: 10.1016/s0022-4804(02)00083-5.
- Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973 Aug;60(8):646-9. doi: 10.1002/bjs.1800600817. No abstract available.
- Wang Y, Lin H, Lin BW, Lin JD. Effects of different ascorbic acid doses on the mortality of critically ill patients: a meta-analysis. Ann Intensive Care. 2019 May 20;9(1):58. doi: 10.1186/s13613-019-0532-9.
- Toy P, Popovsky MA, Abraham E, Ambruso DR, Holness LG, Kopko PM, McFarland JG, Nathens AB, Silliman CC, Stroncek D; National Heart, Lung and Blood Institute Working Group on TRALI. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005 Apr;33(4):721-6. doi: 10.1097/01.ccm.0000159849.94750.51.
- Vlaar AP, Binnekade JM, Prins D, van Stein D, Hofstra JJ, Schultz MJ, Juffermans NP. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2010 Mar;38(3):771-8. doi: 10.1097/CCM.0b013e3181cc4d4b.
- Fowler AA 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, Farthing CA, Larus TL, Martin E, Brophy DF, Gupta S; Medical Respiratory Intensive Care Unit Nursing; Fisher BJ, Natarajan R. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014 Jan 31;12:32. doi: 10.1186/1479-5876-12-32.
- Peters AL, Van Stein D, Vlaar AP. Antibody-mediated transfusion-related acute lung injury; from discovery to prevention. Br J Haematol. 2015 Sep;170(5):597-614. doi: 10.1111/bjh.13459. Epub 2015 Apr 28.
- Vlaar AP, Juffermans NP. Transfusion-related acute lung injury: a clinical review. Lancet. 2013 Sep 14;382(9896):984-94. doi: 10.1016/S0140-6736(12)62197-7. Epub 2013 May 1.
- Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. Hematology Am Soc Hematol Educ Program. 2018 Nov 30;2018(1):585-594. doi: 10.1182/asheducation-2018.1.585. Epub 2018 Dec 14.
- Peters AL, van Hezel ME, Juffermans NP, Vlaar AP. Pathogenesis of non-antibody mediated transfusion-related acute lung injury from bench to bedside. Blood Rev. 2015 Jan;29(1):51-61. doi: 10.1016/j.blre.2014.09.007. Epub 2014 Sep 20.
- Andreu G, Boudjedir K, Muller JY, Pouchol E, Ozier Y, Fevre G, Gautreau C, Quaranta JF, Drouet C, Rieux C, Mertes PM, Clavier B, Carlier M, Sandid I. Analysis of Transfusion-Related Acute Lung Injury and Possible Transfusion-Related Acute Lung Injury Reported to the French Hemovigilance Network From 2007 to 2013. Transfus Med Rev. 2018 Jan;32(1):16-27. doi: 10.1016/j.tmrv.2017.07.001. Epub 2017 Jul 15.
- Vlaar APJ, Toy P, Fung M, Looney MR, Juffermans NP, Bux J, Bolton-Maggs P, Peters AL, Silliman CC, Kor DJ, Kleinman S. An update of the transfusion-related acute lung injury (TRALI) definition. Transfus Clin Biol. 2019 Nov;26(4):354-356. doi: 10.1016/j.tracli.2019.05.007. Epub 2019 Jun 12. No abstract available.
- Toy P, Gajic O, Bacchetti P, Looney MR, Gropper MA, Hubmayr R, Lowell CA, Norris PJ, Murphy EL, Weiskopf RB, Wilson G, Koenigsberg M, Lee D, Schuller R, Wu P, Grimes B, Gandhi MJ, Winters JL, Mair D, Hirschler N, Sanchez Rosen R, Matthay MA; TRALI Study Group. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012 Feb 16;119(7):1757-67. doi: 10.1182/blood-2011-08-370932. Epub 2011 Nov 23.
- Semple JW, Rebetz J, Kapur R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood. 2019 Apr 25;133(17):1840-1853. doi: 10.1182/blood-2018-10-860809. Epub 2019 Feb 26.
- Roubinian NH, Looney MR, Kor DJ, Lowell CA, Gajic O, Hubmayr RD, Gropper MA, Koenigsberg M, Wilson GA, Matthay MA, Toy P, Murphy EL; TRALI Study Group. Cytokines and clinical predictors in distinguishing pulmonary transfusion reactions. Transfusion. 2015 Aug;55(8):1838-46. doi: 10.1111/trf.13021. Epub 2015 Feb 23.
- Semple JW, McVey MJ, Kim M, Rebetz J, Kuebler WM, Kapur R. Targeting Transfusion-Related Acute Lung Injury: The Journey From Basic Science to Novel Therapies. Crit Care Med. 2018 May;46(5):e452-e458. doi: 10.1097/CCM.0000000000002989.
- Ducharme-Crevier L, Lacroix J. Interleukin-1 Receptor Antagonist and Interleukin-1beta: Risk Marker or Risk Factor for Pediatric Acute Respiratory Distress Syndrome? Pediatr Crit Care Med. 2018 Oct;19(10):993-995. doi: 10.1097/PCC.0000000000001713. No abstract available.
- Kapur R, Kim M, Shanmugabhavananthan S, Liu J, Li Y, Semple JW. C-reactive protein enhances murine antibody-mediated transfusion-related acute lung injury. Blood. 2015 Dec 17;126(25):2747-51. doi: 10.1182/blood-2015-09-672592. Epub 2015 Oct 9.
- Kapur R, Kim M, Rondina MT, Porcelijn L, Semple JW. Elevation of C-reactive protein levels in patients with transfusion-related acute lung injury. Oncotarget. 2016 Nov 22;7(47):78048-78054. doi: 10.18632/oncotarget.12872.
- McNamara R, Deane AM, Anstey J, Bellomo R. Understanding the rationale for parenteral ascorbate (vitamin C) during an acute inflammatory reaction: a biochemical perspective. Crit Care Resusc. 2018 Sep;20(3):174-179. No abstract available.
- Carr AC, Rosengrave PC, Bayer S, Chambers S, Mehrtens J, Shaw GM. Hypovitaminosis C and vitamin C deficiency in critically ill patients despite recommended enteral and parenteral intakes. Crit Care. 2017 Dec 11;21(1):300. doi: 10.1186/s13054-017-1891-y.
- Margaritelis NV, Paschalis V, Theodorou AA, Vassiliou V, Kyparos A, Nikolaidis MG. Rapid decreases of key antioxidant molecules in critically ill patients: A personalized approach. Clin Nutr. 2020 Apr;39(4):1146-1154. doi: 10.1016/j.clnu.2019.04.029. Epub 2019 Apr 29.
- Carr AC, Maggini S. Vitamin C and Immune Function. Nutrients. 2017 Nov 3;9(11):1211. doi: 10.3390/nu9111211.
- Hartmann SE, Waltz X, Kissel CK, Szabo L, Walker BL, Leigh R, Anderson TJ, Poulin MJ. Cerebrovascular and ventilatory responses to acute isocapnic hypoxia in healthy aging and lung disease: effect of vitamin C. J Appl Physiol (1985). 2015 Aug 15;119(4):363-73. doi: 10.1152/japplphysiol.00389.2015. Epub 2015 Jun 18.
- Reynolds PS, Fisher BJ, McCarter J, Sweeney C, Martin EJ, Middleton P, Ellenberg M, Fowler E, Brophy DF, Fowler AA 3rd, Spiess BD, Natarajan R. Interventional vitamin C: A strategy for attenuation of coagulopathy and inflammation in a swine multiple injuries model. J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S57-S67. doi: 10.1097/TA.0000000000001844.
- Rozemeijer S, Spoelstra-de Man AME, Coenen S, Smit B, Elbers PWG, de Grooth HJ, Girbes ARJ, Oudemans-van Straaten HM. Estimating Vitamin C Status in Critically Ill Patients with a Novel Point-of-Care Oxidation-Reduction Potential Measurement. Nutrients. 2019 May 8;11(5):1031. doi: 10.3390/nu11051031.
- Buehner M, Pamplin J, Studer L, Hughes RL, King BT, Graybill JC, Chung KK. Oxalate Nephropathy After Continuous Infusion of High-Dose Vitamin C as an Adjunct to Burn Resuscitation. J Burn Care Res. 2016 Jul-Aug;37(4):e374-9. doi: 10.1097/BCR.0000000000000233.
- Schorah CJ, Downing C, Piripitsi A, Gallivan L, Al-Hazaa AH, Sanderson MJ, Bodenham A. Total vitamin C, ascorbic acid, and dehydroascorbic acid concentrations in plasma of critically ill patients. Am J Clin Nutr. 1996 May;63(5):760-5. doi: 10.1093/ajcn/63.5.760.
- de Grooth HJ, Manubulu-Choo WP, Zandvliet AS, Spoelstra-de Man AME, Girbes AR, Swart EL, Oudemans-van Straaten HM. Vitamin C Pharmacokinetics in Critically Ill Patients: A Randomized Trial of Four IV Regimens. Chest. 2018 Jun;153(6):1368-1377. doi: 10.1016/j.chest.2018.02.025. Epub 2018 Mar 6.
- Kleinman S, Caulfield T, Chan P, Davenport R, McFarland J, McPhedran S, Meade M, Morrison D, Pinsent T, Robillard P, Slinger P. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004 Dec;44(12):1774-89. doi: 10.1111/j.0041-1132.2004.04347.x. No abstract available.
- Wagner DP, Draper EA. Acute physiology and chronic health evaluation (APACHE II) and Medicare reimbursement. Health Care Financ Rev. 1984;Suppl(Suppl):91-105.
- Kdigo AJKIS. Work Group. KDIGO clinical practice guideline for acute kidney injury. 2012;2(1):1-138.
- Klimant E, Wright H, Rubin D, Seely D, Markman M. Intravenous vitamin C in the supportive care of cancer patients: a review and rational approach. Curr Oncol. 2018 Apr;25(2):139-148. doi: 10.3747/co.25.3790. Epub 2018 Apr 30.
- Kassem AB, Ahmed I, Omran G, Megahed M, Habib T. Role of ascorbic acid infusion in critically ill patients with transfusion-related acute lung injury. Br J Clin Pharmacol. 2022 May;88(5):2327-2339. doi: 10.1111/bcp.15167. Epub 2022 Jan 7.
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 (Actual)
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
- Respiratory Tract Diseases
- Immune System Diseases
- Lung Diseases
- Hematologic Diseases
- Thoracic Injuries
- Transfusion Reaction
- Wounds and Injuries
- Acute Lung Injury
- Lung Injury
- Transfusion-Related Acute Lung Injury
- Physiological Effects of Drugs
- Molecular Mechanisms of Pharmacological Action
- Protective Agents
- Micronutrients
- Vitamins
- Antioxidants
- Ascorbic Acid
Other Study ID Numbers
- ASTRALI
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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