The Iron and Muscle Study

Multicentre Prospective Double-blind Randomised Controlled Trial of the Effect of Intravenous Iron Supplementation and Exercise Training in Iron-deficient, But Not Anaemic, Patients With Chronic Kidney Disease on Exercise Capacity, Physical Function, Fatigue, and Skeletal Muscle Metabolism

This is a multi-center randomized controlled trial that will examine the efficacy of IV iron supplementation when compared to placebo, with and without exercise training, on changes in patient exercise capacity. The study aims to provide sufficient data to inform a power calculation for the definitive study to examine whether IV iron therapy in patients with CKD stages 3-4 (non-dialysis) can improve exercise capacity, muscle metabolism and physical function. Specifically, we propose to examine whether a strategy of IV iron therapy in patients with stages 3-4 CKD who are iron-deficient but NOT anaemic leads to improvements in exercise capacity.

Very little is currently known about the effects of iron deficiency on cardiac or skeletal muscle metabolism in patients suffering from CKD. Nevertheless, it seems likely that iron deficiency will contribute to mitochondrial dysfunction and reduced energy production in cardiac or skeletal muscle of CKD patients, and importantly may contribute to the reduced exercise capacity, physical function and overwhelming fatigue commonly reported in this population. The results of this trial will provide data to ascertain whether intravenous iron therapy might be beneficial to exercise capacity, muscle metabolism, physical function, and fatigue and whether iron repletion enhances the effect of an exercise intervention.

Study Overview

• Status: Completed
• Conditions: Iron-deficiency; CKD Stage 4; CKD Stage 3
• Intervention / Treatment: Drug: Ferinject; Other: Placebo: NaCl (sodium chloride 0.9%)

• Study Type: Interventional
• Enrollment (Actual): 75
• Phase: Phase 4

Contacts and Locations

Study Locations

• United Kingdom
  • London, United Kingdom, SE5 9RS
    • King's College Hospital NHS Foundation Trust

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients with established CKD (Stages 3-4) not on dialysis
• Resting BP ≤ 160/95mmHg
• Men and women aged 18 - 80 years
• Serum ferritin level less than 100μg/L AND/OR transferrin saturation ≤20%
• Haemoglobin 110 - 150 g/L

Exclusion Criteria:

• Pregnancy or breast feeding (Female patients of childbearing age will be asked if there is any possibility they may be pregnant. This is standard of care and no pregnancy test will be requested unless there is doubt about this. IV iron is given to many pregnant patients in standard treatment and there is no evidence of harm to mother or foetus).
• Weight < 50kg
• Known allergy to iron therapy
• Haemochromatosis, porphyria cutanea tarda or history of acquired iron overload
• Intravenous iron within previous 6 weeks
• CRP > 50 mg/L
• Serum phosphate < 0.7 mmol/L.
• Active infection
• Current therapy with ESAs
• Uncontrolled atrial fibrillation
• Use of anticoagulants in those under consideration for muscle biopsy
• Unstable angina or heart attack within the last year
• Presence of solid organ cancer
• Known haemoglobinopathy, myelodysplasia, or myeloma
• Patients with peripheral vascular or musculoskeletal disease, who the investigator deems unable to carry out the 6MWT.
• Known severe aortic stenosis and pacemaker in-situ
• History of severe atopy
• Severe liver disease with serum transaminases > x3 upper limit of normal range according to local laboratory values.
• Severe lung disease with FEV1 known to be <50% predicted in last year
• Known heart failure with a left ventricular ejection fraction <45% in last year
• Any other health condition considered by the local Principal Investigator in which IV iron will be contraindicated.
• Insufficient understanding of the trial

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: TRIPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Treatment; Active study medication Medication name: Ferinject® Active ingredient: Ferric carboxymaltose Dosage form: 50 mg iron/ml solution for injection/infusion. Appearance: Dark brown, non-transparent aqueous solution Excipients: Sodium hydroxide, hydrochloric acid and water for injection Strength/Packaging: Each 2 ml vial contains 100 mg of iron as ferric carboxymaltose. Each 10 ml vial contains 500 mg of iron as ferric carboxymaltose. Each 20 ml vial contains 1,000 mg of iron as ferric carboxymaltose. Manufacturer: Vifor Pharma UK Limited	Drug: Ferinject; Active study medication Medication name: Ferinject® Active ingredient: Ferric carboxymaltose Dosage form: 50 mg iron/ml solution for injection/infusion. Appearance: Dark brown, non-transparent aqueous solution Excipients: Sodium hydroxide, hydrochloric acid and water for injection Strength/Packaging: Each 2 ml vial contains 100 mg of iron as ferric carboxymaltose. Each 10 ml vial contains 500 mg of iron as ferric carboxymaltose. Each 20 ml vial contains 1,000 mg of iron as ferric carboxymaltose. Manufacturer: Vifor Pharma UK Limited
PLACEBO_COMPARATOR: Placebo; Medication name: NaCl (sodium chloride 0.9%) Active ingredient: NaCl (sodium chloride 0.9%) Dosage form: 0.9% w/v NaCl as sterile solution in water for injection Excipients: Water Strength/Packaging: 100 ml container with 100 ml normal saline Manufacturer: As per local hospital supplier	Other: Placebo: NaCl (sodium chloride 0.9%); Medication name: NaCl (sodium chloride 0.9%) Active ingredient: NaCl (sodium chloride 0.9%) Dosage form: 0.9% w/v NaCl as sterile solution in water for injection Excipients: Water Strength/Packaging: 100 ml container with 100 ml normal saline Manufacturer: As per local hospital supplier

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Exercise capacity as measured by 6 minute walk distance (6MWD)	An exercise capacity test	4 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Haemoglobin levels	Haemoglobin	12 weeks
Iron status	Ferritin	12 weeks
Renal function	urea,	12 weeks
VO2 peak test (in a sub-set of participants)	To assess physical capacity	12 weeks
Isokinetic dynamometry (muscle strength)	To assess physical capacity	12 weeks
Functional capacity	sit-to-stand 60 to assess lower limb function	12 weeks
KDQOL-36	To assess quality of life by classifying patient general state of health. 1 - Excellent, 2 - Very Good, 3 - Good, 4 - Fair, 5 - Poor.	12 weeks
Skeletal muscle phosphocreatine recovery halftime (PCr t1/2) on MRI spectroscopy (n=40 patients at baseline and 4 weeks)	To assess skeletal muscle metabolism	12 weeks
The Work and Social Adjustment Scale (WSAS)	To assess quality of life by classifying out more about how participant fatigue impacts on their daily life 0 - Not at all, 1 to 2 - Slightly, 3 to 4 - Definitely, 5 to 6 - markedly and 7 to 8 - Very severely impaired /Cannot work	12 weeks
To assess the impact of iron regulatory genes e.g. HFE, TMPRSS6 etc. on the primary and secondary endpoints of the study (exploratory only)	Patients will be asked if they are willing to provide DNA from a single sample of whole blood to facilitate analysis of up to 90 iron regulatory genes, including HFE and TMPRSS. Iron regulatory gene expression measured by qPCR e.g. Hepcidin, Hemojuvelin, Ferroportin, Trf1 receptor, and iron regulatory proteins-1 & -2.	12 Weeks
Iron Status	TSAT	12 weeks
Renal Function	creatinine	12 weeks
Renal Function	estimated glomerular filtration rate to be used to determine renal function	12 weeks

Collaborators and Investigators

• Sponsor: King's College Hospital NHS Trust
• Collaborators: King's College London; University of Leicester
• Investigators: Principal Investigator: Kate Bramham, Kings College Hospital NHS Foundation Trust

Study record dates

Study Major Dates

• Study Start (ACTUAL): April 26, 2019
• Primary Completion (ACTUAL): December 21, 2021
• Study Completion (ACTUAL): February 21, 2022

Study Registration Dates

• First Submitted: April 3, 2019
• First Submitted That Met QC Criteria: April 27, 2021
• First Posted (ACTUAL): April 28, 2021

Study Record Updates

• Last Update Posted (ACTUAL): March 2, 2022
• Last Update Submitted That Met QC Criteria: February 28, 2022
• Last Verified: February 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Metabolic Diseases; Hematologic Diseases; Anemia, Hypochromic; Anemia; Iron Metabolism Disorders; Anemia, Iron-Deficiency
• Other Study ID Numbers: 234820

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No