Impact of Continuous Renal Replacement Therapy on Systemic Hemodynamics and Lactate Clearance in Critically Ill Cirrhotics With Septic Shock.

Consecutive critically ill cirrhotics with septic shock and AKI who give written informed consent will be included in this prospective study. A blood and urine sample (~10 ml) would be stored for assessing the serum cytokine profile, endotoxin levels, NT-Pro BNP, Troponin I levels, urine N-GAL before, 6 hours and at 24 hours after initiation of CRRT. Septic shock will be defined by the presence of two or more diagnostic criteria for the systemic inflammatory response syndrome, proven or suspected infection with hypotension non-responsive to adequate fluid resuscitation assessed by no evidence of stroke volume variation on flow track and need of a vasopressor to achieve a target mean arterial pressure (MAP) of ≥ 65 mm Hg. A record of SVR, SVRI, global ejection fraction, extravascular lung water index and pulmonary vascular permeability index, CVP, IVC diameter and B-lines on ultrasound lung would be recorded. A record of the clearance of lactate at 6, 12 , 24 and daily till recovery or death would be performed. Patients with age less than 18 years, severe known cardiopulmonary disease (structural or valvular heart disease, coronary artery disease, COPD) pregnancy, chronic kidney disease on hemodialysis, extremely moribund patients with an expected life expectancy of less than 24 hours, failure to give informed consent from family members.

Study Overview

• Status: Not yet recruiting
• Conditions: Liver Cirrhosis
• Intervention / Treatment: Other: No intervention

Detailed Description

AIM: Assessment of the impact of CRRT on systemic hemodynamics and microcirculation in critically ill cirrhotics with septic shock and AKI.

Primary Objective To study the impact of continuous renal replacement therapy on systemic hemodynamics (improvement in systemic vascular resistive index, cardiac index) and lactate clearance in critically ill cirrhotics with septic shock.

Secondary Objectives Impact on endothelial function and inflammatory cytokines Impact on renal functions and ammonia Incidence of hemodynamic instability and/or intradialytic hypotension Impact on lung injury scores (as determined by EVLW and PVPI) To study the duration of mechanical ventilation and ICU stay Impact on transplant-free survival To evaluate the improvement in SOFA, MELD and APACHE scores.

Methodology: Consecutive critically ill cirrhotics with septic shock and AKI who give written informed consent will be included in this prospective study. A blood and urine sample (~10 ml) would be stored for assessing the serum cytokine profile, endotoxin levels, NT-Pro BNP, Troponin I levels, urine N-GAL before, 6 hours and at 24 hours after initiation of CRRT. Septic shock will be defined by the presence of two or more diagnostic criteria for the systemic inflammatory response syndrome, proven or suspected infection with hypotension non-responsive to adequate fluid resuscitation assessed by no evidence of stroke volume variation on flow track and need of a vasopressor to achieve a target mean arterial pressure (MAP) of ≥ 65 mm Hg. A record of SVR, SVRI, global ejection fraction, extravascular lung water index and pulmonary vascular permeability index, CVP, IVC diameter and B-lines on ultrasound lung would be recorded. A record of the clearance of lactate at 6, 12 , 24 and daily till recovery or death would be performed. Patients with age less than 18 years, severe known cardiopulmonary disease (structural or valvular heart disease, coronary artery disease, COPD) pregnancy, chronic kidney disease on hemodialysis, extremely moribund patients with an expected life expectancy of less than 24 hours, failure to give informed consent from family members.

Study Design:

Prospective observational cohort study

Study Population: Critically ill cirrhotics with septic shock and AKI undergoing CRRT

Study Period: May 2021- December 2021

Sample size: It will be time based study with a minimum sample size of 50 patients. Currently, there is no study looking at these outcomes in critically ill cirrhotics.

Intervention: (Not a part of the study protocol), Patients on Continuous Renal Replacement Therapy (CRRT) will be enrolled.

Monitoring and Assessment: Hourly till the time patient is on dialysis then as indicated.

Adverse Effects: Worsening of hypotension, sepsis, bleeding, allergic reactions to dailyser, any cardiac side-effects.

Statistical analysis

• All variables shall be expressed in mean (sd) or median (range)
• Variables will be compared by Mann- Whitney U test
• For Categorical variables we will use Chi-Square or Fisher's test
• Survival analysis will be done using cox-proportional regression analysis

Actuarial probability of survival shall be calculated by Kaplan- Meier graph and compared by log- rank test.

Stopping rule: Unstable hemodynamics, worsening of shock and lactic acidosis.

• Study Type: Observational
• Enrollment (Anticipated): 50

Contacts and Locations

Study Locations

• India
  • Delhi
    • New Delhi, Delhi, India, 110070
      • Institute of Liver & Biliary Sciences

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Critically ill cirrhotics with septic shock and AKI undergoing CRRT

Description

Inclusion Criteria:

1. Critically ill cirrhotics undergoing continuous renal replacement therapy.

Exclusion Criteria:

1. Patients with age less than 18 years
2. Severe known cardiopulmonary disease (structural or valvular heart disease, coronary artery disease, COPD)
3. Pregnancy
4. Chronic kidney disease on hemodialysis
5. Extremely moribund patients with an expected life expectancy of less than 24 hours
6. Failure to give informed consent from family members.
7. Hemodynamic instability requiring very high dose of vasopressors.
8. Septic shock would be defined as clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP>=65 mm of Hg and having a serum lactate >2 mmol/L despite adequate volume resuscitation.

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Critically ill cirrhotics with septic shock and AKI undergoing CRRT; Consecutive critically ill cirrhotics with septic shock and AKI who give written informed consent will be included in this prospective study	Other: No intervention; This is an observational study.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Improvement of SVR from baseline by 20% or above 600 and decrease in vasopressors at 24 hours after CRRT initiation.	24 hours

Secondary Outcome Measures

Outcome Measure	Time Frame
Lactate clearance after CRRT initiation	6 hours
Lactate clearance after CRRT initiation	12 hours
Lactate clearance after CRRT initiation	24 hours
Incidence of renal recovery	24 hours
Incidence of dialysis associated complications (hypotension, bleeding, hypothermia, catheter-related blood stream infections would be recorded).	24 hours

Collaborators and Investigators

• Sponsor: Institute of Liver and Biliary Sciences, India

Study record dates

Study Major Dates

• Study Start (Anticipated): June 25, 2021
• Primary Completion (Anticipated): June 30, 2022
• Study Completion (Anticipated): June 30, 2022

Study Registration Dates

• First Submitted: June 25, 2021
• First Submitted That Met QC Criteria: June 25, 2021
• First Posted (Actual): July 2, 2021

Study Record Updates

• Last Update Posted (Actual): July 2, 2021
• Last Update Submitted That Met QC Criteria: June 25, 2021
• Last Verified: June 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Liver Diseases; Fibrosis; Liver Cirrhosis
• Other Study ID Numbers: ILBS-Cirrhosis-41

Drug and device information, study documents

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