- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04991259
To Evaluate the Safety and Efficacy of Preemptive Administration of Continuous Renal Replacement Therapy in Patients With Acute Liver Failure With Cerebral Edema
To Evaluate the Safety and Efficacy of Preemptive Administration of Continuous Renal Replacement Therapy in Patients With Acute Liver Failure With Cerebral Edema -A Prospective Randomized Controlled Trial
In this prospective randomized controlled trial, investigator aim to evaluate the impact of early initiation of CRRT on outcomes in patients with acute liver failure with cerebral edema and hyperammonemia in improving cerebral edema and clinical outcomes. Investigator also aim to evaluate the effects of early initiation of CRRT on systemic hemodynamics (cardiac output and systemic vascular resistive index, extravascular lung water and lung permeability index), endothelial function and coagulation, microcirculation (as assessed by lactate clearance and central venous oxygen saturation), mitochondrial function. Patients with ALF who meet the inclusion and exclusion criteria.
Group 1: CRRT initiation within the first 12 hours Group 2: CRRT would be initiated i) In patients with worsening hyperammonemia despite two sessions of plasma-exchange ii) Patients meeting renal indications (hyperkalemia, volume overload, oliguria or metabolic acidosis etc)
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Hypothesis: Investigator hypothesize that preemptive administration of continuous renal replacement therapy would be synergistic to plasma-exchange in ameliorating the cytokine storm, cerebral edema and improve outcomes in patients with non-acetaminophen ALF with cerebral edema compared to late initiation.
Aim and Objective -
AIM:
Primary
1) 21-day transplant free survival with Prometheus Secondary
- To compare the improvement effect in cerebral edema and hepatic encephalopathy in both groups
- To study the safety of therapy (incidence of intradialytic hypotension, impairment of coagulation, hypothermia)
- Duration of mechanical ventilation and ICU stay in both groups
- Impact on arterial lactate
- Improvement in SIRS
- Effect on systemic hemodynamics and pulmonary function
- Effect on endotoxin, DAMPS, pro-inflammatory cytokines, endothelial functions and coagulation
Methodology Study Protocol
All patients will be evaluated as follows:
- Clinical history and examination
- Etiology of acute event
- Severity assessment indices
- Complications if any Investigations Arterial blood gas analysis
Hematology
- CBC, Prothrombin time and INR
- Peripheral smear, Retics
- Thromboelastogram(ROTEM)
- S.Fibrinogen level
Biochemistry
- Liver function testing
- Kidney function test
- Arterial ammonia levels
- Serum lactate
- CRP and procalcitonin
- S.Ferritin and LDH
Etiology of acute event:
- Infectious etiology: IgM anti HAV, IgM anti HEV, IgM anti HBc ( If HBsAg +ve), IgM anti HDV ( If HBsAg +ve) , total antiHBc, anti HCV
- Non Infectious etiology: Alcohol binging in last 4 weeks, hepatotoxic drugs, ANA (>1: 80), IgG
Non infectious etiology: Autoimmune markers, copper studies, iron studies, HOMA IR, FBS Imaging USG abdomen with Doppler for spleno-portal axis NCCT abdomen and brain Assessment of cerebral edema
- Optic nerve sheath diameter
- Transcranial doppler
- Electroechocardiogram
Study Population: 60 patients with ALF will be randomized to two groups in 1:1 ratio.
Study Design:
- A randomized controlled study.
- The study will be conducted on patients admitted to Department of Hepatology from May 2021 to March 2023 at ILBS, New Delhi
- Study group will comprise of patients with acute liver failure (ALF) with documented cerebral edema on CT-scan and arterial ammonia >150 ug/dl Study Period: May 2021 to March 2023 Sample Size calculation: Currently there are lack of studies investigating the timing of CRRT in patients with ALF therefore a minimum of 60 patients 30 in each group would be included in the current study.
The detailed cytokine profile, endotoxin assay, markers of endothelial dysfunction and bioenergetics would be performed in a subset of 10 patients in each group.
Intervention: Continuous renal replacement therapy
Monitoring and Assessment: Hourly till the patient is in the intensive care unit then every 7 days for 1 month
Statistical analysis
- All variables shall be expressed in median (range)
- Variables will be compared by Mann- Whitney U test
- For Categorical variables - 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.
Standard medical treatment: All patients will undergo plain CT-scan of the brain to screen for the presence and severity of cerebral edema in the emergency before being shifted to the L-ICU. In the L- ICU, patients will be managed by a multidisciplinary team. Intubation and ventilation will be undertaken for standard indications in addition to the development of grade 3 encephalopathy or evidence of cerebral edema on CT-scan. Ventilation will be managed by fentanyl and propofol along with the use of atracurium for paralysis wherever required. All patients will be monitored constantly for macro-hemodynamics, global tissue perfusion, and microcirculation. The macro-hemodynamic parameters included continuous monitoring of mean arterial pressure (MAP), heart rate and urine output per hour. The real-time monitoring of systemic vascular resistance (SVR), stroke volume variation (SVV), cardiac index (CI) and cardiac output (CO) will be done by a hemodynamic monitor (FloTrac™ system 4.0, Edwards Lifesciences, California, US) wherever feasible. Global tissue perfusion adequacy and indirect assessment of microcirculation will be done by measurement of arterial lactate. Fluid management will be done with crystalloids, with the use of colloids (5% albumin) in patients with severe hypoalbuminemia (serum albumin less than 2.5gm/dl). Norepinephrine will be the primary vasopressor used to target a mean arterial pressure of 65-70 mm of Hg. with adjunctive use of intravenous low dose hydrocortisone and vasopressin in patients not responsive to initial therapy.
Cerebral edema: The monitoring of cerebral edema will be performed measuring the optic nerve sheath diameter (ONSD) in both the eyes using a 7.5 MHz probe every 6-8 hours. Apart from this, routine monitoring of pupillary size and reactions, extensor posturing and plantar reflexes will be performed every 6-8 hrs. Transcranial doppler would be done every 6-8 hours. Patients will receive 3% hypertonic saline as a continuous infusion, initially started at 25ml /hr and titrated 6 hourly to between 5 and 20 mL per hour (maximum 100 ml/hour) to achieve serum sodium levels between 145-150 mmol/L. Intravenous 20% mannitol (1 g/kg IV bolus) over 20 to 30 minutes will be administered to those without renal failure. All patients will in addition receive intravenous N-acetylcysteine for 5 day.Routine electroencephalogram (EEG) will be done for all patients daily to screen for non-convulsive seizures which will be managed by intravenous levetiracetam. Assessment of coagulation will be performed by ROTEM at baseline and subsequently as required.
Protocol for standard-volume plasma-exchange
- Standard-Volume Plasma Exchange: SVPE procedures will be performed using either Spectra Optia (SPO, Terumo BCT, Lakewood, CO, USA) continuous-flow centrifugal apheresis system or Haemonetics MCS+ (Braintree, MA, USA) intermittent flow centrifugal apheresis system via a double-lumen central venous dialysis catheter. All patients will receive plasma-exchange within first 6 hours of admission to the L-ICU along with a target volume of 1.5 to 2.0 plasma volumes per session. The replacement fluid used will be 90% FFP and 10% normal saline.PE will be performed on consecutive days until the desired response is achieved. [using investigator previously published protocol].
- The number of sessions of SVPE in each patient will be decided based on the clinical response to SVPE. Dynamic assessment of the clinical parameters (signs of CE as assessed by pupillary size, reaction, and optic nerve-sheath diameter), INR, lactate and arterial ammonia will be performed at after each TPE. In patients with an improvement in INR, and signs of CE along with a reduction in ammonia at 6 hours which was sustained at 12 and 24 hours post-SVPE, subsequent sessions will be discontinued. PE will also be discontinued in patients who would show worsening in either clinical and/ or biochemical parameters. In patients who will develop adverse events, the PE procedure will be resumed or discontinued depending on the severity of adverse event and its resolution.
Randomization will be done by taking 1:1 ratio by computer-generated sealed envelopes by the clinical trial co-ordinator Group 1-Preemptive CRRT: In patients randomized to early CRRT, CRRT would be initiated within 12 hours of randomization.
Group 2: SMT - In patients randomized to SMT group, CRRT would be initiated as per the existing standard protocol.
in patients with worsening hyperammonemia despite two sessions of plasma-exchange patients meeting renal indications (hyperkalemia, volume overload, oliguria or metabolic acidosis etc).
The time to initiation of CRRT would be recorded in both groups after randomization.
Continuous renal replacement therapy will be administered as continuous venovenous hemodiafiltration (CVVHDF) using Prisma and Prismaflex (Gambro) devices, with blood flows ranging from 150-180 mL/hr and target effluent rates of 20 - 25 mL/kg/hr. Anticoagulation was not used during dialysis. CRRT would be continued until resolution of cerebral edema and in decrease in ammonia levels below 150 ug/dl or in those who develop adverse effects of therapy.
Study Type
Enrollment (Anticipated)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Delhi
-
New Delhi, Delhi, India, 110070
- Institute of Liver & Biliary Sciences
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Patients with acute liver failure defined patients with jaundice which is complicated by encephalopathy and coagulopathy within 4 weeks of the onset of jaundice and without underlying chronic liver disease with documented cerebral edema on CT-scan and arterial ammonia >150 ug/dL.
Exclusion Criteria:
- Age <18 or > 70 years
- Hepatocellular Carcinoma
- Active untreated Sepsis/DIC
- Hemodynamic instability requiring high dose of vasopressors
- Post-resection and malignancy related liver failure
- Coma of non-hepatic origin
- Patients with post renal obstructive AKI, AKI suspected due to glomerulonephritis, interstitial nephritis or vasculitis based on clinical history and urine analysis
- Patients already meeting emergency criteria for immediate initiation of dialysis at the time of randomization (serum potassium>6 meq/lt, metabolic acidosis ph<7.12, acute pulmonary edema, severe volume overload with hypoxemia non-responsive to diuretic treatment)
- Patients transferred from other hospitals who have already been on hemodialysis before their arrival in the intensive care unit
- Extremely moribund patients with an expected life expectancy of less than 24 hours
- Pregnancy related liver failure
- Patients with significant renal dysfunction meeting absolute criteria for initiation of dialysis
- Comorbidities associated with poor outcome (Extrahepatic neoplasia, severe cardiopulmonary disease defined by a New York Heart Association score >3, or oxygen/steroid-dependent chronic obstructive pulmonary disease)
- Patients being taken up for liver transplant
- Refusal to participate in the study.
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 |
---|---|
EXPERIMENTAL: Preemptive CRRT
In patients randomized to early CRRT, CRRT would be initiated within 12 hours of randomization.
|
Continuous renal replacement therapy will be administered as continuous venovenous hemodiafiltration (CVVHDF) using Prisma and Prismaflex (Gambro) devices, with blood flows ranging from 150-180 mL/hr and target effluent rates of 20 - 25 mL/kg/hr.
Anticoagulation was not used during dialysis.
CRRT would be continued until resolution of cerebral edema and in decrease in ammonia levels below 150 ug/dl or in those who develop adverse effects of therapy.
|
ACTIVE_COMPARATOR: Standard Medical Treatment
In patients randomized to SMT group, CRRT would be initiated as per the existing standard protocol.
|
Continuous renal replacement therapy will be administered as continuous venovenous hemodiafiltration (CVVHDF) using Prisma and Prismaflex (Gambro) devices, with blood flows ranging from 150-180 mL/hr and target effluent rates of 20 - 25 mL/kg/hr.
Anticoagulation was not used during dialysis.
CRRT would be continued until resolution of cerebral edema and in decrease in ammonia levels below 150 ug/dl or in those who develop adverse effects of therapy.
In the L- ICU, patients will be managed by a multidisciplinary team.
Intubation and ventilation will be undertaken for standard indications in addition to the development of grade 3 encephalopathy or evidence of cerebral edema on CT-scan.
Fluid management will be done with crystalloids, with the use of colloids (5% albumin) in patients with severe hypoalbuminemia (serum albumin less than 2.5gm/dl).
Norepinephrine will be the primary vasopressor used to target a mean arterial pressure of 65-70 mm of Hg. with adjunctive use of intravenous low dose hydrocortisone and vasopressin in patients not responsive to initial therapy.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
Transplant free survival
Time Frame: Day 21
|
Day 21
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Improvement in cerebral edema and hepatic encephalopathy
Time Frame: Day 5
|
Cerebral edema reduction will be assessed by a composite of clinical signs and bedside monitoring tools which includes
|
Day 5
|
Improvement in cerebral edema and hepatic encephalopathy
Time Frame: Day 14
|
Cerebral edema reduction will be assessed by a composite of clinical signs and bedside monitoring tools which includes
|
Day 14
|
Duration of mechanical ventilation in both groups
Time Frame: 28 days
|
28 days
|
|
Duration of ICU stay in both groups
Time Frame: 28 days
|
28 days
|
|
Impact on arterial lactate
Time Frame: 6 hours
|
Reduction or increase in arterial lactate by atleast 10% from baseline (at initiation of CRRT) would be recorded
|
6 hours
|
Impact on arterial lactate
Time Frame: 12 hours
|
Reduction or increase in arterial lactate by atleast 10% from baseline (at initiation of CRRT) would be recorded
|
12 hours
|
Impact on arterial lactate
Time Frame: 24 hours
|
Reduction or increase in arterial lactate by atleast 10% from baseline (at initiation of CRRT) would be recorded
|
24 hours
|
Impact on arterial lactate
Time Frame: Day 5
|
Reduction or increase in arterial lactate by atleast 10% from baseline (at initiation of CRRT) would be recorded
|
Day 5
|
Impact on arterial lactate
Time Frame: Day 14
|
Reduction or increase in arterial lactate by atleast 10% from baseline (at initiation of CRRT) would be recorded
|
Day 14
|
Improvement in SIRS
Time Frame: Day 5
|
Improvement in SIRS is defined reduction in SIRS by atleast one component or its resolution.
|
Day 5
|
Effect on systemic hemodynamics
Time Frame: 24 hours
|
Delta change in systemic hemodynamics ( as assessed by systemic vascular resistance) after intervention in both groups will be recorded.
|
24 hours
|
Effect on systemic hemodynamics
Time Frame: Day 5
|
Day 5
|
|
Effect on pulmonary function
Time Frame: 24 hours
|
Pulmonary functions (assessed by measurement of extravascular lung water index and pulmonary vascular permeability index and PaO2/Fi02 ratio after intervention in both groups will be recorded.
|
24 hours
|
Effect on pulmonary function
Time Frame: Day 5
|
Pulmonary functions (assessed by measurement of extravascular lung water index and pulmonary vascular permeability index and PaO2/Fi02 ratio after intervention in both groups will be recorded.
|
Day 5
|
Effect on endotoxin.
Time Frame: 5 days
|
The delta change in endotoxin will be recorded.
|
5 days
|
Effect on DAMPS.
Time Frame: 5 days
|
The delta change in DAMPS will be recorded.
|
5 days
|
Effect on pro-inflammatory cytokines.
Time Frame: 12 hours
|
The delta change in pro-inflammatory cytokines will be recorded.
|
12 hours
|
Effect on pro-inflammatory cytokines.
Time Frame: 5 days
|
The delta change in pro-inflammatory cytokines will be recorded.
|
5 days
|
Effect on endothelial functions.
Time Frame: 5 days
|
Effect on endothelial functions would be assessed by measurement of endothelin-1, angiopoietin-2, ADAMTs and von-willebrand factor
|
5 days
|
Effect on coagulation.
Time Frame: 5 days
|
Effect on coagulation would be assessed by incidence of bleeding events, delta change in coagulation parameters as assessed by rotational thromboelastometry
|
5 days
|
To study the safety of therapy (incidence of intradialytic hypotension, impairment of coagulation, hypothermia)
Time Frame: 2 years
|
2 years
|
Collaborators and Investigators
Study record dates
Study Major Dates
Study Start (ANTICIPATED)
Primary Completion (ANTICIPATED)
Study Completion (ANTICIPATED)
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
Other Study ID Numbers
- ILBS-ALF-05
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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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