- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05781243
Normal Saline Versus Lactated Ringer's Solution for Acute Pancreatitis Resuscitation (WATERLAND)
Normal Saline Versus Lactated Ringer's Solution for Acute Pancreatitis Resuscitation, an Open-label Multicenter Randomized Controlled Trial: the WATERLAND Trial
Background: Acute pancreatitis (AP) is an acute inflammatory disease of variable severity. Mild cases have an uncomplicated clinical course, but local and systemic complications occur in one-third of patients and are associated with a longer hospital stay, increased morbidity, increased hospital costs, and increased risk of death. Some evidence suggests that fluid resuscitation with lactated Ringer's solution (LR) may have an anti-inflammatory effect on AP when compared to normal saline (NS), and may be associated with a decrease in severity, but randomized controlled trials showed conflicting results. The WATERLAND trial has been designed to investigate the efficacy and safety of fluid resuscitation using LR as compared with NS in patients with AP.
Methods: The WATERLAND trial is an international multicenter, open-label, parallel-group, randomized, controlled, superiority trial. Patients will be randomly assigned in a 1:1 ratio to receive LR versus NS-based moderate fluid resuscitation. The primary outcome will be moderately severe to severe AP, according to the revision of the Atlanta classification. The primary safety outcome will be a composite variable involving any of the following: fluid overload, acute kidney injury, hyperkalemia, hypercalcemia, or acidosis. A total sample of 720 patients, 360 in the LR group and 360 in the NS group will achieve 90% power to detect a difference between the group proportions of 10%, assuming that the frequency of moderately severe to severe AP in LR group will be 17%. The frequency in the NS group is assumed to be 27% under the null hypothesis and 17% under the alternative hypothesis. The test statistic used is the two-sided Z test with pooled variance set at a 0.05 significance level.
Study Overview
Status
Conditions
Intervention / Treatment
Study Type
Enrollment (Estimated)
Phase
- Phase 4
Contacts and Locations
Study Contact
- Name: Alicia Vaillo-Rocamora, BPHARM
- Phone Number: 0034 965913975
- Email: vailloalicia@gmail.com
Study Locations
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-
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Alicante, Spain, 03010
- Recruiting
- Dr. Balmis General University Hospital
-
Contact:
- Alicia Vaillo-Rocamora, BPHARM
- Phone Number: 0034 965913975
- Email: vailloalicia@gmail.com
-
Principal Investigator:
- Enrique de Madaria, MD PhD
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Patient is 18 years or older
- Diagnosis of acute pancreatitis according to the revision of the Atlanta classification (Banks et al, Gut 2013), which requires at least two of the following three criteria: A) typical abdominal pain, B) increase in serum amylase or lipase levels higher than three times the upper limit of normality, and C) signs of acute pancreatitis in imaging
- Signature of informed consent
Exclusion Criteria:
- New York Heart Association class II heart failure (slight limitation of physical activity; fatigue, palpitations, or dyspnea with ordinal physical activity) or worse, or ejection fraction <50% in the last echocardiography
- Decompensated cirrhosis (Child's class B or C)
- Hyper or hyponatremia (<135 or >145 mEq/L)
- Hyperkalemia (>5 mEq/L)
- Hypercalcemia (albumin or protein-corrected calcium >10.5 mg/dL or 2.62 mmol/L)
- Criteria for moderately severe or severe acute pancreatitis (revision of the Atlanta classification, Banks et al, Gut 2013) at recruitment: any of the following: A) presence of creatinine ≥1.9 mg/dL or ≥170 mmol/l, B) PaO2/FiO2≤300, C) systolic blood pressure <90 mmHg despite initial fluid resuscitation, D) presence of local complications (acute peripancreatic fluid collections, acute necrotic collection, pseudocyst, walled-off necrosis, gastric outlet dysfunction, splenic or portal vein thrombosis, or colonic necrosis), E) exacerbation of previous comorbidity such as coronary artery disease or chronic lung disease, precipitated by the acute pancreatitis
- Signs of volume overload or heart failure at recruitment (peripheral edema, pulmonary rales, or increased jugular ingurgitation at 45º)
- Time from pain onset to arrival to emergency room >12 h
- Time from confirmation of pancreatitis to randomization >8 h
- Chronic pancreatitis defined by a Wirsung duct ≥4mm and/or pancreatic calcifications
- More than 1 previous episode of acute pancreatitis (only 2 episodes of acute pancreatitis are allowed, one of them the present episode)
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Lactated Ringer solution (LR)
LR: Lactated Ringer solution.
Patients in the LR treatment arm will receive fluid therapy based on lactated Ringer's solution for a minimum of 48 hours.
|
Patients in the LR (Lactated Ringer solution) treatment arm will receive fluid therapy based on lactated Ringer's solution for a minimum of 48 hours.
|
Active Comparator: Normal saline (NS)
NS: Normal Saline.
Patients in the NS treatment arm will receive fluid therapy based on normal saline for a minimum of 48 hours.
|
Patients in the NS (Normal Saline) treatment arm will receive fluid therapy based on lactated Ringer's solution for a minimum of 48 hours.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Number of Participants with moderately severe or severe acute pancreatitis
Time Frame: From date of randomization until 30 days after randomization
|
Presence of local complications, exacerbation of previous comorbidity or organ failure, according to the definitions of these complications provided by the revised Atlanta Classification (https://doi.org/10.1136/gutjnl-2012-302779)
|
From date of randomization until 30 days after randomization
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Number of participants with systemic inflammatory response syndrome
Time Frame: At 24 and 48 hours
|
At least 2 criteria: A) pulse >90 beats/min, B) respirations >20/min or arterial blood PaCO2 <32 mm Hg, C) temperature <36°C or >38°C, D) white blood cell count <4,000 cells/mm3 or >12,000 cells/mm3 or >10% bands
|
At 24 and 48 hours
|
Number of systemic inflammatory response syndrome criteria
Time Frame: At 24 and 48 hours
|
The criteria are: A) pulse >90 beats/min, B) respirations >20/min or arterial blood PaCO2 <32 mm Hg, C) temperature <36°C or >38°C, D) white blood cell count <4,000 cells/mm3 or >12,000 cells/mm3 or >10% bands
|
At 24 and 48 hours
|
PAN-PROMISE symptom scale
Time Frame: At 24 and 48 hours (change from baseline)
|
PAN-PROMISE scale: a 7-symptom scale patient-reported outcome (range, 0 to 10 for each symptom; overall range, 0 to 70, with higher scores indicating higher symptom intensity).
Details: https://doi.org/10.1136/gutjnl-2020-320729
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At 24 and 48 hours (change from baseline)
|
Number of participants with local complications
Time Frame: From date of randomization until 30 days after randomization
|
Presence of acute peripancreatic fluid collections, acute necrotic collection, pseudocyst, walled-off necrosis, gastric outlet dysfunction, splenic or portal vein thrombosis, and colonic necrosis according to the revised Atlanta Classification (https://doi.org/10.1136/gutjnl-2012-302779).
|
From date of randomization until 30 days after randomization
|
Number of participants with necrotizing pancreatitis
Time Frame: From date of randomization until 30 days after randomization
|
Presence of acute necrotic collections according to the revised Atlanta Classification (https://doi.org/10.1136/gutjnl-2012-302779).
|
From date of randomization until 30 days after randomization
|
Time to oral refeeding
Time Frame: From date of randomization until 30 days after randomization
|
Days from baseline to oral refeeding
|
From date of randomization until 30 days after randomization
|
Number of participants with invasive treatment
Time Frame: From date of randomization until 30 days after randomization
|
Any of the following: thoracocentesis due to pancreatitis-induced pleural effusion, percutaneous and/or endoscopic drainage of pancreatic or peripancreatic fluid collections or necrosis, endoscopic or surgical necrosectomy, endoscopic retrograde cholangiopancreatography due to A) ruptured common bile duct, B) jaundice caused by compression of the common bile duct, C) main pancreatic duct leakage
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From date of randomization until 30 days after randomization
|
Number of participants with nutritional support
Time Frame: From date of randomization until 30 days after randomization
|
Use of enteral (nasogastric or nasojejunal) or parenteral feeding
|
From date of randomization until 30 days after randomization
|
Number of participants with intensive care unit admission
Time Frame: From date of randomization until 30 days after randomization
|
Admission in the intensive care unit
|
From date of randomization until 30 days after randomization
|
Number of participants with exacerbation of coexisting condition
Time Frame: From date of randomization until 30 days after randomization
|
Exacerbation of pre-existing co-morbidity.
The definition provided by the Revised Atlanta Classification is " Exacerbation of pre-existing co-morbidity, such as coronary artery disease or chronic lung disease, precipitated by the acute pancreatitis is defined as a systemic complication.
In this document, we distinguish between persistent organ failure (the defining feature of severe acute pancreatitis) and other systemic complications, which are an exacerbation of pre-existing co-morbid disease."
(revised Atlanta classification: https://doi.org/10.1136/gutjnl-2012-302779)
For the WATERLAND trial we define exacerbation of pre-existing co-morbidity as
|
From date of randomization until 30 days after randomization
|
Number of participants with any organ failure
Time Frame: From date of randomization until 30 days after randomization
|
Definition according to the revised Atlanta classification (https://doi.org/10.1136/gutjnl-2012-302779):
organ failure is defined by the presence of any of the following criteria: A) kidney failure as a creatinine ≥1.9 mg/dL or >170 micromol/L, B) cardiovascular failure as a systolic blood pressure <90 mmHg despite fluid resuscitation, and C) respiratory failure as a PaO2/FIO2≤300
|
From date of randomization until 30 days after randomization
|
Number of participants with persistent organ failure
Time Frame: From date of randomization until 30 days after randomization
|
Organ failure lasting more than 48h (revised Atlanta classification: https://doi.org/10.1136/gutjnl-2012-302779)
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From date of randomization until 30 days after randomization
|
Number of participants with shock
Time Frame: From date of randomization until 30 days after randomization
|
Systolic blood pressure <90 mmHg despite fluid resuscitation (revised Atlanta classification: https://doi.org/10.1136/gutjnl-2012-302779)
|
From date of randomization until 30 days after randomization
|
Number of participants with respiratory failure
Time Frame: From date of randomization until 30 days after randomization
|
PaO2/FIO2≤300 (revised Atlanta classification: https://doi.org/10.1136/gutjnl-2012-302779)
|
From date of randomization until 30 days after randomization
|
Number of participants with kidney failure
Time Frame: From date of randomization until 30 days after randomization
|
Creatinine ≥1.9 mg/dL or >170 micromol/L (revised Atlanta classification: https://doi.org/10.1136/gutjnl-2012-302779)
|
From date of randomization until 30 days after randomization
|
Mortality (number of participants)
Time Frame: From date of randomization until 30 days after randomization
|
Death
|
From date of randomization until 30 days after randomization
|
Hospital stay
Time Frame: From date of randomization until 30 days after randomization
|
Days from recruitment to discharge from index admission
|
From date of randomization until 30 days after randomization
|
C-reactive protein
Time Frame: At 48 hours from randomization
|
C-reactive protein blood levels
|
At 48 hours from randomization
|
Number of participants with hypovolemia
Time Frame: At 24 and 48 hours from randomization
|
WATERFALL trial criteria for hypovolemia (see https://www.nejm.org/doi/10.1056/NEJMoa2202884)
|
At 24 and 48 hours from randomization
|
Number of participants with fluid overload
Time Frame: At 24 and 48 hours from randomization
|
WATERFALL trial criteria for fluid overload (see https://www.nejm.org/doi/10.1056/NEJMoa2202884)
|
At 24 and 48 hours from randomization
|
Number of participants with acute kidney injury
Time Frame: At 24 and 48 hours from randomization
|
KDIGO criteria: increase in serum creatinine of ≥0.3 mg/dL within 48 hr or ≥50% within 7 days or urine output of <0.5 mL/kg/hr for >6 hr (https://doi.org/10.1159/000339789)
|
At 24 and 48 hours from randomization
|
Number of participants with hyperkalemia
Time Frame: At 24 and 48 hours from randomization
|
Venous potassium>5mEq/L
|
At 24 and 48 hours from randomization
|
Number of participants with hypercalcemia
Time Frame: At 24 and 48 hours from randomization
|
Venous calcium corrected by proteins>10.5mg/dL
or 2.62 mmol/L
|
At 24 and 48 hours from randomization
|
Number of participants with hyperchloremia
Time Frame: At 24 and 48 hours from randomization
|
Venous chloride>106mEq/L
|
At 24 and 48 hours from randomization
|
Number of participants with acidosis
Time Frame: At 24 and 48 hours from randomization
|
Venous blood pH <7.35
|
At 24 and 48 hours from randomization
|
Number of participants with composite safety outcome (primary safety outcome)
Time Frame: At 24 and 48 hours from randomization
|
Fluid overload or acute kidney injury or hyperkalemia or hypercalcemia or hyperchloremia or acidosis
|
At 24 and 48 hours from randomization
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Enrique de-Madaria, MD PhD, Dr. Balmis General University Hospital
Publications and helpful links
General Publications
- de-Madaria E, Sanchez-Marin C, Carrillo I, Vege SS, Chooklin S, Bilyak A, Mejuto R, Mauriz V, Hegyi P, Marta K, Kamal A, Lauret-Brana E, Barbu ST, Nunes V, Ruiz-Rebollo ML, Garcia-Rayado G, Lozada-Hernandez EE, Pereira J, Negoi I, Espina S, Hollenbach M, Litvin A, Bolado-Concejo F, Vargas RD, Pascual-Moreno I, Singh VK, Mira JJ. Design and validation of a patient-reported outcome measure scale in acute pancreatitis: the PAN-PROMISE study. Gut. 2021 Jan;70(1):139-147. doi: 10.1136/gutjnl-2020-320729. Epub 2020 Apr 3.
- Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25.
- de-Madaria E, Buxbaum JL, Maisonneuve P, Garcia Garcia de Paredes A, Zapater P, Guilabert L, Vaillo-Rocamora A, Rodriguez-Gandia MA, Donate-Ortega J, Lozada-Hernandez EE, Collazo Moreno AJR, Lira-Aguilar A, Llovet LP, Mehta R, Tandel R, Navarro P, Sanchez-Pardo AM, Sanchez-Marin C, Cobreros M, Fernandez-Cabrera I, Casals-Seoane F, Casas Deza D, Lauret-Brana E, Marti-Marques E, Camacho-Montano LM, Ubieto V, Ganuza M, Bolado F; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. doi: 10.1056/NEJMoa2202884.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
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
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- Eudract 2023-000010-18
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
- Have enrolled patients in the WATERLAND study.
- The Steering Committee will evaluate the project and decide whether it is of sufficient scientific quality.
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
- ICF
- ANALYTIC_CODE
- CSR
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.
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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