Comparison of Angiotensin II to Standard Dose Vasopressors on Change in Arterial Elastance (Ang2)

Comparison of Angiotensin II to Standard Dose Vasopressors on Change in Arterial Elastance in Cirrhotic Patients With Vasodilatory Shock: A Prospective, Randomized Controlled Trial

A study to see whether a medication called Angiotensin II works better than the routinely used medication to raise blood pressure in people with liver disease who are experiencing a serious drop in blood pressure.

The investigators want to find out if Angiotensin II can help the heart and blood vessels work together more effectively than standard treatments.

Study Overview

• Status: Active, not recruiting
• Conditions: Septic Shock; Cirrhosis; Acute Kidney Injury; Vasodilatory Shock
• Intervention / Treatment: Drug: Giapreza

Detailed Description

Sepsis and septic shock remain associated with significant mortality, especially in cirrhotic where the mortality with septic shock exceeds 70%. Cirrhotic cardiomyopathy is a well-recognized consequence of advanced liver dysfunction and is associated with a hyperdynamic circulatory state due to vasoplegia in this population. Our group has shown septic patients with cirrhosis had higher LV systolic function as assessed by Left ventricle Ejection fraction (LVEF %), stroke volume and cardiac output with a significantly higher percentage of patients with hyperdynamic state (LVEF > 70%) than those without cirrhosis.

The investigators measured arterial elastance and ventricular elastance using echocardiography and found cirrhotic patient to have significantly lower arterial elastance with higher ventricular elastance. AII (Angiotensin II) exert its effect after the hydrolysis of Ang-1 by angiotensin converting enzyme (ACE) and is the principal product of the renin-angiotensin-aldosterone system. Advance cirrhosis is associated with reduction in Ang II levels accompanied by an increased Ang-(1-7)/Ang II ratio in the splanchnic circulation may be, at least in part, responsible for changes in vascular splanchnic tone. In addition, the relative decrease in Ang II compared to Ang (1-7), the vasodilator component of RAS causes hyperdynamic circulation from lower SVR in cirrhotic. This study also showed that with progression of liver disease leads to continual splanchnic vasodilation from higher Ang (1-7)/Ang II ratio. In advance stages this resultant hyperdynamic circulation is still insufficient to compensate for the effective arterial hypovolemia. Similar finding was observed in our large study, where the VAC was significantly lower in cirrhotic with sepsis shock despite elevation in LV elastance compared to non-cirrhotic with septic shock.

Angiotensin II, a naturally occurring octapeptide hormone increases blood pressure through various mechanisms, including vasoconstriction of peripheral vessels, potentiation of antidiuretic hormone (ADH) and adrenocorticotropin hormone (ACTH) release, and direct actions on postganglionic sympathetic fibers. The external Ang II administration will be able to reverse the altered Ang (I-7)/Ang II ratio in systemic circulation reversing vasodilation. The investigators hypothesize that external administration of Ang II will cause a higher increase in SVR in cirrhotic with septic shock compared to Standard of Care (SOC) by decreasing arterial elastance restoring non-invasive arterial ventricular coupling.

• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Early Phase 1

Contacts and Locations

Study Locations

• United States
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • The Cleveland Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age ≥ 18 years at the time of enrollment
• Septic shock as defined by Sepsis-3 criteria (highly suspected or confirmed infection, requiring norepinephrine to maintain a MAP ≥ 65 mmHg, and serum lactate > 2 mmol/L after adequate fluid resuscitation) within a 48 hour window prior to enrollment
• Confirmed cirrhotic patient (Radiological/Biopsy/Physician confirmed)
• Preserved cardiac function as assessed using point-of-care ultrasonography or a non-invasive hemodynamic monitoring device with either LVOT VTI > 18 cm or stroke volume > 50 ml Within 48 hours of onset of shock.
• Standard of care vasopressors are at a norepinephrine equivalent of 15 mcg/min

Exclusion Criteria:

• Declined consent.
• Pregnancy
• CKD-Stage IV/V
• ESRD on long-term hemodialysis
• On Dialysis or planned dialysis to be initiated within 24 hours of study of enrollment.
• Clinically determined to have primarily hepatorenal syndrome.
• On other vasoactive medication (phenylephrine, Terlipressin, epinephrine, dobutamine, dopamine)
• Hemorrhagic, obstructive, or hypovolemic shock is not the primary cause of shock based on clinical judgement.
• DNR
• Patients declared Brain dead.
• Anticipated death within 48 hours of enrollment
• Echocardiographic windows not available
• Acute mesenteric Ischemia
• Active gastrointestinal bleeding
• Active cardiac ischemic event defined as NSTEMi, STEMI
• Acute DVT/Pulmonary embolism/Portal vein thrombosis
• > 48 h since initiation of vasopressor agent
• Cardiac function assessment show LVOT VTI < 18 cm or stroke volume < 50 ml/min
• Norepinephrine equivalent dose > 50mcg/min

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Angiotensin II; Angiotensin II will be continued for 24 hours and then discontinued, and SOC vasopressors resumed according to institutional practices.	Drug: Giapreza; 2.5 mg/mL; Other Names: Angiotension II
No Intervention: Standard of Care; Fixed-dose vasopressin and standard of care vasopressors increased as per institutional guidelines according to MAP targets.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in arterial elastance	Change in arterial elastance will be measure by echocardiography at baseline, 6 hours and 24 hours. Dynamic arterial elastance will be calculated as the ratio between pulse pressure variation and stroke volume variation obtained from arterial line waveform.	6 hours
Change in arterial elastance	Change in arterial elastance will be measure by echocardiography at baseline, 6 hours and 24 hours. Dynamic arterial elastance will be calculated as the ratio between pulse pressure variation and stroke volume variation obtained from arterial line waveform.	24 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in arterial ventricular coupling	Change in arterial ventricular coupling will be measured by echocardiogram at baseline, 6 hours and 24 hours. The ventricular-arterial coupling will be assessed using previously validated method where Left ventricular end-systolic elastance will be calculated by a modified single-beat method employing systolic and diastolic pressure from the arterial line, echo-Doppler stroke volume (SV), echo-derived ejection fraction (EF) and an estimated normalized ventricular elastance at arterial end-diastole (E(Nd)): E(es(sb)) = [P(d) - (E(Nd(est)) x P(s) x 0.9)[/(E(Nd(est)) x SV).	6 hours
Change in arterial ventricular coupling	Change in arterial ventricular coupling will be measured by echocardiogram at baseline, 6 hours and 24 hours. The ventricular-arterial coupling will be assessed using previously validated method where Left ventricular end-systolic elastance will be calculated by a modified single-beat method employing systolic and diastolic pressure from the arterial line, echo-Doppler stroke volume (SV), echo-derived ejection fraction (EF) and an estimated normalized ventricular elastance at arterial end-diastole (E(Nd)): E(es(sb)) = [P(d) - (E(Nd(est)) x P(s) x 0.9)[/(E(Nd(est)) x SV).	24 hours
Change in norepinephrine equivalent dose	The change in norepinephrine equivalent dose at (6 hours and 24 hours) using the following formula6 Norepinephrine dose (µg/kg/min) + epinephrine dose (µg/kg/min) + 1/150 × dopamine dose (µg/kg/min) + 1/10 × phenylephrine dose (µg/kg/min) + 2.5 × vasopressin dose (U/min)	6 hours
Change in norepinephrine equivalent dose	The change in norepinephrine equivalent dose at (6 hours and 24 hours) using the following formula6 Norepinephrine dose (µg/kg/min) + epinephrine dose (µg/kg/min) + 1/150 × dopamine dose (µg/kg/min) + 1/10 × phenylephrine dose (µg/kg/min) + 2.5 × vasopressin dose (U/min)	24 hours
Change in renal perfusion index	Improvement in renal perfusion index (Renal Resistive index) at (6 hours and 24 hours). The Doppler-based renal restrictive index (RI) will be used for measurement using spectral Doppler at the arcuate arteries or interlobar arteries. The formula for calculating the RI is: RI = (Peak Systolic Velocity - End Diastolic Velocity) / Peak Systolic Velocity. The normal range for the RI is 0.50 to 0.70, and elevated values are associated with poorer prognosis in various renal disorders and renal transplant outcomes.	6 hours
Change in renal perfusion index	Improvement in renal perfusion index (Renal Resistive index) at (6 hours and 24 hours). The Doppler-based renal restrictive index (RI) will be used for measurement using spectral Doppler at the arcuate arteries or interlobar arteries. The formula for calculating the RI is: RI = (Peak Systolic Velocity - End Diastolic Velocity) / Peak Systolic Velocity. The normal range for the RI is 0.50 to 0.70, and elevated values are associated with poorer prognosis in various renal disorders and renal transplant outcomes.	24 hours
Evaluation of 28 day renal replacement therapy free survival	The number of days alive free of renal-replacement therapy at 28 days	28 days after hospital discharge
Change in Renin levels	A blood sample will be obtained at two time points. The first sample will be obtained when the participant is randomized but before infusion in initiated. The second sample will be obtained at 24 hours after the initiation of the drug. Plasma Renin Activity (PRA) is measured in ng/mL/h.	24 hours
Change in Angiotension II levels	A blood sample will be obtained at two time points. The first sample will be obtained when the participant is randomized but before infusion in initiated. The second sample will be obtained at 24 hours after the initiation of the drug. Angiotensin II will be expressed in ng/dL.	24 hours
Change in Microcirculation	Tissue oxygen saturation (StO₂) will be measured using near-infrared spectroscopy (NIRS) at the thenar eminence. Microvascular reactivity will be assessed using a vascular occlusion test (VOT). Dynamic variables derived from the VOT will include baseline StO₂, minimum StO₂ during occlusion, and reperfusion slope.	6 hours
Change in Microcirculation	Tissue oxygen saturation (StO₂) will be measured using near-infrared spectroscopy (NIRS) at the thenar eminence. Microvascular reactivity will be assessed using a vascular occlusion test (VOT). Dynamic variables derived from the VOT will include baseline StO₂, minimum StO₂ during occlusion, and reperfusion slope.	24 hours

Collaborators and Investigators

• Sponsor: The Cleveland Clinic
• Collaborators: Innoviva Specialty Therapeutics
• Investigators: Principal Investigator: Siddharth Dugar, M.D., The Cleveland Clinic

Study record dates

Study Major Dates

• Study Start (Actual): November 15, 2024
• Primary Completion (Estimated): January 1, 2028
• Study Completion (Estimated): January 1, 2028

Study Registration Dates

• First Submitted: February 19, 2026
• First Submitted That Met QC Criteria: April 28, 2026
• First Posted (Actual): May 5, 2026

Study Record Updates

• Last Update Posted (Actual): May 5, 2026
• Last Update Submitted That Met QC Criteria: April 28, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Urogenital Diseases; Pathologic Processes; Male Urogenital Diseases; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Infections; Sepsis; Systemic Inflammatory Response Syndrome; Inflammation; Renal Insufficiency; Shock; Pathological Conditions, Signs and Symptoms; Acute Kidney Injury; Fibrosis; Shock, Septic; Giapreza; angiotensin II, Phe(4)-
• Other Study ID Numbers: 24-913

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: After the study is completed, de-identified data and study documents may be shared on ClinicalTrials.gov in accordance with institutional policies and regulatory requirements.
• IPD Sharing Time Frame: Starting in January 2029.
• IPD Sharing Access Criteria: Researchers can access the information on clinicaltrials.gov.
• 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: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: Yes