Hemoadsorpion in Patients With Septic Shock: Efficacy and Safety Evaluation (HAdSS)
Hemoadsorpion in Patients With Septic Shock: Efficacy and Safety Evaluation. A Pilot Multicenter Randomized Controlled Trial
Hemoadsorpion in Patients With Septic Shock: Efficacy and Safety Evaluation. A Pilot Multicenter Randomized Controlled Trial.
The goal of this clinical trial is the estimation of the efficacy and safety of hemoadsorption procedures (LPS (Lipopolysaccharide) and inflammatory mediators adsorption) in participants with septic shock.
The main questions it aims to answer are:
Does hemoadsorption decrease the severity of MODS (multiple organ disfunction syndrome)?
The study will include participants aged 18 to 80 years with a verified diagnosis of septic shock according to SEPSIS 3 criteria, diagnosed within 12 hours, and a SOFA (sequential organ failure assessment) score of 9 or more.
In addition to Standard of Care (SOC), blood purification, including hemoadsorption, will be used. The minimum waiting time after diagnosis of septic shock and initiation of basic therapy before inclusion of the patient in the study therapy is 4 hours.
The choice of procedure will be based on the EAA (Endotoxin Activity Assay) result:
- for an EAA level of 0.6-0.9, selective lipopolysaccharide (LPS) adsorption with duration from 2 to 10 hours;
- for an EAA level less than 0.6, inflammatory mediator adsorption with duration from 6 to 12 hours.
The choice of a specific adsorbers within the LPS and inflammatory mediator adsorption group will be based on randomization.
The use of LPS adsorption is planned based on randomization: Toramyxin R-20 or Efferon LPS. The use of inflammatory mediator adsorption is planned based on randomization: Jafron (HA 330) or CytoSorb.
Aperçu de l'étude
Statut
Les conditions
Intervention / Traitement
Description détaillée
Every participant will receive 2 adsorption procedures. The second procedure will be initiated no later than 24 hours after the initiation of the first procedure.
LPS adsorption will be performed in 38 participants (Efferon LPS in 19 participants and Toramyxin in 19 participants), two procedures per participant.
Inflammatory mediator adsorption will be performed in 38 participants (Jafron HA 330 in 19 participants and CytoSorb in 19 participants), two procedures per participant.
Sample size calculations were performed separately for each treatment cohort. For the endotoxemia cohort (EAA level of 0.6-0.9), this randomized trial is designed to compare Efferron LPS and Toraymyxin with respect to change in SOFA score at 72 hours.
At present, no universally accepted minimal clinically important difference (MCID) has been established for the SOFA score in participants with septic shock. Therefore, the assumed treatment effect was derived from published evidence and expert clinical judgment.
In the EUPHAS trial, polymyxin B hemoperfusion was associated with a mean reduction in SOFA score of approximately 3.4 points at 72 hours, whereas minimal change was observed in the control group. Similarly, the LASSO study demonstrated substantial improvement in organ dysfunction following endotoxin adsorption therapy.
For the inflammatory mediator adsorption cohort (EAA level less than 0.6), this randomized trial is designed to compare CytoSorb and Jafron HA 330 with respect to change in SOFA score at 72 hours.
In the retrospective study Mehta et al., CytoSorb hemoperfusion was associated with a mean reduction in SOFA score of approximately 2.0 points after treatment in survival group. Similarly, the case series Onuk et al. demonstrated substantial improvement in organ dysfunction following inflammatory adsorption therapy with Jafron HA 330 with a mean reduction in SOFA score of approximately 3.5 points at 72 hours.
A between-group difference of 2.5 SOFA points was considered clinically meaningful for both Endotoxin hemoadsorption and inflammatory mediators hemoadsorption because it represents a substantial proportion of the treatment effect observed in previous hemoperfusion studies and corresponds to a clinically relevant difference in the degree of organ dysfunction improvement.
The sample size for both groups (LPS and inflammatory mediator adsorption) was calculated based on the following assumption: the primary endpoint was the change in SOFA score at 72 hours (ΔSOFA); the expected between-group difference - 2.5 points on the SOFA score; standard deviation of ΔSOFA - 2.5 points; equal allocation ratio (1:1); two-sided significance level (α) of 0.05; statistical power of 80%.
Sample size estimation was performed in R using the power.t.test() function. The calculation yielded a required sample size of 16.7 participants per group. Therefore, a minimum of 17 participants per group (34 participants in total) is required to achieve the planned statistical power.
To account for an anticipated 10% dropout rate, the final sample size will be 19 patients per group (38 participants in total for LPS+ 38 participants in total for Inflammatory mediators adsorption. 76 participants in total).
Type d'étude
Inscription (Estimé)
Phase
- N'est pas applicable
Contacts et emplacements
Coordonnées de l'étude
- Nom: Aleksandr Burov, PHD
- Numéro de téléphone: +79854215478
- E-mail: Aleksander.bour@mail.ru
Lieux d'étude
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Moscow, Russie
- Petrovsky National Research Centre of Surgery
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Contact:
- Maxim Babaev, MD, PHD
- Numéro de téléphone: +79160269066
- E-mail: maxbabaev@mail.ru
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Moscow, Russie
- Bakulev Scientific Center of Cardiovascular Surgery
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Contact:
- Mikhail Yarustovskiy, MD, PHD
- Numéro de téléphone: +79104194682
- E-mail: mbyar@yandex.ru
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Moscow, Russie
- City clinical hospital named after S. S. Yudin, Moscow City Health
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Contact:
- Nikolay Krotenko, PHD
- Numéro de téléphone: +79268664976
- E-mail: npkrotenko@gmail.com
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Moscow, Russie
- City Clinical Hospital No 52, Moscow, Russia
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Contact:
- Rustam Iskhakov
- Numéro de téléphone: +79265317813
- E-mail: stamius@yandex.ru
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Moscow, Russie
- Moscow Multi-disciplinary Clinical Center "Kommunarka"
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Moscow, Russie
- Sklifosovsky Institute of Emergency Care
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Contact:
- Sergei Rei, PHD
- Numéro de téléphone: +79166001362
- E-mail: reysi@sklif.mos.ru
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Rostov-on-Don, Russie
- National Medical Research Centre for Oncology Rostov-on-Don
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Contact:
- Natalia Ushakova, MD, PHD
- Numéro de téléphone: +79185533155
- E-mail: ndu2000@rambler.ru
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Critères de participation
Critère d'éligibilité
Âges éligibles pour étudier
- Adulte
- Adulte plus âgé
Accepte les volontaires sains
La description
Inclusion Criteria:
- Septic shock according to SEPSIS-3 criteria
- Age: 18-80 years
- SOFA ≥9 points
- Diagnosis of septic shock established <12 hours ago
- Invasive hemodynamic monitoring
- Norepinephrine dose >0.2 mcg/kg/min
Exclusion Criteria:
- Absolute neutrophil count less than 500 cells/μL
- Pregnancy
- End-stage heart failure (NYHA stage IV)
- Pulmonary embolism with obstructive shock
- Ongoing bleeding
- Atonic coma
- More than 30 points on the MELD scale, class C on the Child-Pugh scale
- HIV infection
- Burns over 10% of the body surface area
- Patients with oncohematological diseases
- Patients with a recognized palliative status or the definition of "metastatic cancer"
- RRT using membranes with a high cutoff point and increased adsorption capacity within 72 hours from the initiation of the first hemoadsorption procedure
- Use of plasma exchange within 72 hours from the initiation of the first hemoadsorption procedure
Plan d'étude
Comment l'étude est-elle conçue ?
Détails de conception
- Objectif principal: Traitement
- Répartition: Randomisé
- Modèle interventionnel: Affectation parallèle
- Masquage: Double
Armes et Interventions
Groupe de participants / Bras |
Intervention / Traitement |
|---|---|
|
Expérimental: Inflammatory mediatiors adsorption with CytoSorb
Inflammatory mediatiors adsorption with EAA <0,6 with CytoSorb
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Blood purification with Jafron HA 330
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Comparateur actif: Inflammatory mediatiors adsorption with Jafron HA 330
Inflammatory mediatiors adsorption with EAA <0,6 with Jafron HA 330
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Blood purification with Jafron HA 330
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Expérimental: Endotoxin haemoadsorption with Toramyxin PMX 20R
Endotoxin haemoadsorption with EAA [0.6-0.9] with Toramyxin PMX 20R
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Blood purification with Toramyxin PMX 20R
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Comparateur actif: Endotoxin haemoadsorption with Efferon LPS
Endotoxin haemoadsorption with EAA [0.6-0.9] with Efferon LPS
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Blood purification with Efferon LPS
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Que mesure l'étude ?
Principaux critères de jugement
Mesure des résultats |
Description de la mesure |
Délai |
|---|---|---|
|
SOFA (sequential organ failure assessment) score
Délai: Assessed at 72 hours after hemoadsorption initiation
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MODS (multiple organ disfunction syndrome) dynamics majored by SOFA (sequential organ failure assessment) score.
SOFA score ranges from 0 (best) to 24 (worst) points.
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Assessed at 72 hours after hemoadsorption initiation
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Mesures de résultats secondaires
Mesure des résultats |
Description de la mesure |
Délai |
|---|---|---|
|
Lactate level dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Lactate level dynamics (mmol/l)
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Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Total bilirubin level dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Total bilirubin level dynamics (mcmol/l)
|
Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
|
Indirect bilirubin level dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Indirect bilirubin level dynamics (mcmol/l)
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
|
Direct bilirubin level dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Direct bilirubin level dynamics (mcmol/l)
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Ferritin level dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Ferritin level dynamics (mcg/l)
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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28 - days mortality
Délai: Will be calculated for 28 days after hemoadsorption initiation
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28 - days mortality
|
Will be calculated for 28 days after hemoadsorption initiation
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90 - days mortality
Délai: Will be calculated for 90 days after hemoadsorption initiation
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90 - days mortality
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Will be calculated for 90 days after hemoadsorption initiation
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Vasoactive Inotropic Score (VIS) dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
Vasoactive Inotropic Score (VIS) dynamics VIS = dopamine dose (mcg∕kg∕ min ) + dobutamine dose (mcg∕kg∕ min ) + 100 × epinephrine dose (mcg∕kg∕ min ) + 10 × milrinone dose (mcg∕kg∕ min ) + 10,000 × vasopressin dose (units∕kg∕ min ) + 100 × norepinephrine dose (mcg∕kg∕ min ) |
Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
|
Norepinephrine dose dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Norepinephrine dose dynamics (mcg/kg/min)
|
Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Hemodynamic index dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
Hemodynamic index: Mean arterial pressure (MAP) to Vasoactive Inotropic Score (VIS); VIS = dopamine dose (mcg∕kg∕ min ) + dobutamine dose (mcg∕kg∕ min ) + 100 × epinephrine dose (mcg∕kg∕ min ) + 10 × milrinone dose (mcg∕kg∕ min ) + 10,000 × vasopressin dose (units∕kg∕ min ) + 100 × norepinephrine dose (mcg∕kg∕ min ) |
Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
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Horowitz index dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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Arterial oxygen partial pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio (Horowitz index) dynamics
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Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
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Procalcitonin (PCT) level dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
Procalcitonin (PCT) level dynamics (ng/ml)
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
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C- reactive protein (CRP) level dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
C- reactive protein (CRP) level dynamics (mg/l)
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
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NLR (neutrophil-to-lymphocyte ratio) dynamics
Délai: Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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NLR (neutrophil-to-lymphocyte ratio) dynamics
|
Time Frame: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
|
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PLR (Platelet-to-lymphocyte ratio) dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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PLR (Platelet-to-lymphocyte ratio) dynamics
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Assessed at 4 time points: before hemoadsorption initiation (baseline); 24 hours, 48 hours and 72 hours after hemoadsorption initiation
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TNF (Tumor necrosis factor-alpha) level dynamics
Délai: Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
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TNF (Tumor necrosis factor-alpha) level dynamics (pg/ml)
|
Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
|
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IL 6 (Interleukin 6) level dynamics
Délai: Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
|
IL 6 (Interleukin 6) level dynamics (pg/ml)
|
Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
|
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IL 10 (Interleukin 10) level dynamics
Délai: Time Frame: Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
|
IL 10 (Interleukin 10) level dynamics (pg/ml)
|
Time Frame: Assessed at 3 time points: before hemoadsorption initiation (baseline); 48 hours and 72 hours after hemoadsorption initiation
|
|
SOFA (sequential organ failure assessment) dynamics
Délai: Assessed at 4 time points: before hemoadsorption initiatioin (baseline); at 24, 48 and 120 hours after hemoadsorption initiation
|
MODS (multiple organ disfunction syndrome) dynamics majored by SOFA (sequential organ failure assessment) score
|
Assessed at 4 time points: before hemoadsorption initiatioin (baseline); at 24, 48 and 120 hours after hemoadsorption initiation
|
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SOFA 2 (sequential organ failure assessment) dynamics
Délai: Assessed at 5 time points: before hemoadsorption initiatioin (baseline); at 24, 48, 72 and 120 hours after hemoadsorption initiation
|
MODS (multiple organ disfunction syndrome) dynamics majored by SOFA 2 (sequential organ failure assessment) score
|
Assessed at 5 time points: before hemoadsorption initiatioin (baseline); at 24, 48, 72 and 120 hours after hemoadsorption initiation
|
Autres mesures de résultats
Mesure des résultats |
Description de la mesure |
Délai |
|---|---|---|
|
Ventilator-free days
Délai: Will be calculated for 28 days after hemoadsorption initiation
|
Ventilator-free days
|
Will be calculated for 28 days after hemoadsorption initiation
|
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Vasopressor-free days
Délai: Will be calculated for 28 days after hemoadsorption initiation
|
Vasopressor-free days
|
Will be calculated for 28 days after hemoadsorption initiation
|
|
Dialysis-free days
Délai: Will be calculated for 28 days after hemoadsorption initiation
|
Dialysis-free days
|
Will be calculated for 28 days after hemoadsorption initiation
|
|
Hospital length of stay
Délai: Will be calculated for 28 days after hemoadsorption initiation
|
Hospital length of stay
|
Will be calculated for 28 days after hemoadsorption initiation
|
|
Intensive care unit (ICU) length of stay
Délai: Will be calculated for 28 days after hemoadsorption initiation
|
Intensive care unit (ICU) length of stay
|
Will be calculated for 28 days after hemoadsorption initiation
|
|
AEs (adverse events)
Délai: Serious AEs will be reported up to Day 28
|
The safety will be assessed by analysing the number of adverse events (AEs) where causal relationship with the intervention cannot be excluded, up until Day 28.
|
Serious AEs will be reported up to Day 28
|
Collaborateurs et enquêteurs
Collaborateurs
Les enquêteurs
- Directeur d'études: Denis Protsenko, MD, PHD, Moscow Multi-disciplinary Clinical Center "Kommunarka"
Publications et liens utiles
Publications générales
- Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, Malcangi V, Petrini F, Volta G, Bobbio Pallavicini FM, Rottoli F, Giunta F, Ronco C. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009 Jun 17;301(23):2445-52. doi: 10.1001/jama.2009.856.
- Onuk S, Akin AK, Sari A, Gundogan K, Baskol G, Dogru K, Sungur M. The Clinical and Laboratory Efficacy of HA 330 Treatment Combined with Continuous Renal Replacement Therapy in Septic Shock Patients: A Case Series. Blood Purif. 2023;52(2):140-147. doi: 10.1159/000528150. Epub 2023 Jan 12.
- Mehta Y, Mehta C, Kumar A, George JV, Gupta A, Nanda S, Kochhar G, Raizada A. Experience with hemoadsorption (CytoSorb(R)) in the management of septic shock patients. World J Crit Care Med. 2020 Jan 31;9(1):1-12. doi: 10.5492/wjccm.v9.i1.1. eCollection 2020 Jan 31.
- Rey S, Kulabukhov VM, Popov A, Nikitina O, Berdnikov G, Magomedov M, Kim T, Masolitin S, Ignatenko O, Krotenko N, Marysheva A, Chaus N, Ohinko L, Mendibaev M, Chumachenko A, Pisarev V. HEMOPERFUSION USING THE LPS-SELECTIVE MESOPOROUS POLYMERIC ADSORBENT IN SEPTIC SHOCK: A MULTICENTER RANDOMIZED CLINICAL TRIAL. Shock. 2023 Jun 1;59(6):846-854. doi: 10.1097/SHK.0000000000002121. Epub 2023 Apr 6.
- Klein DJ, Foster D, Walker PM, Bagshaw SM, Mekonnen H, Antonelli M. Polymyxin B hemoperfusion in endotoxemic septic shock patients without extreme endotoxemia: a post hoc analysis of the EUPHRATES trial. Intensive Care Med. 2018 Dec;44(12):2205-2212. doi: 10.1007/s00134-018-5463-7. Epub 2018 Nov 23.
Dates d'enregistrement des études
Dates principales de l'étude
Début de l'étude (Estimé)
Achèvement primaire (Estimé)
Achèvement de l'étude (Estimé)
Dates d'inscription aux études
Première soumission
Première soumission répondant aux critères de contrôle qualité
Première publication (Réel)
Mises à jour des dossiers d'étude
Dernière mise à jour publiée (Réel)
Dernière mise à jour soumise répondant aux critères de contrôle qualité
Dernière vérification
Plus d'information
Termes liés à cette étude
Termes MeSH pertinents supplémentaires
Autres numéros d'identification d'étude
- HAdSS
Plan pour les données individuelles des participants (IPD)
Prévoyez-vous de partager les données individuelles des participants (DPI) ?
Description du régime IPD
Délai de partage IPD
Critères d'accès au partage IPD
Type d'informations de prise en charge du partage d'IPD
- PROTOCOLE D'ÉTUDE
- SÈVE
- RSE
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