Administrative information
Title {1} | Liver-HERO: Hepatorenal Syndrome-acute kidney injury (HRS-AKI) treatment with transjugular intrahepatic portosystemic shunt in patients with cirrhosis. A randomized controlled trial |
Trial registration {2a and 2b}. | Clinicaltrials.gov identifier: NCT05346393. Registered on 26th of April 2022, https://clinicaltrials.gov/ct2/show/NCT05346393 |
Protocol version {3} | Version V01 of 03-AUG-2022 |
Funding {4} | German Research Fundation (Deutsche Forschungsgemeinschaft, DFG) Funding number: 431667134 Reference number: RI 3205/1–1 |
Author details {5a} | Cristina RIPOLL, Clinic for Internal Medicine IV, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Stephanie PLATZER, Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Philipp FRANKEN, Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Rene ASCHENBACH, Department of Radiology, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Ulrike SCHUHMACHER, Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Andreas WIENKE, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg Andreas STALLMACH Clinic for Internal Medicine IV, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Isabella SCHILLER, Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Jörg STEIGHARDT, Coordinating Center for Clinical Studies, University Medicine Halle (Saale), Martin-Luther-University Halle-Wittenberg, Germany Alexander ZIPPRICH Clinic for Internal Medicine IV, Jena University Hospital, Friedrich-Schiller-University Jena, Germany Liver-HERO Study Group |
Name and contact information for the trial sponsor {5b} | Friedrich-Schiller-University; sponsor representative Prof. Dr. Cristina Ripoll, Jena University Hospital, Clinic for Internal Medicine IV (Gastroenterology, Hepatology, Infectiology, Interdisciplinary Endoscopy), Am Klinikum 1, 07,747 Jena Tel: + 49 3641 9–32 42 29 Fax: + 49 3641 9–32 42 22 Cristina.Ripoll@med.uni-jena.de |
Role of sponsor {5c} | The funder of the study (Deutsche Forschungsgemeinschaft, DFG) has no direct role in the design of the study, the writing of the protocol nor the decision to submit the report. The sponsor of the study is the Friedrich Schiller University, represented by the PI of the study, Prof. Cristina Ripoll, and who is responsible for every step of the trial. |
Introduction
Background and rationale {6a}
Objectives {7}
Trial design {8}
Methods: participants, interventions, and outcomes
Study setting {9}
Eligibility criteria {10}
Inclusion criteria
Exclusion criteria
Eligibility criteria for participating sites and investigators
Who will take informed consent? {26a}
Additional consent provisions for collection and use of participant data and biological specimens {26b}
Interventions
Explanation for the choice of comparators {6b}
Intervention description {11a}
Criteria for discontinuing or modifying allocated interventions {11b}
Strategies to improve adherence to interventions {11c}
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Massive bleeding requiring placement of an ELLA Danis stent or Sengstaken-Blakemore or Linton balloon (emergency TIPS)
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Esophageal variceal bleeding (in patients with Child–Pugh B 7–9 points and active bleeding at endoscopy or patients with Child–Pugh C 10–13 points) (pre-emptive TIPS)
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Recurrent esophageal bleeding despite adequate secondary prophylaxis with beta-blockers and endoscopic band ligation
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Refractory ascites as defined by the IAC (see Ch. 14.3) [32]
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Recurrent ascites as defined by the need of 3 large paracenteses within 3 months (in a stable situation). Only paracentesis that takes place in a stable situation, namely without concurrent infection, without AKI, without bleeding, etc., will be considered [23].
Relevant concomitant care permitted or prohibited during the trial {11d}
Provisions for post-trial care {30}
Outcomes {12}
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Reversal of HRS-AKI at 3 and 12 months (vs baseline), defined as the return of serum creatinine level within 0.3 mg/dl (26 µmol/L).
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Partial response to treatment at 3 and 12 months (vs baseline), defined as reduction of at least one AKI stage with decrease of serum creatinine to ≥ 0.3 mg/dl (26 µmol/L) above the baseline value.
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3-month liver transplant-free survival
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In-hospital, 28-day, and 90-day survival
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Development of cirrhosis-associated complications (further decompensation) during follow-up: overt hepatic encephalopathy, refractory or recurrent ascites, dilutional hyponatremia, new AKI-HRS, variceal bleeding
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Requirement of TIPS implantation or TIPS revision during follow-up. The accepted indications for TIPS implantation/revision are◦Pre-emptive TIPS for variceal bleeding in patients with Child–Pugh C cirrhosis (≤ 13 points) or Child–Pugh B > 7 points cirrhosis with active bleeding at endoscopy◦Recurrence of variceal bleeding in Child–Pugh A or B 7 points patients or Child–Pugh B patients without active bleeding at endoscopy despite adequate secondary prophylaxis with beta-blockers and endoscopic band ligation◦Refractory ascites—this diagnosis can only be established if the patient is in a stable situation without complications such as bleeding and infection◦Recurrent ascites—this diagnosis can only be established if the patient is in a stable situation without complications such as bleeding and infection◦Additionally, TIPS revision can be undertaken if there is a clinical suspicion of TIPS dysfunction
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Development of acute on chronic liver failure (ACLF) during follow-up
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Length of in-hospital-stay
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Relative changes in HrQoL (as measured by SF36 and Chronic Liver Disease Questionnaire (CLDQ)) at 3 and 12 months (vs. baseline)
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The incidence of adverse events in the TIPS patients compared to standard of care (with specific focus on ACLF and heart failure)
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Need for renal replacement therapy
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Recurrence of HRS-AKI after treatment at 3 and 12 months
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Impact of the presence of intrinsic nephropathy as assessed by cystatin C and Urine neutrophil gelatinase-associated lipocalin (UnGAL) on outcomes
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Association of pathophysiological mechanisms of cirrhosis with outcomes (in further studies)
Participant timeline {13}
Pre-screening within SoC/confirmation of HRS-AKI diagnosis | Screening/baseline | FU days 1–5 | FU days 12 and 19 | FU day 30 (1 MFU) | FU 2 months (2 MFU) | FU 3 months (3 MFU) | FU 6 and 9 months (6 MFU, 9 MFU) | FU 12 months (12 MFU) | |
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Medical history/anamnesisa | X | X | |||||||
Demographic data | X | ||||||||
Physical examinationb | X | X | X | X | X | X | X | X | X |
Routine laboratory examinationc | X | X | X | X | X | X | X | X | X |
24-h urine | X | X | |||||||
uETG/alcohol consumption | X | X | X | X | X | X | X | ||
Echocardiography | X | ||||||||
Abdominal ultrasound | X | X | X | X | |||||
Diagnostic paracentesis | X | ||||||||
Chest-X-ray | X | ||||||||
Inclusion/exclusion criteria | X | ||||||||
ICF | X | ||||||||
Randomization | X | ||||||||
Blood and urine sampling | X | X (D3) | X | X | X | X | |||
Optional ascites sampling | X | X (D3) | X | X | X | X | |||
Optional stool sampling | X | X | X | X | |||||
Terlipressin/albumin treatmentd | X | # | |||||||
TIPS | X | Angioe | |||||||
HrQoL Questionnaires (SF-36, CLDQ) | X | X | X | ||||||
AE/SAEs | X | ||||||||
Length of in-hospital stay | X | ||||||||
Liver transplantation performed | X | ||||||||
Requirement of renal replacement therapy | X |