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Clinical Trial Details — Status: Recruiting

Administrative data

NCT number NCT05700708
Other study ID # NK-2020-2141
Secondary ID
Status Recruiting
Phase
First received
Last updated
Start date November 15, 2022
Est. completion date July 15, 2024

Study information

Verified date September 2023
Source Postgraduate Institute of Medical Education and Research
Contact Madhumita Premkumar
Phone 01722754777
Email drmadhumitap@gmail.com
Is FDA regulated No
Health authority
Study type Observational

Clinical Trial Summary

Point-of-care echocardiography (POC-Echo) is used to determine left ventricular systolic and diastolic dysfunction (LVDD), inferior vena cava (IVC) dynamics and volume status in cirrhosis and Acute-on-chronic liver failure ACLF accurately. We will assess IVC dynamics, LV systolic function [LV ejection fraction (EF) & cardiac output (CO)], and diastolic dysfunction (E/e', e' and E/A ratio) and urinary biomarkers (cystatin C and NGAL) in patients with cirrhosis and Refractory Ascites.


Description:

The decrease in systemic vascular resistance (SVR) and redistribution of blood volume with reduced intravascular volume compartment and third space fluid losses. Systemic vasodilatation is compensated by an increase in cardiac output (CO) in the initial stages of compensated cirrhosis. However, as the stage of liver cirrhosis progresses to decompensation, more prominent arterial vasodilatation and reduced SVR leads to a fall in CO. Thus, the cardiac homeostat is reset in a cirrhotic hyperdynamic circulation, wherein an increased heart rate, and therefore, increased cardiac output will no longer be able to compensate for the reduced mean arterial pressure (MAP), and decreased blood volumes in central venous territories.18 Consequent activation of vasoconstrictor systems including renin-angiotensin-aldosterone, vasopressin and the sympathetic nervous system comes into play to maintain the intravascular blood volume and pressure. These compensatory pathways cause an increase in sodium and water retention resulting in refractory ascites and hepatorenal syndrome (HRS). In critically ill patients with cirrhosis, the limited cardiac reserve is further stressed, CCM and heart failure may be diagnosed for the first time when the patient develops sepsis or septic shock. Point-of-care echocardiography (POC-Echo) is used to determine left ventricular systolic and diastolic dysfunction (LVDD), inferior vena cava (IVC) dynamics and volume status in cirrhosis accurately. We will assess IVC dynamics, LV systolic function [LV ejection fraction (EF) & cardiac output (CO)], and diastolic dysfunction (E/e', e' and E/A ratio) in patients with cirrhosis ACLF and refractory ascites Definition of CCM is as per updated CCMC criteria of 2020.


Recruitment information / eligibility

Status Recruiting
Enrollment 80
Est. completion date July 15, 2024
Est. primary completion date November 15, 2023
Accepts healthy volunteers No
Gender All
Age group 18 Years to 65 Years
Eligibility Inclusion Criteria: - Cirrhosis of any Etiology - Patient with Refractory Ascites Exclusion Criteria: - Hepatocellular carcinoma - Patients with active variceal bleeding - HIV or severe immunocompromised state - Chronic kidney disease (CKD) on renal replacement therapy (RRT), - Previous transjugular intra hepatic portosystemic shunt (TIPS) - Porto-pulmonary hypertension, - Coronary artery disease - Congenital or valvular heart disease - Prosthetic cardiac valves

Study Design


Intervention

Diagnostic Test:
Echocardiographic assessment
POC-Echocardiography to assess dynamic changes in cardiac output to assess therapeutic responses with albumin, midodrine, diuretics and domiciliary albumin

Locations

Country Name City State
India PGIMER Chandigarh Delhi

Sponsors (1)

Lead Sponsor Collaborator
Postgraduate Institute of Medical Education and Research

Country where clinical trial is conducted

India, 

References & Publications (5)

Adebayo D, Neong SF, Wong F. Refractory Ascites in Liver Cirrhosis. Am J Gastroenterol. 2019 Jan;114(1):40-47. doi: 10.1038/s41395-018-0185-6. — View Citation

Cardenas A, Arroyo V. Refractory ascites. Dig Dis. 2005;23(1):30-8. doi: 10.1159/000084723. — View Citation

Izzy M, VanWagner LB, Lin G, Altieri M, Findlay JY, Oh JK, Watt KD, Lee SS; Cirrhotic Cardiomyopathy Consortium. Redefining Cirrhotic Cardiomyopathy for the Modern Era. Hepatology. 2020 Jan;71(1):334-345. doi: 10.1002/hep.30875. Epub 2019 Oct 11. Erratum — View Citation

Larrue H, Vinel JP, Bureau C. Management of Severe and Refractory Ascites. Clin Liver Dis. 2021 May;25(2):431-440. doi: 10.1016/j.cld.2021.01.010. Epub 2021 Mar 11. — View Citation

Salerno F, Guevara M, Bernardi M, Moreau R, Wong F, Angeli P, Garcia-Tsao G, Lee SS. Refractory ascites: pathogenesis, definition and therapy of a severe complication in patients with cirrhosis. Liver Int. 2010 Aug;30(7):937-47. doi: 10.1111/j.1478-3231.2010.02272.x. Epub 2010 May 21. Erratum In: Liver Int. 2010 Sep;30(8):1244. — View Citation

Outcome

Type Measure Description Time frame Safety issue
Primary Cardiac output measurement by echocardiography after albumin Echocardiographic assessment of cardiac output in L/min will be recorded at least 3 time points, day 0, day 1 and day 2.
The cardiac output at 3 days after enrollment and albumin therapy will also be documented. The Doppler velocity time integral (VTI) method in estimating stroke volume and cardiac output correlates well with results of concurrent thermodilution cardiac output determinations in patients without significant left-sided valvular regurgitation.
Cardiac output(CO), Stroke volume (SV), Heart rate (HR)
CO = [SV * HR]/ 1000
Day 0
Primary Cardiac output measurement by echocardiography after albumin Echocardiographic assessment of cardiac output in L/min will be recorded at least 3 time points, day 0, day 1 and day 2.
The cardiac output at 3 days after enrollment and albumin therapy will also be documented. The Doppler velocity time integral (VTI) method in estimating stroke volume and cardiac output correlates well with results of concurrent thermodilution cardiac output determinations in patients without significant left-sided valvular regurgitation.
Cardiac output(CO), Stroke volume (SV), Heart rate (HR)
CO = [SV * HR]/ 1000
Day 1
Primary Cardiac output measurement by echocardiography after albumin Echocardiographic assessment of cardiac output in L/min will be recorded at least 3 time points, day 0, day 1 and day 2.
The cardiac output at 3 days after enrollment and albumin therapy will also be documented. The Doppler velocity time integral (VTI) method in estimating stroke volume and cardiac output correlates well with results of concurrent thermodilution cardiac output determinations in patients without significant left-sided valvular regurgitation.
Cardiac output(CO), Stroke volume (SV), Heart rate (HR)
CO = [SV * HR]/ 1000
Day 2
Primary Cardiac output measurement by echocardiography after albumin Echocardiographic assessment of cardiac output in L/min will be recorded at least 3 time points, day 0, day 1 and day 2.
The cardiac output at 3 days after enrollment and albumin therapy will also be documented. The Doppler velocity time integral (VTI) method in estimating stroke volume and cardiac output correlates well with results of concurrent thermodilution cardiac output determinations in patients without significant left-sided valvular regurgitation.
Cardiac output(CO), Stroke volume (SV), Heart rate (HR)
CO = [SV * HR]/ 1000
Day 3
Secondary Change in Cystatin C and Neutrophil gelatinase associated lipocalin (NGAL) level day 0
Secondary Change in NT Pro brain natriuretic peptide (BNP) level day 0
Secondary Change in plasma renin activity level day 0
Secondary Change in Galectin-3 level day 0
Secondary IVC size and collapsibility changes after 20% albumin IVC maximum and Minimum diameter and collapsibility index determined by percentage change in IVC diameter will be recorded. Day 0
Secondary IVC size and collapsibility changes after 20% albumin IVC maximum and Minimum diameter and collapsibility index determined by percentage change in IVC diameter will be recorded. Day 2
Secondary Lung Ultrasound score change after 20% Albumin Day 1
Secondary IVC size and collapsibility changes after 20% albumin IVC maximum and Minimum diameter and collapsibility index determined by percentage change in IVC diameter will be recorded. Day 1
Secondary Lung Ultrasound score change after 20% Albumin Day 0
Secondary Lung Ultrasound score change after 20% Albumin Day 2
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