Pancreatic Necrosis Clinical Trial
Official title:
Study of Plasma mitDNA in Predicting Pancreatic Necrosis in Acute Pancreatitis
Multiple predictors have been used for early pancreatic necrosis, prediction, detection, and monitoring. These include clinical score systems and circulating biomarkers. Ranson and APACHE II score systems are widely used albeit complex and time-consuming. Recently, the role of circulating biomarkers . Of these novel biomarkers, only CRP has been used routinely in cases of pancreatic necrosis prediction. Mitochondrial DNA (mtDNA) is an extra chromosomal genome occurring in the mitochondria of eukaryotic cells. High levels of mtDNA suggest the presence of pancreatic necrosis and close observation should be given to avoid the development of SAP and pancreatitis infection.
Acute pancreatitis (AP) is inflammation of the pancreas that can become a fatal disease or
lead to severe complications . It is characterized clinically by abdominal pain and by
increased pancreatic enzyme levels in the blood or urine. Gallstone migration and alcohol
abuse are the two major risk factors for AP in humans . According to the updated Atlanta
classification, AP is generally divided into mild, moderate or severe pancreatitis according
to the presence or absence of multiple organ failure (MOF) or local or systemic complications
. Mild pancreatitis has a good prognosis with rapid recovery. The late consequences of AP
include impaired pancreatic exocrine function and glucose tolerance, diabetes and development
of chronic pancreatitis . Moderately severe AP is characterized by the presence of transient
organ failure, local complications or exacerbation of comorbid disease . About one-third of
patients with AP develop severe necrotizing pancreatitis with persistent MOF and a high
mortality rate. The main goals in the clinical management of AP are adequate fluid
resuscitation and the prevention of MOF . Both genetic and environmental factors affect the
development and severity of pancreatitis .
Although the pathogenic mechanisms remain largely unknown, increasing evidence suggests that
damage-associated molecular pattern molecules (DAMPs) play a central role in the pathogenesis
of AP. DAMPs link local tissue damage to systemic inflammation response syndrome (SIRS),
which, if severe or sustained, can lead to subsequent MOF and even death . Most DAMPs are
recognized by membrane-bound and cytosolic pattern recognition receptors (PRRs) expressed by
both immune and nonimmune cell types. This triggers downstream signaling and manifests as
sterile inflammation .
The development of AP involves a complex cascade of events , which start with injury or
disruption of the pancreatic acini, which then permits the leakage of active pancreatic
enzymes including amylolytic, lipolytic and proteolytic enzymes that destroy local tissues.
This results in edema, vascular damage, hemorrhage and cell death . In addition to oxidative
stress and calcium overload , hypotension and low acinar pH contribute to these initiation
processes. After initial production of active pancreatic enzymes, local cell death and
systemic inflammation ensue.
Mitochondria, the energy factories of cells, regulate pancreatic cell death through control
of the production of adenosine triphosphate (ATP) and reactive oxygen species (ROS), as well
as calcium . Dysfunction of mitochondrial calcium uptake and efflux, including elevation of
cytosolic calcium from the endoplasmic reticulum, can cause mitochondrial calcium overload,
which leads to enhanced generation of mitochondrial ROS and mitochondrial membrane
permeabilization. Mitochondria dysfunction-mediated oxidative injury results in endoplasmic
reticulum stress, lysosomal damage and the release of proteases (for example, cathepsin and
trypsin) to degrade cytosolic proteins that cause pancreatic acinar cell death . Dead, dying
and injured pancreatic acinar cells release intra-cellular contents, including DAMPs (for
example, high mobility group box 1 [HMGB1], DNA, histones and ATP), which in turn promote
infiltration of various immune cells (for example, neutrophils, monocytes and macrophages)
and activation of inflammatory signaling pathways.
The severity of experimental AP correlates with the extent and type of cell injury and death.
Although multiple forms of cell death exist in physiological and pathological conditions ,
necrosis and apoptosis are the most widely studied types in both clinical and experimental AP
. Necrotic cells are capable of activating proinflammatory and immunostimulatory responses by
releasing DAMPs and other molecules, whereas apoptosis is usually considered immunologically
silent because the cytoplasmic content is packaged in apoptotic bodies and these
membrane-bound cell fragments are rapidly taken up and degraded by phagocytes or autophagy .
Why is the immune system so concerned with cell death? The current notion is that DAMPs
released or exposed from dying or dead cells contribute to inflammatory and immune responses
to remove dead cells and initiate tissue healing . Failure of this control mechanism can lead
to uncontrolled inflammation and serious diseases such as sepsis, arthritis, atherosclerosis,
lupus and cancer.
Mitochondria are now recognized not only as central players in cell death but also as an
important source of DAMPs. mit-DAMPs, including mitDNA, N-formyl peptides, transcription
factor A (TFAM, a mitochondrial HMGB1 homologue) and ROS, play emerging roles in inflammation
by the activation of neutrophils, monocytes and macrophages .
The clinical course of AP is generally mild; however, nearly 25% of patients progress into
severeAP (SAP) which consists of organ failure and/or pancreatic necrosis (PNec) . Although
advances in the diagnosis and management have been made, AP remains a major healthissue to
the society, PNec is a major complication of AP which manifests as non-opacified parenchyma
with intravenous contrast, as identified via contrast-enhanced CT (CECT) scan. Patients with
PNec are more likely to develop pancreatic infection and suffer a greater risk for mortality
. Currently,CECT scans remain the "gold standard" to diagnosis PNec clinically . However, the
extent of PNec is best seen about 3 days after the presentation of disease and may be missed
in early CT scan. In addition, repeated CT scanningis not convenient to monitor changes in
necrosis, most not ably for those who are receiving mechanical ventilation or hemofiltration.
Multiple predictors have alternatively been used for early PNec prediction, detection, and
monitoring. These include clinical score systems and circulating biomarkers. Ranson and
APACHE II score systems are widely used albeit complex and time-consuming. Recently, the role
of circulating biomarkers, such as peak creatinine levels, C-reactive protein(CRP), and
leptin, has been investigated . Of these novel biomarkers, only CRP has been used routinely
in casesof PNec prediction. It is reported that CRP levels higher than 150 mg/l were 86%
sensitive, but only 46% specific for pancreatic necrosis . Thus, additional investigationof
these novel biomarkers is necessary to further improve PNec prediction.
Mitochondrial DNA (mtDNA) is an extrachromosomal genome occurring in the mitochondria of
eukaryotic cells.
Normally, it is strictly contained in mitochondria and notexposed to the innate immune system
even following cellapoptosis. However, in times of cell death elicited bystress (e.g., trauma
and sepsis), mtDNA is released into systemic circulation and leads to an array of
inflammatory reactions . Elevated mtDNA levels have been reported in a variety of clinical
situations, including trauma,severe sepsis , and cancer . As PNec is caused by intracellular
activation of digestive enzymes and autodigestion.
New therapeutic methods targeting PNec such as endoscopic ultrasound guided transmural
drainage and necrosectomy are being tested. Early identification of PNec will be helpful for
early treatment. High levels of mtDNA suggest the presence of PNec and close observation
should be given to avoid the developmentof SAP and pancreatitis infection.
Necrotic substances released into the blood stimulate the production of inflammatory
cytokines and mediators, trigger an inflammatory cascade and eventually lead to the SIRS or
multiple organ dysfunction syndrome.
;
| Status | Clinical Trial | Phase | |
|---|---|---|---|
| Completed |
NCT03002051 -
EUS-guided Transenteric Drainage With a Novel Lumen-apposing Metal Stent
|
N/A | |
| Completed |
NCT04113499 -
Endoscopic Necrosectomy Versus Step-up Endoscopic Intervention
|
N/A | |
| Recruiting |
NCT05601687 -
Endoscopic Step-up Approach vs Aggressive Debridement of Large Pancreatic Walled-off Necrosis
|
N/A | |
| Recruiting |
NCT06179459 -
Registry of Patients Undergoing Endoscopic Management of Pancreatic Fluid Collections
|
||
| Not yet recruiting |
NCT06134024 -
The Role of Double Pigtail Plastic Stents During Endoscopic Transmural Drainage of Pancreatic Fluid Collections.
|
N/A | |
| Completed |
NCT05508828 -
Percutaneous Continuous Irrigation Combined With Transgastric Necrosectomy usingLAMS in Treatment of SAP
|
||
| Terminated |
NCT02673541 -
Study of a Lumen- Apposing, Covered, Self-Expanding Metal Stent (Axios™) Versus Multiple Double Pigtail Stents
|
N/A | |
| Recruiting |
NCT05252897 -
Timing of Necrosectomy After Endoscopic Drainage of Walled-off Pancreatic Necrosis (WON)
|
N/A |