Microbiota and Protein-energy Wasting (MIDIWA)

Undernutrition Clinical Trial

— MIDIWA  

Official title:

Do Branched Chain Amino Acids Counteract Protein Energy Wasting Through Gut Microbiota Changes in Hemodialysis Patients ?

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02962089
• Other study ID #: CER 13-239
• Status: Completed
• Phase: N/A
• Start date: August 2016
• Est. completion date: August 2019

Study information

• Verified date: April 2021
• Source: University Hospital, Geneva
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Oral supplementation with branched chain amino acids (BCAA) increases the levels of circulating BCAA, stimulates BCAA uptake in muscles, and decreases amino acid release from muscle, eventually promoting muscle anabolism. However, uptake of oral BCAA by muscle is not complete, pointing out that non-muscular tissues, as the splanchnic bed and gut microbiota, may play a role in BCAA metabolism.

This protocol aims at studying the impact of protein-energy wasting (PEW) and of refeeding with branched chain amino acids (BCAA), on gut barrier including gut microbiota, in chronic hemodialysis (HD) patients. The investigators speculate that:

1. HD patients with PEW have altered composition and function of gut microbiota, increased permeability of epithelial gut barrier, increased systemic inflammation but decreased fecal immunoglobulin A (IgA), and a dysbalance of plasma appetite mediators in favor of anorexigenic mediators, compared to HD patients without PEW, non dialyzed patients with chronic kidney disease and well-nourished non obese subjects,

2. BCAA supplementation of HD patients with PEW reverses these changes, thereby improving nutritional state, physical function, quality of life and resistance to infections.

Description:

General description :

This protocol is multicenter (University Hospitals of Geneva (HUG), Lausanne University Hospital (CHUV), Hospital of Sion (HVS), dialysis center of the Champel clinic in Geneva and dialysis center of the Cécil clinic in Lausanne) and encompasses two parts, a cross-sectional and a longitudinal study:

1. Cross-sectional study: It is performed to differentiate the respective impact of uremia and protein-energy wasting (PEW) on gut barrier and gut microbiota. It will compare gut barrier of hemodialysis (HD) patients with PEW, with gut barrier of age-matched HD well-nourished patients, non dialyzed patients with chronic kidney disease (CKD), and healthy non obese volunteers (10 in each group). This study part is essential for interpretation of the changes occurring in the longitudinal study.

2. Longitudinal double blind randomized crossover study: HD patients with PEW (36 patients), receive, in a randomized double-blind order, either BCAA or an isocaloric isonitrogenous placebo for 4 months each, with a wash-out period of 1 month.

Randomization :

1. Cross-sectional study: No randomization will be performed. HD patients without PEW, non dialyzed patients with CKD and healthy non obese volunteers will be included if matched for gender and age with the included HD patients with PEW. Age-matching will allow a discrepancy of +/- 5 years compared to the HD patient.

2. Longitudinal study: Sequence assignment will be randomized separately in each center to ensure an equal percentage of each sequence in both centers. For this purpose, the investigators will generate 2 lists of randomization with the method of randomly permuted blocks with random block sizes of 2 and 4.

Recruitment :

Patients will be recruited among the outpatients of the Nephrology Divisions or Services of the HUG, CHUV, HVS and Champel and Cécil clinics. Healthy volunteers will be recruited among hospital staff or their relatives.

Inclusion Criteria :

1. HD patients with PEW

• Age ≥ 18 years.

• Maintenance HD for at least 3 months.

• Fasting predialysis plasma albumin < 38 g/l in the absence of an known acute infection during the last 2 weeks or body weight loss > 5% of estimated dry body weight over 3 months

• Dietary intakes (24h dietary recall) between 20-30 kcal/kg/d and < 1 g protein/kg/d on one occasion, during screening. These intakes will not include the intake of oral nutritional supplements, as intakes below 20 kcal/kg/d request artificial nutrition.

• Absence of any systematic antibiotic treatment for an acute infection in the month preceding the inclusion.

2. HD patients without PEW

• Patients matched for age and gender to HD patients with PEW.

• Maintenance HD for at least 3 months.

• Fasting predialysis plasma albumin ≥ 40 g/l, in the absence of any known acute infection during the last 2 weeks

• Dietary intakes (24h dietary recall) > 30 kcal/kg/d and > 1.2 g protein/kg/d, once during screening.

• Absence of any systematic antibiotic treatment for an acute infection in the month preceding the inclusion.

3. Non dialysed patients with chronic kidney disease stage 4

• Patients matched for age and gender to HD patients with PEW.

• Chronic kidney disease, stage 4 or 5, not requiring HD.

• Fasting predialysis plasma albumin ≥ 40 g/l, in the absence of any known acute infection during the last 2 weeks

• Dietary intakes (24h dietary recall) > 30 kcal/kg/d once during screening.

• Absence of any systematic antibiotic treatment for an acute infection in the month preceding the inclusion.

4. Healthy non obese volunteers

• Subjects matched for age and gender to HD patients with PEW.

• Body mass index < 30 kg/m2

• Absence of chronic disease potentially leading to wasting or cachexia.

• Absence of plasma C-reactive protein > 50 mg/l in the last 2 weeks or known acute infection.

• Absence of any systematic antibiotic treatment for an acute infection in the month preceding the inclusion.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 37
• Est. completion date: August 2019
• Est. primary completion date: August 2019
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Age = 18 years.

• Maintenance hemodialysis for at least 3 months.

• Fasting predialysis plasma albumin < 38 g/l in the absence of any known acute infection during the last 2 weeks or body weight loss > 5% of estimated dry body weight over 3 months

• Dietary intakes (24h dietary recall) between 20-30 kcal/kg/d and < 1 g protein/kg/d on one occasion, during screening. These intakes will not include the intake of oral nutritional supplements, as intakes below 20 kcal/kg/d request artificial nutrition

• Absence of any systematic antibiotic treatment for an acute infection in the month preceding the inclusion

Exclusion Criteria:

• Known psychiatric or cognitive disorder, precluding protocol compliance.

• Life expectancy below 1 year.

• Inadequate dialysis (Kt/V<1.2 on 3 consecutive occasions, for HD patients only), if applicable.

• Enteral or parenteral nutrition.

• Drugs or oral nutritional supplements containing fibers since = 1 month.

• Known reasons for decreased plasma albumin levels as liver failure or exudative enteropathy.

• Drugs influencing body composition, = 1 month : systemic corticosteroids, anabolic drugs as insulin or testosterone, post-menopausal hormone therapy, injectable contraceptives.

• Known endocrinological disorders potentially leading to hypo- or hypermetabolism, untreated or treated since = 1 month : disorders of thyroid gland, adrenal glands...

• Pregnancy and breast-feeding.

Related Conditions & MeSH terms

• Cachexia
• Malnutrition
• Undernutrition

Intervention

Dietary Supplement:
• Branched chain amino acids (BCAA)

• Placebo

Locations

Country	Name	City	State
Switzerland	Champel clinic	Geneva
Switzerland	Geneva University Hospital	Geneva
Switzerland	Cécil clinic	Lausanne	Vaud
Switzerland	Lausanne University Hospital	Lausanne	Vaud
Switzerland	Hospital of Sion	Sion	Valais

Sponsors (1)

Lead Sponsor	Collaborator
University Hospital, Geneva

Country where clinical trial is conducted

Switzerland, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Gut microbiota composition by 16-S high throughput sequencing		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Primary	Gut microbiota function by 16-S high throughput sequencing		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Epithelial gut barrier function by fasting level of plasma glucagon-like peptide-2		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Epithelial gut barrier function by fasting level of plasma lipopolysaccharide		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Intestinal immunity by level of fecal IgA		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Systemic inflammation by fasting level of plasma interleukin 10		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Systemic inflammation by fasting level of plama interleukin 6		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Systemic inflammation by fasting level of plama tumor necrosis factor alpha		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma cholecystokinin		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma leptin		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma peptide YY		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma glucagon-like peptide-1		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma neuropeptide Y		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma ghrelin		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Appetite by fasting level of plasma endocannabinoids		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Calorie and protein intakes by 3-day food diary		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Body composition by dual-energy x-rax absorptiometry (DEXA)		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Resting energy expenditure (REE) by indirect calorimetry		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Physical activity level by 7-day pedometry		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Handgrip strength by dynamometer		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Quality of life score by Short Form Health Survey (SF-36)		Changes between baseline and end of each treatment (i.e.changes between Month 0 and Month 4 and between Month 5 and Month 9)
Secondary	Body composition by bioelectrical impedance analysis		Changes between baseline and end of each treatment (i.e.changes between Month 0,2, and Month 4 and between Month 5,7 and Month 9)