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Profermin®: Prevention of Progression in Alcoholic Liver Disease by Modulating Dysbiotic Microbiota (SYN-ALD)

Primary Purpose

Alcoholic Liver Disease, Liver Cirrhosis, Alcoholic, Probiotics

Status
Active
Phase
Not Applicable
Locations
Denmark
Study Type
Interventional
Intervention
Profermin Plus, FSMP, probiotics
Fresubin, dietary supplement
Sponsored by
Odense University Hospital
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional prevention trial for Alcoholic Liver Disease focused on measuring Food for special medical purposes, Gut and liver axis

Eligibility Criteria

30 Years - 75 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Prior or ongoing harmful alcohol intake defined as an average of ≥24g alcohol/day for women and ≥36g/d for men for ≥ 5 year.

    • Outpatients with compensated advanced chronic alcohol-related liver disease, defined as stable patients with:

      1. liver stiffness ≥15 kPa and asymptomatic and/or
      2. New liver biopsy (<6months) with at least F3 fibrosis (kleiner) and/or
      3. Liver biopsy older that 6 months with liver stiffness ≥10 kPa
    • Understand and speak Danish written and orally
    • Informed consent

Exclusion Criteria:

  • Hospitalised
  • Moderete or severe Ascites, determined from imaging diagnostics
  • High-risk varices needing interventional treatment (endoscopy, TIPS)
  • Child-Pugh C score
  • MELD-Na ≥15
  • Lactose intolerance
  • Coeliac disease
  • Irritable bowel syndrome defined by ROME III criteria
  • Antibiotic treatment the prior 3 months
  • Treatment with nutritional drinks, probiotics or prebiotics within the last 3 months
  • The investigator judge that the patient would not be compliant with trial medicine
  • Pregnancy
  • Known liver disease other than alcoholic, of any aetiology
  • Severe malnutrition
  • Malignancy - except spino- or basocellular skin cancer. Patients with prior malignant disease are allowed if cancer-free for at least one year
  • Recent infectious gastroenteritis (for the last 6 weeks)

Sites / Locations

  • FLASH - Centre of Liver Research
  • Odense University Hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

Profermin Plus®

Fresubin®

Arm Description

Intervention group will be drinking the liver-specialized product Profermin Plus®, based on fermented oats, Lactobacillus Plantarum 299v, barley malt and lecithin. The product also contains Thiamin, which is beneficial in patients with liver diseases.

Fresubin® is a standard FSMP and will be used as control product. Since Profermin Plus® is a disease-specific FSMP, the documentation must prove an effect that cannot be achieved by modification of the normal diet alone or by standard FSMP's. Therefor the comparator must be a standard FSMP, i.e. a nutritionally complete FSMP with standard nutrient formulation, which may constitute the sole source of nourishment of a person, hence the reason for using Fresubin® as comparator.

Outcomes

Primary Outcome Measures

Hepatic stellate cell activity
Attenuation of liver hepatic stellate cell activity, defined as the proportion of patients with a 10% or more reduction in activated hepatic stellate cells, measured by a-smooth muscle actin (a-SMA) stain quantification of liver biopsies.

Secondary Outcome Measures

Hepatic a-SMA activity
Reduction in hepatic a-SMA activity
Hepatic inflammation
Evaluated by hepatic inflammation markers and metabolites
Alfa-smooth muscle actin concentration
Reduction in circulating a-smooth muscle actin concentration
Hepatic venous pressure gradient (HVPG)
Reduction in portal pressure measured by the HVPG in unit mmhg
Reduction in non-invasive fibrosis markers
Reduction in Ultrasound shear wave elastography (transient and 2-dimensional) (kPa)
Reduction in non-invasive fibrosis markers
ProC3 and ProC4 (ng/ml)
Reduction in non-invasive fibrosis markers
ELF test
Reduction in non-invasive fibrosis markers
Forns index
Reduction in non-invasive fibrosis marker
APRI score
Reduction in non-invasive fibrosis markers
FIB4 (points)
Markers of liver inflammation
Reduction in circulating markers of liver inflammation (cytokeratin-18 degradation products M30 and M65)
Improvement of liver histological lesions
Improvement in semiquantitative liver histological lesions that fulfil at least one of two criteria: At least one stage of liver fibrosis improvement according to the Kleiner fibroses classification (0-4), with no worsening of hepatic inflammatory activity Complete resolution of hepatic inflammatory activity, with no worsening of fibrosis. [Worsening defined as an increase of at least one stage of either lobular inflammation or hepatocyte ballooning. Resolution defined as ballooning=0 and lobular inflammation=0-1]
Improvement in gut dysbiosis
Defined as: Improved taxonomy, defined as increased relative abundance of species characteristic of healthy individuals and decreased relative abundance of species characteristic of cirrhosis and severe alcoholic liver disease Increase in gut microbial richness
Liver vein outflow of microbial products
Change in Liver vein outflow of microbial products
Lipid profile
Improvement of lipid profile defined as: Rising HDL, decrease in triglycerids, LDL and total cholesterol
Any changes in non-invasive markers of steatosis
Controlled Attenuation Parameter(CAP) and ultrasonographic steatosis assessment (bright liver echo pattern)
Individual domains of NAS scoring systemt
Any changes in individual domains of the NAS scoring system (fibrosis 0-4, steatosis 0-3, lobular inflammation 0-2, portal inflammation 0-1, ballooning 0-2) or in collagen proportionate area (%)
Metabolic changes
Water soluble metabolites in circulation will be evaluated with metabolomics
Changes in circulating cytokines
Cytokines related to cardiovascular disease and inflammation will be analysed
Changes in hepatic macrophage activity
Changes in digital imaging analysis of hepatic CD163 expression in liver biopsies
Changes in intestinal fibrosis markers
C4M generated by decomposition of type 4 collagen
Changes in intestinal fibrosis markers
CPA9-HNE a fragment degraded from calprotectin
Changes bile acids
Changes in bile acids will be measured in both stool and circulation
Metabolic changes
Amino acids in circulation will be evaluated with metabolomics
Metabolic changes
Lipidomics in circulation will be evaluated with metabolomics
Metabolic changes
Lipidomics in liver samples will be evaluated with metabolomics
Metabolic changes
Short chain fatty acids in circulation will be evaluated with metabolomics
Metabolic changes
Short chain fatty acids in stool samples will be evaluated with metabolomics

Full Information

First Posted
February 28, 2019
Last Updated
August 18, 2022
Sponsor
Odense University Hospital
Collaborators
Region of Southern Denmark, Odense Patient Data Explorative Network, University of Southern Denmark, Nordisk Rebalance A/S
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1. Study Identification

Unique Protocol Identification Number
NCT03863730
Brief Title
Profermin®: Prevention of Progression in Alcoholic Liver Disease by Modulating Dysbiotic Microbiota
Acronym
SYN-ALD
Official Title
Profermin®: Prevention of Progression in Alcoholic Liver Disease by Modulating Dysbiotic Microbiota - a Randomized Controlled Clinical Trial
Study Type
Interventional

2. Study Status

Record Verification Date
August 2022
Overall Recruitment Status
Active, not recruiting
Study Start Date
March 1, 2019 (Actual)
Primary Completion Date
July 15, 2021 (Actual)
Study Completion Date
February 2031 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Odense University Hospital
Collaborators
Region of Southern Denmark, Odense Patient Data Explorative Network, University of Southern Denmark, Nordisk Rebalance A/S

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Investigators wishes to influence the gut microbiota in patients with alcoholic liver disease in a randomized controlled clinical trial. The investigators hypothesize that the alcohol-related dysbiosis seen in these patients can be changed and disease progression haltered by modulating microbiota with probiotics during 24 weeks.
Detailed Description
Chronic alcohol overuse is associated with increased gut permeability and in addition, the intestinal microbiota changes qualitatively (dysbiosis) and quantitatively (bacterial overgrowth) in alcoholic liver disease in favour of a microbiota with increased invasive potential. As a consequence, an increased load of bacterial products is transported to the liver leading to inflammation and fibrogenesis. This cross talk between the intestinal microbiota and the liver constitute a gut-liver axis, which is increasingly recognized as key mechanism in the progression of liver disease and pathogenesis of liver related complications. The investigators hypothesize that the gut microbiota and its metabolites are major drivers of fibrosis in human liver disease and that modulating the intestinal flora by Profermin® (a food for special medical purposes) will modulate the alcohol related dysbiotic signatures in the microbiota which may halter disease progression by reducing activity of hepatic stellate cells. Dietary supplements that alter the microbiome towards a more beneficent type may improve liver inflammation and thus be a better alternative than supplements that simply add nutrients. Investigators expect that the trial will provide proof-of-concept for a sustainable dietary strategy in liver fibrosis. Examples of biopsies which did not meet quality criteria for reliable histological reading, led to inclusion of 16 extra patients. In total we included 56 patients to ensure an adequate number of participants with valid liver biopsy data for assessment of the primary endpoint and intention-to-treat analysis.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Alcoholic Liver Disease, Liver Cirrhosis, Alcoholic, Probiotics, Liver Fibrosis
Keywords
Food for special medical purposes, Gut and liver axis

7. Study Design

Primary Purpose
Prevention
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
Patients will be randomized 1:1 to receive Profermin Plus® versus a general FSMP, Fresubin®, for 24 weeks.
Masking
None (Open Label)
Masking Description
Pathologist will perform outcome assessment blinded
Allocation
Randomized
Enrollment
56 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Profermin Plus®
Arm Type
Experimental
Arm Description
Intervention group will be drinking the liver-specialized product Profermin Plus®, based on fermented oats, Lactobacillus Plantarum 299v, barley malt and lecithin. The product also contains Thiamin, which is beneficial in patients with liver diseases.
Arm Title
Fresubin®
Arm Type
Active Comparator
Arm Description
Fresubin® is a standard FSMP and will be used as control product. Since Profermin Plus® is a disease-specific FSMP, the documentation must prove an effect that cannot be achieved by modification of the normal diet alone or by standard FSMP's. Therefor the comparator must be a standard FSMP, i.e. a nutritionally complete FSMP with standard nutrient formulation, which may constitute the sole source of nourishment of a person, hence the reason for using Fresubin® as comparator.
Intervention Type
Dietary Supplement
Intervention Name(s)
Profermin Plus, FSMP, probiotics
Intervention Description
Participants will have to supply their normal intake with Profermin Plus, FSMP, Prbiotics product twice every day for 24 weeks. The product Profermin Plus® has changed its name to ReFerm®. The content of the product is unchanged. The change occurred after the clinical part of the study was completed.
Intervention Type
Dietary Supplement
Intervention Name(s)
Fresubin, dietary supplement
Intervention Description
Participants will have to supply their normal intake with the control product, Fresubin, dietary supplement twice every day for 24 weeks.
Primary Outcome Measure Information:
Title
Hepatic stellate cell activity
Description
Attenuation of liver hepatic stellate cell activity, defined as the proportion of patients with a 10% or more reduction in activated hepatic stellate cells, measured by a-smooth muscle actin (a-SMA) stain quantification of liver biopsies.
Time Frame
24 weeks
Secondary Outcome Measure Information:
Title
Hepatic a-SMA activity
Description
Reduction in hepatic a-SMA activity
Time Frame
24 weeks
Title
Hepatic inflammation
Description
Evaluated by hepatic inflammation markers and metabolites
Time Frame
24 weeks
Title
Alfa-smooth muscle actin concentration
Description
Reduction in circulating a-smooth muscle actin concentration
Time Frame
24 weeks
Title
Hepatic venous pressure gradient (HVPG)
Description
Reduction in portal pressure measured by the HVPG in unit mmhg
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis markers
Description
Reduction in Ultrasound shear wave elastography (transient and 2-dimensional) (kPa)
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis markers
Description
ProC3 and ProC4 (ng/ml)
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis markers
Description
ELF test
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis markers
Description
Forns index
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis marker
Description
APRI score
Time Frame
24 weeks
Title
Reduction in non-invasive fibrosis markers
Description
FIB4 (points)
Time Frame
24 weeks
Title
Markers of liver inflammation
Description
Reduction in circulating markers of liver inflammation (cytokeratin-18 degradation products M30 and M65)
Time Frame
24 weeks
Title
Improvement of liver histological lesions
Description
Improvement in semiquantitative liver histological lesions that fulfil at least one of two criteria: At least one stage of liver fibrosis improvement according to the Kleiner fibroses classification (0-4), with no worsening of hepatic inflammatory activity Complete resolution of hepatic inflammatory activity, with no worsening of fibrosis. [Worsening defined as an increase of at least one stage of either lobular inflammation or hepatocyte ballooning. Resolution defined as ballooning=0 and lobular inflammation=0-1]
Time Frame
24 weeks
Title
Improvement in gut dysbiosis
Description
Defined as: Improved taxonomy, defined as increased relative abundance of species characteristic of healthy individuals and decreased relative abundance of species characteristic of cirrhosis and severe alcoholic liver disease Increase in gut microbial richness
Time Frame
24 weeks
Title
Liver vein outflow of microbial products
Description
Change in Liver vein outflow of microbial products
Time Frame
24 weeks
Title
Lipid profile
Description
Improvement of lipid profile defined as: Rising HDL, decrease in triglycerids, LDL and total cholesterol
Time Frame
24 weeks
Title
Any changes in non-invasive markers of steatosis
Description
Controlled Attenuation Parameter(CAP) and ultrasonographic steatosis assessment (bright liver echo pattern)
Time Frame
24 weeks
Title
Individual domains of NAS scoring systemt
Description
Any changes in individual domains of the NAS scoring system (fibrosis 0-4, steatosis 0-3, lobular inflammation 0-2, portal inflammation 0-1, ballooning 0-2) or in collagen proportionate area (%)
Time Frame
24 weeks
Title
Metabolic changes
Description
Water soluble metabolites in circulation will be evaluated with metabolomics
Time Frame
24 weeks
Title
Changes in circulating cytokines
Description
Cytokines related to cardiovascular disease and inflammation will be analysed
Time Frame
24 weeks
Title
Changes in hepatic macrophage activity
Description
Changes in digital imaging analysis of hepatic CD163 expression in liver biopsies
Time Frame
24 weeks
Title
Changes in intestinal fibrosis markers
Description
C4M generated by decomposition of type 4 collagen
Time Frame
24 weeks
Title
Changes in intestinal fibrosis markers
Description
CPA9-HNE a fragment degraded from calprotectin
Time Frame
24 weeks
Title
Changes bile acids
Description
Changes in bile acids will be measured in both stool and circulation
Time Frame
24 weeks
Title
Metabolic changes
Description
Amino acids in circulation will be evaluated with metabolomics
Time Frame
24 weeks
Title
Metabolic changes
Description
Lipidomics in circulation will be evaluated with metabolomics
Time Frame
24 weeks
Title
Metabolic changes
Description
Lipidomics in liver samples will be evaluated with metabolomics
Time Frame
24 weeks
Title
Metabolic changes
Description
Short chain fatty acids in circulation will be evaluated with metabolomics
Time Frame
24 weeks
Title
Metabolic changes
Description
Short chain fatty acids in stool samples will be evaluated with metabolomics
Time Frame
24 weeks

10. Eligibility

Sex
All
Minimum Age & Unit of Time
30 Years
Maximum Age & Unit of Time
75 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Prior or ongoing harmful alcohol intake defined as an average of ≥24g alcohol/day for women and ≥36g/d for men for ≥ 5 year. Outpatients with compensated advanced chronic alcohol-related liver disease, defined as stable patients with: liver stiffness ≥15 kPa and asymptomatic and/or New liver biopsy (<6months) with at least F3 fibrosis (kleiner) and/or Liver biopsy older that 6 months with liver stiffness ≥10 kPa Understand and speak Danish written and orally Informed consent Exclusion Criteria: Hospitalised Moderete or severe Ascites, determined from imaging diagnostics High-risk varices needing interventional treatment (endoscopy, TIPS) Child-Pugh C score MELD-Na ≥15 Lactose intolerance Coeliac disease Irritable bowel syndrome defined by ROME III criteria Antibiotic treatment the prior 3 months Treatment with nutritional drinks, probiotics or prebiotics within the last 3 months The investigator judge that the patient would not be compliant with trial medicine Pregnancy Known liver disease other than alcoholic, of any aetiology Severe malnutrition Malignancy - except spino- or basocellular skin cancer. Patients with prior malignant disease are allowed if cancer-free for at least one year Recent infectious gastroenteritis (for the last 6 weeks)
Facility Information:
Facility Name
FLASH - Centre of Liver Research
City
Odense
State/Province
Fyn
ZIP/Postal Code
5000
Country
Denmark
Facility Name
Odense University Hospital
City
Odense
ZIP/Postal Code
5000
Country
Denmark

12. IPD Sharing Statement

Plan to Share IPD
No

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Profermin®: Prevention of Progression in Alcoholic Liver Disease by Modulating Dysbiotic Microbiota

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