Back to resultsTargeting Central Pulsatile Hemodynamics in Chronic Kidney Disease
Primary Purpose
Renal Insufficiency, Chronic
Status
Terminated
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
ISMN
Vitamin C
Sponsored by
About this trial
This is an interventional other trial for Renal Insufficiency, Chronic focused on measuring Chronic Kidney Diseases, Chronic Kidney Insufficiency, Chronic Renal Diseases, Chronic Renal Insufficiency, Kidney Insufficiency, Chronic, Cardiac Failure, Congestive Heart Failure, Heart Decompensation, Heart Failure, Congestive, Myocardial Failure
Eligibility Criteria
Inclusion Criteria:
- Chronic kidney disease stage 3
- Elevated left ventricular mass index or LV posterior wall thickness >1.4 cm documented in a clinically indicated echocardiographic or MRI examination within the previous 24 months or electrocardiographic LV hypertrophy
- Stable medical therapy as defined by no addition, removal or change in dosage >100% of Angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, or calcium channel blockers for > 30 days
- Current therapy with an ACE inhibitor, hydralazine or a statin, all of which have been shown to reduce nitrate tolerance
Exclusion Criteria:
- A clinically- indicated stress test demonstrating significant myocardial ischemia within 1 year of enrollment, not followed by coronary revascularization
- Rhythm other than sinus (i.e., atrial fibrillation)
- Non-cardiac condition limiting life expectancy to <1 year
- Current or anticipated future need for long acting organic nitrate therapy
- Severe aortic or mitral valve disease
- Hypertrophic cardiomyopathy
- Known infiltrative or inflammatory myocardial disease (amyloid, sarcoid)
- Pericardial disease
- Primary pulmonary arteriopathy
- History of myocardial infarction, unstable angina, percutaneous transluminal coronary angiography (PTCA) or coronary artery bypass grafting (CABG) within 60 days, or requirement for either PTCA or CABG at the time of consent
- Resting heart rate (HR) >100 bpm
- A reduced LV ejection fraction (EF<50%)
- Known severe liver disease (AST >3x normal, alkaline phosphatase or bilirubin >2x normal)
- Allergy to ISMN
- Current therapy with phosphodiesterase inhibitors, such as sildenafil, vardanafil or tadalafil
- Therapy with rosiglitazone
- Current pregnancy or a positive urine pregnancy test; women who become pregnant during the study will be discontinued from the trial
- Therapy with warfarin
- History of kidney stones
- History of glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Systolic blood pressure <110 mmHg or diastolic blood pressure <40 mmHg;
- Contraindications to a cardiac MRI: (a) Central nervous system aneurysm clips; (b) Implanted neural stimulators; (c) Implanted cardiac pacemaker or defibrillator; (d) Cochlear implant; (e) Ocular foreign body (e.g. metal shavings); (f) Other implanted medical devices: (e.g. drug infusion ports); (g) Insulin pump; (h) Metal shrapnel or bullet; (i) Claustrophobia; (j) Extreme obesity rendering the patient unable to fit into narrow-bore scanners; (k) Unwillingness of the patient to undergo a cardiac MRI.
Sites / Locations
- Hospital of the University of Pennsylvania
Arms of the Study
Arm 1
Arm 2
Arm Type
Experimental
Experimental
Arm Label
ISMN Only
ISMN AND Vitamin C
Arm Description
Patients receive only ISMN
Patients receive both ISMN and Vitamin C
Outcomes
Primary Outcome Measures
Change in LV Mass
Variability seen in change in LV mass with ISMN administration measured with steady-state free precession cardiac MRI, outcomes reflect the change, in grams
Secondary Outcome Measures
Changes in Diffuse Myocardial Fibrosis
Myocardial ECV was assessed using a modified Look-Locker inversion recovery sequence to assess T1 times before and following the IV administration of gadolinium contrast in a mid-ventricular short-axis slice. Parameters for modified Look-Locker inversion recovery were: field of view=340mm2; matrix size=144×192; slice thickness=6mm; repetition time=2.4ms; echo time=1.18ms; flip angle=30 degrees, bandwidth=1000 Hz/pixel, integrated parallel acquisition techniques=2. Myocardial T1measurements were performed before and at several time points (5, 10, 15, and 20-40 min) post-gadolinium administration. Modified Look-Locker inversion recovery was performed with a 5-3-3 schema with (2 inversions, 5 echo times after inversion 1, 3 T1 recovery heartbeats, and 3 echo times after inversion 2). All T1 measurements were used to compute lambda (the myocardium-blood partition coefficient) as the slope of the myocardial 1/T1 over the blood 1/T1 change, by linear regression.
Changes in Myocardial Systolic and Diastolic Function
Variability in changes in myocardial function with ISMN administration, assessed via systolic longitudinal strain (measured with tissue tracking MRI) with adequate data for tissue tracking. Strain is the shortening during contraction, expressed as a promotion of the end-diastolic myocardial length. Shortening is indicated by a negative value. Strain is a unit-less metric and is thus expressed in %. A change with negative sign indicates more pronounced shortening of baseline compared to 6 months; a change with positive sign indicates less pronounced shortening during contraction.
Pulse Wave Reflection Magnitude
Measured by arterial tonometry and echocardiography. The data reflects estimated changes in each group utilizing all available measurements, collected at all timepoints (baseline visit and weeks 1, 2, 3, 12, and 24 visits). Numbers are estimated changes in each group utilizing available measurements. The change represents the absolute change in the ratio of backward to forward wave amplitudes, multiplied by 100.
Aerobic Capacity
Variability in changes in aerobic capacity (peak oxygen consumption during maximal supine bicycle exercise test)
Full Information
1. Study Identification
Unique Protocol Identification Number
NCT02791906
Brief Title
Targeting Central Pulsatile Hemodynamics in Chronic Kidney Disease
Official Title
Targeting Central Pulsatile Hemodynamics in Chronic Kidney Disease
Study Type
Interventional
2. Study Status
Record Verification Date
July 2020
Overall Recruitment Status
Terminated
Why Stopped
lack of funding
Study Start Date
May 2016 (undefined)
Primary Completion Date
March 2019 (Actual)
Study Completion Date
March 2019 (Actual)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
University of Pennsylvania
4. Oversight
5. Study Description
Brief Summary
Heart failure (HF) is an epidemic and is a major burden on the US healthcare system. The most common cardiovascular endpoint is HF. Thus, novel interventions to prevent HF in chronic kidney disease (CKD) are highly desirable. This study will assess: the variability in the response to isosorbide mononitrate (ISMN) therapy; the degree of change in central hemodynamics and cardiac endpoints through analysis of changes in left ventricle (LV) mass, diffuse myocardial fibrosis, and myocardial systolic and diastolic function.
Detailed Description
This is a open label, parallel arm, randomized study of ISMN with or without vitamin C to improve exercise capacity and LV remodeling in CKD. Twenty subjects with CKD will be enrolled in this study and three different daily doses of sustained release isosorbide mononitrate (SR-ISMN) will be administered over time accompanied by a random administration of vitamin C in half of the subjects (500 mg three times daily). Before administration of SR-ISMN, baseline assessments will be performed. These include arterial tonometry, Doppler echocardiography, reflection magnitude measurements, a bicycle exercise test, activity monitoring, cardiac MRI, 24-hour blood pressure monitoring, and blood drawing. After these assessments, a dose of 30 mg of SR-ISMN will be administered daily (either with or without vitamin C) for the first week, 60 mg SR-ISMN for the second week, and 120 mg for the third week. After each week, blood pressure and central hemodynamics will be assessed. The third week visit also includes the bicycle exercise study and initiating the long term dose (60 or 120 mg) of SR-ISMN. In the long-term phase, blood pressure and hemodynamics are assessed at 12-weeks post initiation of the study medication(s). After 24 weeks we will perform the final assessment, which includes the same tests performed during the baseline assessment. Enrollment will take place at the Hospital of the University of Pennsylvania and the Penn Presbyterian Medical Center.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Renal Insufficiency, Chronic
Keywords
Chronic Kidney Diseases, Chronic Kidney Insufficiency, Chronic Renal Diseases, Chronic Renal Insufficiency, Kidney Insufficiency, Chronic, Cardiac Failure, Congestive Heart Failure, Heart Decompensation, Heart Failure, Congestive, Myocardial Failure
7. Study Design
Primary Purpose
Other
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
8 (Actual)
8. Arms, Groups, and Interventions
Arm Title
ISMN Only
Arm Type
Experimental
Arm Description
Patients receive only ISMN
Arm Title
ISMN AND Vitamin C
Arm Type
Experimental
Arm Description
Patients receive both ISMN and Vitamin C
Intervention Type
Drug
Intervention Name(s)
ISMN
Intervention Type
Dietary Supplement
Intervention Name(s)
Vitamin C
Primary Outcome Measure Information:
Title
Change in LV Mass
Description
Variability seen in change in LV mass with ISMN administration measured with steady-state free precession cardiac MRI, outcomes reflect the change, in grams
Time Frame
Measured at Baseline Visit and 24 Week Visit
Secondary Outcome Measure Information:
Title
Changes in Diffuse Myocardial Fibrosis
Description
Myocardial ECV was assessed using a modified Look-Locker inversion recovery sequence to assess T1 times before and following the IV administration of gadolinium contrast in a mid-ventricular short-axis slice. Parameters for modified Look-Locker inversion recovery were: field of view=340mm2; matrix size=144×192; slice thickness=6mm; repetition time=2.4ms; echo time=1.18ms; flip angle=30 degrees, bandwidth=1000 Hz/pixel, integrated parallel acquisition techniques=2. Myocardial T1measurements were performed before and at several time points (5, 10, 15, and 20-40 min) post-gadolinium administration. Modified Look-Locker inversion recovery was performed with a 5-3-3 schema with (2 inversions, 5 echo times after inversion 1, 3 T1 recovery heartbeats, and 3 echo times after inversion 2). All T1 measurements were used to compute lambda (the myocardium-blood partition coefficient) as the slope of the myocardial 1/T1 over the blood 1/T1 change, by linear regression.
Time Frame
Measured at Baseline Visit and 24 Week Visit
Title
Changes in Myocardial Systolic and Diastolic Function
Description
Variability in changes in myocardial function with ISMN administration, assessed via systolic longitudinal strain (measured with tissue tracking MRI) with adequate data for tissue tracking. Strain is the shortening during contraction, expressed as a promotion of the end-diastolic myocardial length. Shortening is indicated by a negative value. Strain is a unit-less metric and is thus expressed in %. A change with negative sign indicates more pronounced shortening of baseline compared to 6 months; a change with positive sign indicates less pronounced shortening during contraction.
Time Frame
Measured at Baseline Visit and 24 visits
Title
Pulse Wave Reflection Magnitude
Description
Measured by arterial tonometry and echocardiography. The data reflects estimated changes in each group utilizing all available measurements, collected at all timepoints (baseline visit and weeks 1, 2, 3, 12, and 24 visits). Numbers are estimated changes in each group utilizing available measurements. The change represents the absolute change in the ratio of backward to forward wave amplitudes, multiplied by 100.
Time Frame
Measured between Baseline Visit-Week 24
Title
Aerobic Capacity
Description
Variability in changes in aerobic capacity (peak oxygen consumption during maximal supine bicycle exercise test)
Time Frame
Change from Baseline at Week 24 reported
10. Eligibility
Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria:
Chronic kidney disease stage 3
Elevated left ventricular mass index or LV posterior wall thickness >1.4 cm documented in a clinically indicated echocardiographic or MRI examination within the previous 24 months or electrocardiographic LV hypertrophy
Stable medical therapy as defined by no addition, removal or change in dosage >100% of Angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, or calcium channel blockers for > 30 days
Current therapy with an ACE inhibitor, hydralazine or a statin, all of which have been shown to reduce nitrate tolerance
Exclusion Criteria:
A clinically- indicated stress test demonstrating significant myocardial ischemia within 1 year of enrollment, not followed by coronary revascularization
Rhythm other than sinus (i.e., atrial fibrillation)
Non-cardiac condition limiting life expectancy to <1 year
Current or anticipated future need for long acting organic nitrate therapy
Severe aortic or mitral valve disease
Hypertrophic cardiomyopathy
Known infiltrative or inflammatory myocardial disease (amyloid, sarcoid)
Pericardial disease
Primary pulmonary arteriopathy
History of myocardial infarction, unstable angina, percutaneous transluminal coronary angiography (PTCA) or coronary artery bypass grafting (CABG) within 60 days, or requirement for either PTCA or CABG at the time of consent
Resting heart rate (HR) >100 bpm
A reduced LV ejection fraction (EF<50%)
Known severe liver disease (AST >3x normal, alkaline phosphatase or bilirubin >2x normal)
Allergy to ISMN
Current therapy with phosphodiesterase inhibitors, such as sildenafil, vardanafil or tadalafil
Therapy with rosiglitazone
Current pregnancy or a positive urine pregnancy test; women who become pregnant during the study will be discontinued from the trial
Therapy with warfarin
History of kidney stones
History of glucose-6-phosphate dehydrogenase (G6PD) deficiency
Systolic blood pressure <110 mmHg or diastolic blood pressure <40 mmHg;
Contraindications to a cardiac MRI: (a) Central nervous system aneurysm clips; (b) Implanted neural stimulators; (c) Implanted cardiac pacemaker or defibrillator; (d) Cochlear implant; (e) Ocular foreign body (e.g. metal shavings); (f) Other implanted medical devices: (e.g. drug infusion ports); (g) Insulin pump; (h) Metal shrapnel or bullet; (i) Claustrophobia; (j) Extreme obesity rendering the patient unable to fit into narrow-bore scanners; (k) Unwillingness of the patient to undergo a cardiac MRI.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Julio Chirinos, MD, PhD
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
Facility Information:
Facility Name
Hospital of the University of Pennsylvania
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
12. IPD Sharing Statement
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Targeting Central Pulsatile Hemodynamics in Chronic Kidney Disease
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