Contrast NephropathyREMEDIALIIINCT02489669
Renal Insufficiency Following Contrast Media Administration Trial III
A study testing RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA) in people with Contrast Nephropathy, run by Clinica Mediterranea.
Trial summary
The urine flow rate (UFR)-guided and the left-ventricular end-diastolic pressure (LVEDP)-guided hydration regimens have been proposed to prevent contrast-induced acute kidney injury (CI-AKI). Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Contrast Nephropathy
- What is being tested?
- RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA)
- Type of treatment
- Injection or infusion, Medical device
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 700 participants
- Where
- No sites listed yet
- Study dates
- 15 Jul 2015to Dec 2019
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- All consecutive patients with chronic kidney disease (CKD) scheduled for coronary and/or peripheral angiography and/or angioplasty with an eGFR <45 ml/min/1.73 m2 and/or
- At high risk for CI-AKI according to Mehran's score ≥11 and/or Gurm's score >7
Who cannot join
- Age <18 years
- Women who are pregnant
- Acute pulmonary edema
- Acute myocardial infarction
- Recent contrast media exposure
- End-stage CKD on chronic dialysis
Show all 10Show fewer
- Multiple myeloma
- Current enrolment in any other study when enrolment in the REMEDIAL III would involve deviation from either protocol
- Cardiogenic shock
- Administration of theophilline, dopamine, mannitol and fenoldopam
About this study
Official title: Renal Insufficiency Following Contrast Media Administration Trial III (REMEDIAL III): Renalguard System Versus Left-ventricular End-diastolic Pressure-guided Hydration in High-risk Patients for Contrast-induced Acute Kidney Injury
The urine flow rate (UFR)-guided and the left-ventricular end-diastolic pressure (LVEDP)-guided hydration regimens have been proposed to prevent contrast-induced acute kidney injury (CI-AKI). The REnal Insufficiency Following Contrast MEDIA Administration TriaL III (REMEDIAL III) trial is a randomized, multicenter, investigator-sponsored trial aiming to compare these 2 hydration strategies in high risk patients.
Patients with estimated glomerular filtration rate <45 ml/min/1.73 m2 and/or a high risk for CI-AKI (as defined according to both Mehran's score ≥11 and/or Gurm's score >7) will be enrolled. Patients will be divided in high (>12 mm Hg) and normal LVEDP, non-invasively estimated by transmitral flow velocity to annular velocity ratio (E/E' index). Patients in each group will be randomly assigned to 1) LVEDP-guided hydration with normal saline (LVEDP-guided group). The fluid infusion rate will be adjusted according to the LVEDP as follows: 5 mL/kg/hr for LVEDP <12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/hr for >18 mmHg. 2) UFR-rate guided hydration (RenalGuard group). In this group, hydration with normal saline plus low-dose of furosemide is controlled by the RenalGuard system, in order to reach and maintain a high (>300 mL/h) UFR. In all cases iobitridol (an low-osmolar, non ionic contrast agent) will be administered. The primary endpoint is the composite of CI-AKI (i.e., serum creatinine increase ≥ 25% and ≥ 0.5 mg/dl from the baseline value at 48 hours after contrast media exposure) and/or acute pulmonary edema.
Read the detailed description
Contrast-induced acute kidney injury (CI-AKI) is a powerful predictor of unfavorable early and late outcome. Hydration represents the cornerstone in CI-AKI prevention1. However, at present there is no consensus on how hydration should be carried out. The most recommended hydration regimen is normal saline infusion at 1 mL/kg/h 12 hours before and 12 hours after CM exposure. Limitations of this hydration regimen include 1) preclusion in urgent/emergent settings, and 2) suboptimal efficacy in high- and very high risk patients. Indeed, in high and very-high risk patients the rate of CI-AKI may be still high, whereas a forced hydration regimen may increase the risk of pulmonary edema.
In order to clarify how to carry out optimal hydration, 2 regimens have been recently proposed: 1) left ventricular end-diastolic pressure (LVEDP)-guided hydration and 2) urine flow rate (UFR)-guided hydration. The POSEIDON trial demonstrated that the left ventricular end-diastolic pressure (LVEDP)-guided hydration is superior to the conventional hydration regimen in preventing CI-AKI. In the LVEDP-guided hydration, the fluid infusion rate was adjusted according to the LVEDP as follows: 5 mL/kg/hr for LVEDP <12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/hr for >18 mmHg. The reported rate of pulmonary edema was 1.5%.
Another theory for CI-AKI prophylaxis suggests to induction and maintenance of a high UFR. This high UFR should allow the body to rapidly eliminate contrast media, reducing contact time within nephron. The RenalGuard™ System (PLC Medical Systems, Inc.) in combination with limited (0.25 mg/kg) dose of furosemide induces an maintains a high UFR (>300 mL/h) safely by maintaining the intravascular blood volume and minimizing the risk of over or under-hydration. Furthermore, the reported rate of pulmonary edema was <1%.
The purpose of the present study is to compare the LVEDP-guided hydration and the UFR-guided hydration in patients at high risk for CI-AKI.
Following enrollment, patients will be randomly assigned to one of the following treatments: 1) LVEDP-guided group, and 2) RenalGuard group. Enrolled patients will be stratified, according to the estimated LVEDP value, into high LVEDP and normal LVEDP group. LVEDP will be non-invasively estimated by the transmitral flow velocity to annular velocity ratio (E/E' index). Estimated LVEDP pressure >12 mm Hg will be considered high. Patients allocated in both groups will receive intravenous 0.9% sodium chloride for at least one hour prior to cardiac catheterization. In both groups the fluid rate will be adjusted according to the non-invasive LVEDP estimate as follows: 5 mL/kg/hr for LVEDP ≤12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/h for >18 mmHg, as suggested in the POSEIDON trial. Invasive LVEDP measurement will be also estimated in all patients by placing an angled 5 or 6-French pigtail catheter in the mid-cavity of the left ventricle at the beginning of the procedure and before contrast media injection in order to confirm the non-invasive estimated value.
The sample size was calculated to demonstrate the superiority of the RenalGuard therapy over the LVEDP-guided hydration regimen. The investigators expect a reduction in the primary composite endpoint from 9% in the LVEDP-guided group to 5% in the RenalGuard group. Using a two-sided Chi-square test with a significance level of 0.05, a total of at least 750 randomized patients (350 in each arm) afforded the study 80% power. The endpoints will be analyzed in the global population and also in the subgroups stratified according to the LVEDP value.
Serum creatinine, cystatin C, blood urea nitrogen, sodium and potassium will be measured the day before, 12, 24, 48 hours and 1 week after administration of the contrast agent; additional measurements will be performed in all cases of deterioration of baseline renal function. CI-AKI is defined as an increase of serum creatinine >=0.3 mg/dl at 48 hours after contrast media exposure.
Patient demographic details, medical history, current medication, eGFR, risk score for CI-AKI, and left ventricular ejection fraction are recorded at baseline. Total hydration volume administered according to the prophylaxis and during the 24 and 48 hours following the procedure as well as the total urine volume will be recorded. The pre-procedure sCr level is considered as the sCr concentration before the initiation of any prophylaxis. End-point data and adverse events are collected during the in-hospital stay and at 1-month. Six-month and 12-month MAE will be also collected. All adverse events are recorded in the case report form and the data coordinating center will be informed by facsimile within 72 hours of any events. Serious events and any other safety issues will be reviewed by an independent Data Monitoring and Safety Committee. All events will be adjudicated by a Clinical Events Committee (CEC), who is blinded to treatment assignment. At least 2 members of the CEC review clinical data and relevant documentation and determine whether end points have occurred according to the study definitions. In case of disagreement between reviewers, a third member of the CEC will adjudicate and the data will be considered by the entire committee if 2 of the 3 reviewers do not agree.
- Conditions
- Contrast Nephropathy
- Being tested
- RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA)
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA)Device
Patients in the RenalGuard group will be treated by hydration with normal saline controlled by the RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA). The RenalGuard system includes a) a closed loop fluid management system; b) a high volume fluid pump, c) a high accuracy dual weight measuring system; d) motion detection artifact reduction; e) a single use intravenous set and urine collection system that interfaces with a standard Foley catheter; f) real-time display of urine and replacement fluid volume; g) a timely alerts to drain the urine bag or to replace the hydration fluid bag; f) and safety features such as automatic air and occlusion detection.
| Study group | Role | What they receive |
|---|---|---|
| LVEDP-guided group | No intervention | Patients allocated to the LVEDP-guided group will continue to receive intravenous 0.9% sodium chloride, according to the protocol suggested in the POSEIDON trial (that is, 5 mL/kg/hr for LVEDP ≤12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/h for >18 mmHg). The fluid rate will be eventually modified at the start of the procedure in case of discordance between non-invasive and invasive LVEDP pressure estimate, being the invasive value considered as gold-standard. The fluid rate will continued during the procedure, and for 4 hours post-procedure. |
| Renalguard group | Experimental | Patients enrolled in this group will be treated by hydration with 0.9% saline controlled by the RenalGuard system. On top of the 1.5-5.0 ml/kg/h that patients would have received over the previous hour (according to the non-invasive estimate LVEDP), an initial bolus of 250 ml will be administered. In case of LV ejection fraction ≤30% and/or LVEDP >18 mm Hg the bolus will 150 mL. Therefore, furosemide (0.25 mg/kg) will be administered in order to achieve the optimal urine flow rate (≥300 mL/h). The controlled hydration by the RenalGuard system will be continued during the procedure and for 4 hours following the procedure. Urine flow rate is monitored and maintained at the target value through the procedure and during the following 4 hours. Additional furosemide doses are allowed in case of decrease of the urine flow rate below the target value. Receives: Device: RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA) |
What is being measured
The primary outcome is the main question the study is designed to answer.
Composite of 1) development of CI-AKI, and/or acute pulmonary edema.
The primary outcome measure is composite of 1) development of CI-AKI, and/or acute pulmonary edema. CI-AKI is defined as an increase in the serum creatinine concentration >=25% and >=0.5 mg/dl from the baseline value at 48 hours after administration of the contrast media or the need for dialysis
Measured: within 48 hours after contrast media exposure
Secondary outcomes (6)
Creatinine change
an increase in the serum creatinine concentration >=0.3 mg/dl at 48 hours after contrast exposure
Measured: 48 hours
Cystatin C change
changes in the serum cystatin C concentration at 24 and 48 hours after contrast exposure
Measured: 48 hours
Dialysis rate
the rate of acute renal failure requiring dialysis (defined as a decrease in renal function necessitating acute hemodialysis, ultrafiltration or peritoneal dialysis within the first 5 days post-intervention)
Measured: 5 days
Major adverse event rate
the rate of in-hospital, 6 and 12-month major adverse events (MAE), including death, renal failure requiring dialysis, acute pulmonary edema, and sustained kidney injury. Sustained kidney injury is defined as a persistent ≥25% GFR compared to baseline at the last available value during the follow up.
Measured: 12 months
Length of in-hospital stay (LOS)
the length of in-hospital stay (LOS), calculated as the sum of the number of days since admission until discharge from the hospital.
Measured: 30 days
Impact of LVEDP
the occurrence of the primary endpoint in the 2 groups stratified according to the LVEDP
Measured: 48 hours
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted3 Jul 2015 (estimated)
- Study start15 Jul 2015
- Primary completionDec 2018 (estimated)
- Study completionDec 2019 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (18)Papers the sponsor has linked to this study.
- Other trials for Contrast NephropathyStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Double blind
- Who is masked
- Participant, Outcomes assessor
- Enrolment
- 700 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Clinica Mediterranea
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Carlo Briguori, Clinica Mediterranea
- Investigators
- Carlo Briguori, Principal investigator, Clinica Mediterranea
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT02489669
- Sponsor's protocol ID
- NCT004
- Acronym
- REMEDIALIII
- Status last verified
- Sep 2018
- First submitted
- 8 Jun 2015
- Last updated
- 7 Sep 2018
- Results posted
- No
- Data monitoring committee
- Yes
Publications
McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008 Apr 15;51(15):1419-28. doi: 10.1016/j.jacc.2007.12.035.
PubMed 18402894Tepel M, Aspelin P, Lameire N. Contrast-induced nephropathy: a clinical and evidence-based approach. Circulation. 2006 Apr 11;113(14):1799-806. doi: 10.1161/CIRCULATIONAHA.105.595090. No abstract available.
PubMed 16606801Briguori C, Visconti G, Rivera NV, Focaccio A, Golia B, Giannone R, Castaldo D, De Micco F, Ricciardelli B, Colombo A. Cystatin C and contrast-induced acute kidney injury. Circulation. 2010 May 18;121(19):2117-22. doi: 10.1161/CIRCULATIONAHA.109.919639. Epub 2010 May 3.
PubMed 20439784Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents. N Engl J Med. 1994 Nov 24;331(21):1416-20. doi: 10.1056/NEJM199411243312104.
PubMed 7969280Brar SS, Aharonian V, Mansukhani P, Moore N, Shen AY, Jorgensen M, Dua A, Short L, Kane K. Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial. Lancet. 2014 May 24;383(9931):1814-23. doi: 10.1016/S0140-6736(14)60689-9.
PubMed 24856027Stevens MA, McCullough PA, Tobin KJ, Speck JP, Westveer DC, Guido-Allen DA, Timmis GC, O'Neill WW. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation. J Am Coll Cardiol. 1999 Feb;33(2):403-11. doi: 10.1016/s0735-1097(98)00574-9.
PubMed 9973020Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, Golia B, Ricciardelli B, Condorelli G; REMEDIAL II Investigators. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury. Circulation. 2011 Sep 13;124(11):1260-9. doi: 10.1161/CIRCULATIONAHA.111.030759. Epub 2011 Aug 15.
PubMed 21844075National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266. No abstract available.
PubMed 11904577World Medical Association Inc. Declaration of Helsinki. Ethical principles for medical research involving human subjects. J Indian Med Assoc. 2009 Jun;107(6):403-5. No abstract available.
PubMed 19886379Anello C, O'Neill RT, Dubey S. Multicentre trials: a US regulatory perspective. Stat Methods Med Res. 2005 Jun;14(3):303-18. doi: 10.1191/0962280205sm398oa.
PubMed 15969305Kasner M, Westermann D, Steendijk P, Gaub R, Wilkenshoff U, Weitmann K, Hoffmann W, Poller W, Schultheiss HP, Pauschinger M, Tschope C. Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation. 2007 Aug 7;116(6):637-47. doi: 10.1161/CIRCULATIONAHA.106.661983. Epub 2007 Jul 23.
PubMed 17646587Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation. 2000 Oct 10;102(15):1788-94. doi: 10.1161/01.cir.102.15.1788.
PubMed 11023933How to diagnose diastolic heart failure. European Study Group on Diastolic Heart Failure. Eur Heart J. 1998 Jul;19(7):990-1003. doi: 10.1053/euhj.1998.1057. No abstract available.
PubMed 9717033Gurm HS, Dixon SR, Smith DE, Share D, Lalonde T, Greenbaum A, Moscucci M; BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) Registry. Renal function-based contrast dosing to define safe limits of radiographic contrast media in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol. 2011 Aug 23;58(9):907-14. doi: 10.1016/j.jacc.2011.05.023.
PubMed 21851878Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med. 2005 Dec 29;353(26):2788-96. doi: 10.1056/NEJMcp052699. No abstract available.
PubMed 16382065
Study at a glance
From the registry record, last updated by the sponsor on 7 Sep 2018. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Renal Insufficiency Following Contrast Media Administration Trial III (REMEDIAL III): Renalguard System Versus Left-ventricular End-diastolic Pressure-guided Hydration in High-risk Patients for Contrast-induced Acute Kidney Injury
- ClinicalTrials.gov ID
- NCT02489669
- Acronym / sponsor ID
- REMEDIALIII / NCT004
- Conditions
- Contrast Nephropathy
- Study type
- Interventional
- Recruitment status
- Unknown status
- Enrolment
- 700 participants (estimated)
- Lead sponsor
- Clinica MediterraneaUniversity, hospital or other
- Study start
- 15 Jul 2015 (actual)
- Primary completion
- Dec 2018 (estimated)
- Study completion
- Dec 2019 (estimated)
- First posted
- 3 Jul 2015 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The urine flow rate (UFR)-guided and the left-ventricular end-diastolic pressure (LVEDP)-guided hydration regimens have been proposed to prevent contrast-induced acute kidney injury (CI-AKI). The REnal Insufficiency Following Contrast MEDIA Administration TriaL III (REMEDIAL III) trial is a randomized, multicenter, investigator-sponsored trial aiming to compare these 2 hydration strategies in high risk patients.
Patients with estimated glomerular filtration rate <45 ml/min/1.73 m2 and/or a high risk for CI-AKI (as defined according to both Mehran's score ≥11 and/or Gurm's score >7) will be enrolled. Patients will be divided in high (>12 mm Hg) and normal LVEDP, non-invasively estimated by transmitral flow velocity to annular velocity ratio (E/E' index). Patients in each group will be randomly assigned to 1) LVEDP-guided hydration with normal saline (LVEDP-guided group). The fluid infusion rate will be adjusted according to the LVEDP as follows: 5 mL/kg/hr for LVEDP <12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/hr for >18 mmHg. 2) UFR-rate guided hydration (RenalGuard group). In this group, hydration with normal saline plus low-dose of furosemide is controlled by the RenalGuard system, in order to reach and maintain a high (>300 mL/h) UFR. In all cases iobitridol (an low-osmolar, non ionic contrast agent) will be administered. The primary endpoint is the composite of CI-AKI (i.e., serum creatinine increase ≥ 25% and ≥ 0.5 mg/dl from the baseline value at 48 hours after contrast media exposure) and/or acute pulmonary edema.
Detailed description
Contrast-induced acute kidney injury (CI-AKI) is a powerful predictor of unfavorable early and late outcome. Hydration represents the cornerstone in CI-AKI prevention1. However, at present there is no consensus on how hydration should be carried out. The most recommended hydration regimen is normal saline infusion at 1 mL/kg/h 12 hours before and 12 hours after CM exposure. Limitations of this hydration regimen include 1) preclusion in urgent/emergent settings, and 2) suboptimal efficacy in high- and very high risk patients. Indeed, in high and very-high risk patients the rate of CI-AKI may be still high, whereas a forced hydration regimen may increase the risk of pulmonary edema.
In order to clarify how to carry out optimal hydration, 2 regimens have been recently proposed: 1) left ventricular end-diastolic pressure (LVEDP)-guided hydration and 2) urine flow rate (UFR)-guided hydration. The POSEIDON trial demonstrated that the left ventricular end-diastolic pressure (LVEDP)-guided hydration is superior to the conventional hydration regimen in preventing CI-AKI. In the LVEDP-guided hydration, the fluid infusion rate was adjusted according to the LVEDP as follows: 5 mL/kg/hr for LVEDP <12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/hr for >18 mmHg. The reported rate of pulmonary edema was 1.5%.
Another theory for CI-AKI prophylaxis suggests to induction and maintenance of a high UFR. This high UFR should allow the body to rapidly eliminate contrast media, reducing contact time within nephron. The RenalGuard™ System (PLC Medical Systems, Inc.) in combination with limited (0.25 mg/kg) dose of furosemide induces an maintains a high UFR (>300 mL/h) safely by maintaining the intravascular blood volume and minimizing the risk of over or under-hydration. Furthermore, the reported rate of pulmonary edema was <1%.
The purpose of the present study is to compare the LVEDP-guided hydration and the UFR-guided hydration in patients at high risk for CI-AKI.
Following enrollment, patients will be randomly assigned to one of the following treatments: 1) LVEDP-guided group, and 2) RenalGuard group. Enrolled patients will be stratified, according to the estimated LVEDP value, into high LVEDP and normal LVEDP group. LVEDP will be non-invasively estimated by the transmitral flow velocity to annular velocity ratio (E/E' index). Estimated LVEDP pressure >12 mm Hg will be considered high. Patients allocated in both groups will receive intravenous 0.9% sodium chloride for at least one hour prior to cardiac catheterization. In both groups the fluid rate will be adjusted according to the non-invasive LVEDP estimate as follows: 5 mL/kg/hr for LVEDP ≤12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/h for >18 mmHg, as suggested in the POSEIDON trial. Invasive LVEDP measurement will be also estimated in all patients by placing an angled 5 or 6-French pigtail catheter in the mid-cavity of the left ventricle at the beginning of the procedure and before contrast media injection in order to confirm the non-invasive estimated value.
The sample size was calculated to demonstrate the superiority of the RenalGuard therapy over the LVEDP-guided hydration regimen. The investigators expect a reduction in the primary composite endpoint from 9% in the LVEDP-guided group to 5% in the RenalGuard group. Using a two-sided Chi-square test with a significance level of 0.05, a total of at least 750 randomized patients (350 in each arm) afforded the study 80% power. The endpoints will be analyzed in the global population and also in the subgroups stratified according to the LVEDP value.
Serum creatinine, cystatin C, blood urea nitrogen, sodium and potassium will be measured the day before, 12, 24, 48 hours and 1 week after administration of the contrast agent; additional measurements will be performed in all cases of deterioration of baseline renal function. CI-AKI is defined as an increase of serum creatinine >=0.3 mg/dl at 48 hours after contrast media exposure.
Patient demographic details, medical history, current medication, eGFR, risk score for CI-AKI, and left ventricular ejection fraction are recorded at baseline. Total hydration volume administered according to the prophylaxis and during the 24 and 48 hours following the procedure as well as the total urine volume will be recorded. The pre-procedure sCr level is considered as the sCr concentration before the initiation of any prophylaxis. End-point data and adverse events are collected during the in-hospital stay and at 1-month. Six-month and 12-month MAE will be also collected. All adverse events are recorded in the case report form and the data coordinating center will be informed by facsimile within 72 hours of any events. Serious events and any other safety issues will be reviewed by an independent Data Monitoring and Safety Committee. All events will be adjudicated by a Clinical Events Committee (CEC), who is blinded to treatment assignment. At least 2 members of the CEC review clinical data and relevant documentation and determine whether end points have occurred according to the study definitions. In case of disagreement between reviewers, a third member of the CEC will adjudicate and the data will be considered by the entire committee if 2 of the 3 reviewers do not agree.
Study design
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Double blind (participant, outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| LVEDP-guided group | No intervention | –Patients allocated to the LVEDP-guided group will continue to receive intravenous 0.9% sodium chloride, according to the protocol suggested in the POSEIDON trial (that is, 5 mL/kg/hr for LVEDP ≤12 mmHg; 3 mL/kg/hr for 13-18 mmHg; and 1.5 mL/kg/h for >18 mmHg). The fluid rate will be eventually modified at the start of the procedure in case of discordance between non-invasive and invasive LVEDP pressure estimate, being the invasive value considered as gold-standard. The fluid rate will continued during the procedure, and for 4 hours post-procedure. |
| Renalguard group | Experimental | Device: RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA)Patients enrolled in this group will be treated by hydration with 0.9% saline controlled by the RenalGuard system. On top of the 1.5-5.0 ml/kg/h that patients would have received over the previous hour (according to the non-invasive estimate LVEDP), an initial bolus of 250 ml will be administered. In case of LV ejection fraction ≤30% and/or LVEDP >18 mm Hg the bolus will 150 mL. Therefore, furosemide (0.25 mg/kg) will be administered in order to achieve the optimal urine flow rate (≥300 mL/h). The controlled hydration by the RenalGuard system will be continued during the procedure and for 4 hours following the procedure. Urine flow rate is monitored and maintained at the target value through the procedure and during the following 4 hours. Additional furosemide doses are allowed in case of decrease of the urine flow rate below the target value. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (2 listed)
- All consecutive patients with chronic kidney disease (CKD) scheduled for coronary and/or peripheral angiography and/or angioplasty with an eGFR <45 ml/min/1.73 m2 and/or
- At high risk for CI-AKI according to Mehran's score ≥11 and/or Gurm's score >7
Key exclusion criteria (10 listed)
- Age <18 years
- Women who are pregnant
- Acute pulmonary edema
- Acute myocardial infarction
- Recent contrast media exposure
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA)Patients in the RenalGuard group will be treated by hydration with normal saline controlled by the RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA). The RenalGuard system includes a) a closed loop fluid management system; b) a high volume fluid pump, c) a high accuracy dual weight measuring system; d) motion detection artifact reduction; e) a single use intravenous set and urine collection system that interfaces with a standard Foley catheter; f) real-time display of urine and replacement fluid volume; g) a timely alerts to drain the urine bag or to replace the hydration fluid bag; f) and safety features such as automatic air and occlusion detection. | Device | Renalguard group |
Primary outcome
Composite of 1) development of CI-AKI, and/or acute pulmonary edema.
Time frame: within 48 hours after contrast media exposure
The primary outcome measure is composite of 1) development of CI-AKI, and/or acute pulmonary edema. CI-AKI is defined as an increase in the serum creatinine concentration >=25% and >=0.5 mg/dl from the baseline value at 48 hours after administration of the contrast media or the need for dialysis
6 secondary outcomes
Creatinine change
Time frame: 48 hours
Cystatin C change
Time frame: 48 hours
Dialysis rate
Time frame: 5 days
Major adverse event rate
Time frame: 12 months
Length of in-hospital stay (LOS)
Time frame: 30 days
Impact of LVEDP
Time frame: 48 hours
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 7 Sep 2018.
- Results publication: PubMed 18402894McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008 Apr 15;51(15):1419-28. doi: 10.1016/j.jacc.2007.12.035.
- Results publication: PubMed 16606801Tepel M, Aspelin P, Lameire N. Contrast-induced nephropathy: a clinical and evidence-based approach. Circulation. 2006 Apr 11;113(14):1799-806. doi: 10.1161/CIRCULATIONAHA.105.595090. No abstract available.
- Results publication: PubMed 20439784Briguori C, Visconti G, Rivera NV, Focaccio A, Golia B, Giannone R, Castaldo D, De Micco F, Ricciardelli B, Colombo A. Cystatin C and contrast-induced acute kidney injury. Circulation. 2010 May 18;121(19):2117-22. doi: 10.1161/CIRCULATIONAHA.109.919639. Epub 2010 May 3.
- Results publication: PubMed 7969280Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents. N Engl J Med. 1994 Nov 24;331(21):1416-20. doi: 10.1056/NEJM199411243312104.
- Results publication: PubMed 24856027Brar SS, Aharonian V, Mansukhani P, Moore N, Shen AY, Jorgensen M, Dua A, Short L, Kane K. Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial. Lancet. 2014 May 24;383(9931):1814-23. doi: 10.1016/S0140-6736(14)60689-9.
- Results publication: PubMed 9973020Stevens MA, McCullough PA, Tobin KJ, Speck JP, Westveer DC, Guido-Allen DA, Timmis GC, O'Neill WW. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation. J Am Coll Cardiol. 1999 Feb;33(2):403-11. doi: 10.1016/s0735-1097(98)00574-9.
- Results publication: PubMed 21844075Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, Golia B, Ricciardelli B, Condorelli G; REMEDIAL II Investigators. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury. Circulation. 2011 Sep 13;124(11):1260-9. doi: 10.1161/CIRCULATIONAHA.111.030759. Epub 2011 Aug 15.
- Results publication: PubMed 11904577National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266. No abstract available.
- Results publication: PubMed 19886379World Medical Association Inc. Declaration of Helsinki. Ethical principles for medical research involving human subjects. J Indian Med Assoc. 2009 Jun;107(6):403-5. No abstract available.
- Results publication: PubMed 15969305Anello C, O'Neill RT, Dubey S. Multicentre trials: a US regulatory perspective. Stat Methods Med Res. 2005 Jun;14(3):303-18. doi: 10.1191/0962280205sm398oa.
- Results publication: PubMed 17646587Kasner M, Westermann D, Steendijk P, Gaub R, Wilkenshoff U, Weitmann K, Hoffmann W, Poller W, Schultheiss HP, Pauschinger M, Tschope C. Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation. 2007 Aug 7;116(6):637-47. doi: 10.1161/CIRCULATIONAHA.106.661983. Epub 2007 Jul 23.
- Results publication: PubMed 11023933Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation. 2000 Oct 10;102(15):1788-94. doi: 10.1161/01.cir.102.15.1788.
Related trials for Contrast Nephropathy
RecruitingPhase 2
Inorganic Nitrate (NaNO3) Prevention of Contrast-Associated Acute Kidney Injury
Kidney Injury, Acute
Active, not recruiting
Preventing Kidney Injury Using Carbon Dioxide as Contrast Medium in Patients With Peripheral Arterial Disease (PAD) and Chronic Kidney Disease (CKD) Having Arterial Intervention
Peripheral Arterial Disease, Chronic Kidney Diseases
Recruiting
Effectiveness of Remote Ischemic Preconditioning for Prevention of Contrast Induced Acute Kidney Injury in Patients Undergoing Coronary Angiograms.
Contrast-induced Acute Kidney Injury (CI-AKI) Following Coronary Angiogram (CI-AKI), Contrast-induced Nephropathy Following Coronary Angiogram (CIN)
Not yet recruitingObservational study
Uric Acid to Albumin Ratio for Predicting Contrast Associated Acute Kidney Injury After Cardiac and Non Cardiac Procedures
Contrast-Induced Nephropathy, Acute Kidney Injury
Not yet recruitingObservational study
An Observational Study of Percutaneous Glomerular Filtration Rate (TGFR) in the Early Warning of Contrast-induced Acute Kidney Injury During the Peri-examination Period of Emergency Enhanced CT
Contrast-associated Acute Kidney Injury
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Carlo Briguori principal investigator
Clinica Mediterranea
Questions about this trial
What is this clinical trial studying?
A study testing RenalGuard system™® (PLC Medical Systems, Inc. Franklin, MA, USA) in people with Contrast Nephropathy, run by Clinica Mediterranea.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 2 inclusion and 10 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: status not confirmed, as of the sponsor's last update on 7 Sep 2018. Status can change between updates, so confirm with the study contact before making plans.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Composite of 1) development of CI-AKI, and/or acute pulmonary edema. (time frame: within 48 hours after contrast media exposure). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT02489669, which also lists 18 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 7 Sep 2018.