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Adrenal InsufficiencyPhase 3NCT03368066

Is Adrenal Insufficiency Under-diagnosed in Hospitalized Cirrhosis Patients?

A Phase 3 study testing Cosyntropin in people with Adrenal Insufficiency and Cirrhosis, run by University of Virginia at 1 site in United States.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

The hepatoadrenal syndrome has been well described in the literature and is known to be associated with poorer outcomes in both stable and critically ill cirrhotic patients. In chronic liver disease, adrenal (and more specifically cortisol) insufficiency is thought to be a byproduct of altered lipid metabolism that… Read more about this study

Who is it for?
Ages 18 to 110 years
Conditions the study is for
Adrenal Insufficiency, Cirrhosis, Spur Cell Anemia
What is being tested?
Cosyntropin
Could I receive a placebo?
No, everyone receives an active treatment
How many people
100 participants
Where
1 siteUnited States
Study dates
29 Jan 2018to 12 Mar 2019
Phase
Phase 3
Are there results?
Yes, posted in the registrySummary in the doctors' view

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 to 110 years
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • Age >=18 years
  • Diagnosis of cirrhosis
  • Admission to hospital

Who cannot join

  • Age < 18 years
  • Prior enrollment in study (i.e. readmission)
  • Prisoner
  • Pregnancy
  • Prednisone or Hydrocortisone use in last 24 hours

Trial locations and contacts

1 site in 1 country.

United States1 site
  • University of Virginia Health System

    Charlottesville, Virginia, 22903

Other trials in United States

About this study

The hepatoadrenal syndrome has been well described in the literature and is known to be associated with poorer outcomes in both stable and critically ill cirrhotic patients. In chronic liver disease, adrenal (and more specifically cortisol) insufficiency is thought to be a byproduct of altered lipid metabolism that results in decreased HDL production and thus decreased delivery of cholesterol to the adrenal for subsequent corticosteroid production. Studies to date have implicated lecithin-cholesterol acetyltransferase (LCAT) as the key enzyme which is deficient in some cirrhotic patients, leading to an impaired ability to esterify cholesterol and thus a loss of normal cellular functioning and membrane stability. The investigators seek to quantify this LCAT deficiency in a cohort of cirrhotic patients and demonstrate its association with various abnormal physiologies associated with chronic liver disease, including spur cell anemia, low HDL levels, and adrenal insufficiency.

Hospitalized cirrhotic patients at UVA that meet study eligibility criteria will be approached by a member of the study team to obtain consent for participation. If a patient agrees to become a study subject, they will have an approximate total of 35ml of blood drawn the following morning. Lab tests to be performed include: peripheral blood smear, lipid panel, free cortisol, cortisol binding globulin, serum cholesterol esters (surrogate for LCAT enzyme activity), and a standard-dose cortisol stimulation test. The latter involves blood drawn with the initial collection, administration of an intravenous 250mcg dose of synthetic ACTH, and then repeat small-volume blood draws at 30 minutes and 60 minutes later.

Subjects will be classified as adrenally sufficient or insufficient on the basis of as standard-dose cortisol stimulation test. Variables of interest for comparison between the groups include MELD score, Child-Turcotte-Pugh (CTP) classification, high-density lipoprotein (HDL) levels, presence of spur cell anemia, serum cholesterol ester percentage (surrogate for LCAT enzymatic activity), cortisol binding globulin levels, and free cortisol levels. Student's t-test and Chi Square tests will be utilized to determine significance; a p <0.05 value will be used as our threshold for significance. If multiple factors are found to be significantly different in a univariate fashion between classification groups, a multivariate logistic regression analysis will be performed for adjusted analysis. The investigators will also seek to define any correlations between variables. Furthermore, the investigators will assess correlation between MELD score and serum cholesterol ester percentage, spur cell anemia, HDL levels, cortisol binding globulin levels, and free cortisol levels; similar correlate analysis will be done using CTP classification instead of MELD score.

Being tested
Cosyntropin
Medical subject headings
Adrenal Insufficiency, Fibrosis, Abetalipoproteinemia, Lecithin Cholesterol Acyltransferase Deficiency

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • CosyntropinDrug

    Administer 250mcg cosyntropin to hospitalized cirrhosis patients to assess for the presence of adrenal insufficiency

Study groups in NCT03368066
Study groupRoleWhat they receive
Hospitalized cirrhosis patientsExperimentalAdministration of cortisol stimulation test to assess for presence or absence of adrenal insufficiency
Receives: Drug: Cosyntropin

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Number of Participants With Cholesterol Esterification Deficiency

    A percent quantification of serum cholesterol esterification will be measured via blood draw. Low values represent deficiency in esterification, which is a surrogate measure of lecthicin-cholesterol acetyltransferase (LCAT) enzymatic deficiency.

    Measured: 24 hours

  2. Number of Participants With Spur Cell Anemia

    A peripheral blood smear will be obtained and assessed for presence of acanthocytes (spur cells). Spur cell anemia is defined as a serum hemoglobin < 10g/dL and the presence of >= 5% spur cells on blood smear.

    Measured: 24 hours

  3. Participant Transplant-Free Survival

    Transplant and Death are considered equivalent outcomes

    Measured: 6 months

Secondary outcomes (8)
  1. Number of Participants With Relative Adrenal Insufficiency (RAI)

    A baseline total cortisol level will be obtained and then patients will receive a standard-dose synthetic ACTH (250mcg of Cosyntropin) stimulation test to assess for the presence of adrenal insufficiency. RAI is defined as a change in the total cortisol level in response to the stimulation test of <9mcg/dL when measured 60 minutes after the Cosyntropin is administered.

    Measured: 24 hours

  2. Number of Participants With Low Free Cortisol

    Patients will have their free cortisol levels measured to assess for deficiency.

    Measured: 24 hours

  3. Number of Participants Who Received Liver Transplantation at 90 Days

    Patients who received a liver transplant within 90 days of enrollment

    Measured: 90 days

  4. Number of Participants Who Received Liver Transplantation at 6 Months

    Patients who received a liver transplant within 6 months of enrollment

    Measured: 6 months

  5. Number of Participants Who Died Within Index Hospitalization

    Patients who died within the same hospitalization as enrollment

    Measured: Within Hospitalization

  6. Number of Participants Who Died at 30 Days

    Patients who died within 30 days of enrollment

    Measured: 30 days

  7. Number of Participants Who Died at 90 Days

    Patients who died within 90 days of enrollment

    Measured: 90 days

  8. Number of Participants Who Died at 6 Months

    Patients who died within 6 months of enrollment

    Measured: 6 months

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted11 Dec 2017
  2. Study start29 Jan 2018
  3. Primary completion12 Mar 2019
  4. Study completion12 Mar 2019

Resources

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 3
Primary purpose
Diagnosis
Allocation
Not applicable
Intervention model
Single group
Masking
None (open label)
Enrolment
100 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT03368066
Sponsor's protocol ID
20212
Status last verified
Dec 2021
First submitted
20 Nov 2017
Last updated
9 Dec 2021
Data monitoring committee
No
FDA-regulated drug
Yes
FDA-regulated device
No
Individual data sharing
No

Publications

  • Fede G, Spadaro L, Tomaselli T, Privitera G, Germani G, Tsochatzis E, Thomas M, Bouloux PM, Burroughs AK, Purrello F. Adrenocortical dysfunction in liver disease: a systematic review. Hepatology. 2012 Apr;55(4):1282-91. doi: 10.1002/hep.25573.

    PubMed 22234976
  • O'Beirne J, Holmes M, Agarwal B, Bouloux P, Shaw S, Patch D, Burroughs A. Adrenal insufficiency in liver disease - what is the evidence? J Hepatol. 2007 Sep;47(3):418-23. doi: 10.1016/j.jhep.2007.06.008. Epub 2007 Jun 28.

    PubMed 17629587
  • Triantos CK, Marzigie M, Fede G, Michalaki M, Giannakopoulou D, Thomopoulos K, Garcovich M, Kalafateli M, Chronis A, Kyriazopoulou V, Jelastopoulou E, Nikolopoulou V, O'Beirne J, Burroughs AK. Critical illness-related corticosteroid insufficiency in patients with cirrhosis and variceal bleeding. Clin Gastroenterol Hepatol. 2011 Jul;9(7):595-601. doi: 10.1016/j.cgh.2011.03.033. Epub 2011 Apr 8.

    PubMed 21545846
  • Fede G, Spadaro L, Tomaselli T, Privitera G, Piro S, Rabuazzo AM, Sigalas A, Xirouchakis E, O'Beirne J, Garcovich M, Tsochatzis E, Purrello F, Burroughs AK. Assessment of adrenocortical reserve in stable patients with cirrhosis. J Hepatol. 2011 Feb;54(2):243-50. doi: 10.1016/j.jhep.2010.06.034. Epub 2010 Sep 15.

    PubMed 21056503
  • Fede G, Spadaro L, Tomaselli T, Privitera G, Scicali R, Vasianopoulou P, Thalassinos E, Martin N, Thomas M, Purrello F, Burroughs AK. Comparison of total cortisol, free cortisol, and surrogate markers of free cortisol in diagnosis of adrenal insufficiency in patients with stable cirrhosis. Clin Gastroenterol Hepatol. 2014 Mar;12(3):504-12.e8; quiz e23-4. doi: 10.1016/j.cgh.2013.08.028. Epub 2013 Aug 24.

    PubMed 23978347
  • Tan T, Chang L, Woodward A, McWhinney B, Galligan J, Macdonald GA, Cohen J, Venkatesh B. Characterising adrenal function using directly measured plasma free cortisol in stable severe liver disease. J Hepatol. 2010 Nov;53(5):841-8. doi: 10.1016/j.jhep.2010.05.020. Epub 2010 Jul 17.

    PubMed 20739086
  • Jang JY, Kim TY, Sohn JH, Lee TH, Jeong SW, Park EJ, Lee SH, Kim SG, Kim YS, Kim HS, Kim BS. Relative adrenal insufficiency in chronic liver disease: its prevalence and effects on long-term mortality. Aliment Pharmacol Ther. 2014 Oct;40(7):819-26. doi: 10.1111/apt.12891. Epub 2014 Jul 30.

    PubMed 25078874
  • Tamer S, Cefle K, Palanduz S, Vatansever S. Rheological properties of blood in patients with chronic liver disease. Clin Hemorheol Microcirc. 2002;26(1):9-14.

    PubMed 11904466
  • Tamer S, Cefle K, Gokkusu C, Ademoglu E, Ozturk S, Vatansever S, Palanduz S, Guler K. Comparison of rheological parameters in patients with post hepatitic and alcoholic cirrhosis. Clin Hemorheol Microcirc. 2007;36(3):247-52.

    PubMed 17361026
  • Kakimoto H, Imai Y, Kawata S, Inada M, Ito T, Matsuzawa Y. Altered lipid composition and differential changes in activities of membrane-bound enzymes of erythrocytes in hepatic cirrhosis. Metabolism. 1995 Jul;44(7):825-32. doi: 10.1016/0026-0495(95)90233-3.

    PubMed 7616839
  • Alexopoulou A, Vasilieva L, Kanellopoulou T, Pouriki S, Soultati A, Dourakis SP. Presence of spur cells as a highly predictive factor of mortality in patients with cirrhosis. J Gastroenterol Hepatol. 2014 Apr;29(4):830-4. doi: 10.1111/jgh.12473.

    PubMed 24325340
  • Cooper RA, Diloy Puray M, Lando P, Greenverg MS. An analysis of lipoproteins, bile acids, and red cell membranes associated with target cells and spur cells in patients with liver disease. J Clin Invest. 1972 Dec;51(12):3182-92. doi: 10.1172/JCI107145.

    PubMed 4640953
  • Miller JP. Dyslipoproteinaemia of liver disease. Baillieres Clin Endocrinol Metab. 1990 Dec;4(4):807-32. doi: 10.1016/s0950-351x(05)80080-1.

    PubMed 2082907
  • Kaiser T, Kinny-Koster B, Bartels M, Berg T, Scholz M, Engelmann C, Seehofer D, Becker S, Ceglarek U, Thiery J. Cholesterol esterification in plasma as a biomarker for liver function and prediction of mortality. BMC Gastroenterol. 2017 Apr 20;17(1):57. doi: 10.1186/s12876-017-0614-9.

    PubMed 28427335

Questions about this trial

What is this clinical trial studying?

A Phase 3 study testing Cosyntropin in people with Adrenal Insufficiency and Cirrhosis, run by University of Virginia at 1 site in United States.

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 3 inclusion and 5 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: finished, as of the sponsor's last update on 9 Dec 2021. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.

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.

What does this phase mean?

Phase 3 studies compare the treatment with the current standard treatment or a placebo in a large group, to confirm how well it works and watch for side effects.

Not every study follows the same path, and some studies (observational studies, device studies) have no phase.

Are results available for this study?

Yes. Results are posted in the registry (first posted 9 Dec 2021). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.

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?

Number of Participants With Cholesterol Esterification Deficiency (time frame: 24 hours). The study lists 3 primary outcomes in all. 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 NCT03368066, which also lists 14 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 9 Dec 2021.

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