TIPS treatment for patients with cirrhosis and acute kidney injury

Hepatorenal Syndrome-acute Kidney Injury (HRS-AKI) Treatment With Transjugular Intrahepatic Portosystemic Shunt in Patients With Cirrhosis. A Randomized Controlled Trial

This study is testing if a procedure called TIPS can help people with liver cirrhosis and kidney problems feel better compared to standard treatments.

Quick facts

• Phase: Not applicable
• Study type: Interventional
• Enrollment: 124 (estimated)
• Ages: 18 Years to 80 Years
• Sex: All
• Sponsor: Jena University Hospital (Academic / other)
• Locations: 14 sites (Aachen and 13 other locations)
• Trial ID: NCT05346393 on ClinicalTrials.gov

What this trial studies

This study evaluates the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) implantation in patients suffering from hepatorenal syndrome acute kidney injury (HRS-AKI) and liver cirrhosis, comparing it to standard therapy involving terlipressin and albumin. HRS-AKI is a severe condition that arises in patients with ascites, particularly those with portal hypertension. The study aims to determine if TIPS can provide better outcomes for these patients, who are at high risk for renal failure and liver transplantation. Participants will be monitored for their response to the intervention and any adverse effects.

Who should consider this trial

Good fit: Ideal candidates include adults aged 18 to 80 with confirmed cirrhosis, clinically evident ascites, and diagnosed HRS-AKI.

Not a fit: Patients with contraindications for TIPS or those with non-cirrhotic causes of acute kidney injury may not benefit from this study.

Why it matters

Potential benefit: If successful, this treatment could significantly improve kidney function and overall survival rates for patients with cirrhosis and acute kidney injury.

How similar studies have performed: While the use of TIPS in similar patient populations has shown promise, this specific approach in the context of HRS-AKI is still being evaluated and may provide novel insights.

Eligibility criteria

Inclusion Criteria:

1. Patients with cirrhosis confirmed by histology or liver stiffness or with unequivocal signs in ultrasound, endoscopy and/or blood tests
2. Clinically evident ascites due to portal hypertension
3. HRS-AKI
4. Age: ≥ 18 to ≤ 80 years old at the time of consent
5. ECOG \< 4 prior to hospital admission
6. Subject has been informed of the nature of the study, is willing to comply with all required follow-up evaluations within the defined follow-up visit windows and has signed an Ethics Committee (EC) approved consent form.
7. Female subjects of childbearing potential have a negative pregnancy test ≤ 7 days before the procedure and are willing to use a reliable method of birth control for the duration of study participation. Female subjects will be exempted from this requirement in case they are sterile, infertile, or have been post-menopausal for at least 12 months (no menses). A contraceptive method with a pearl index below 1% is assumed to be effective.

Exclusion Criteria:

1. Recent or current use of nephrotoxic drugs (NSAIDS, Aminoglycosides or high-dosed iodinated contrast medium) in the previous 72 hours before AKI diagnosis
2. Improvement of renal function after 1 day of diuretic removal and plasma volume expansion with albumin 1-1.5 gr/kg
3. Uncontrolled shock within the last 48 hours prior to randomization
4. Patients with uncontrolled infection (defined by a 20 % increase in inflam-matory parameters (CRP, leucocytes or insufficient decrease of PMN in ascitic fluid \< 25 % from baseline in the case of a SBP) despite 48 hours of antibiotic treatment.
5. Patients with cardiac cirrhosis as defined by the development of cirrhosis in a patient with chronic heart failure due to a primary cardiac disease (is-chemic cardiomyopathy, hypertensive cardiomyopathy, etc.)
6. Patients with contraindications to TIPS placement (e.g. Bilirubin \> 85.5 µmol/L (≙ 5 mg/dL), recurrent hepatic encephalopathy, clinically relevant pulmonary hypertension, aortic stenosis)
7. Patients with cavernous portal vein thrombosis, splenic vein thrombosis or mesenteric vein thrombosis
8. Patients with clinically significant cardiac disease (NYHA ≥ II)
9. Patients with diastolic dysfunction grade 3.
10. Patients with a reduced systolic function with an ejection fraction ≤ 50 %
11. Patients with ACLF grade 3
12. Patients with creatinine value \> 442 µmol/L (≙ 5 mg/dL)
13. Patients with an acute variceal bleeding at the time of screening who have indication for pre-emptive TIPS and/or terlipressin.
14. Patients with refractory ascites as defined by the International Ascites Club (\< 800 gr weight loss over 4 days in patients on low salt diet and high dose diuretics (spironolactone 400 mg /day and furosemide \* 160 mg /day), or lower dose of diuretics with complications secondary to the use of diuretics such as hyponatremia, renal failure, hepatic encephalopathy. \*equivalent dose of torasemide 40 mg/day
15. Patients with hepatocellular carcinoma outside of the Milan criteria
16. Patients with hepatocellular carcinoma within the Milan criteria in whom the tumor is located in the puncture tract.
17. Patients with benign liver tumors (except regenerative nodules) which are located in the puncture tract.
18. Patients who already have a TIPS placed
19. Patients who already had a liver transplantation
20. Patients with other comorbidities that lead to an estimated life expectancy under 1 year.
21. Patients with respiratory insufficiency which requires mechanical ventila-tion
22. Patients with circulatory failure which requires administration of other vas-opressors (catecholamines)
23. Patients receiving renal replacement therapy
24. The subject is currently enrolled in another investigational device or drug trial.
25. Patients with pregnancy or lactation
26. Patients which are suspected to be incompliant for study participation.

Where this trial is running

Aachen and 13 other locations

• University Hospital RWTH Aachen — Aachen, Germany (Recruiting)
• Charité - Universitätsmedizin Berlin CVK — Berlin, Germany (Not_yet_recruiting)
• University Hospital Dresden, Medical Clinic I, Gastroenterology — Dresden, Germany (Recruiting)
• Universitätsklinikum Essen (AöR) — Essen, Germany (Not_yet_recruiting)
• University Hospital Freiburg — Freiburg im Breisgau, Germany (Recruiting)
• University Hospital Halle — Halle, Germany (Recruiting)
• University Hospital Hamburg-Eppendorf — Hamburg, Germany (Recruiting)
• Medical University Hannover — Hanover, Germany (Recruiting)
• Jena University Hospital, Clinic for Inner Medicine IV — Jena, Germany (Recruiting)
• Klinikum Landshut AdöR der Stadt Landshut — Landshut, Germany (Not_yet_recruiting)
• University Hospital Leipzig — Leipzig, Germany (Not_yet_recruiting)
• RKH Clinic Ludwigsburg — Ludwigsburg, Germany (Recruiting)
• Ludwig-Maximilians-University, Klinikum Großhadern — Munich, Germany (Recruiting)
• University Hospital Münster, Medical Clinic B — Münster, Germany (Recruiting)

Study contacts

• Study coordinator: Cristina Ripoll, Prof. Dr.

Conditions Cirrhosis, Liver; Hepatorenal Syndrome; Acute Kidney Injury; Ascites Hepatic; Ascites; Cirrhosis; TIPS; transjugular intrahepatic portosystemic shunt