Efficacy and Mechanisms of GLN Dipeptide in the SICU (GLND)

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborator:
Information provided by (Responsible Party):
Thomas R. Ziegler, MD, Emory University
ClinicalTrials.gov Identifier:
NCT00248638
First received: November 3, 2005
Last updated: December 19, 2013
Last verified: December 2013
  Purpose

Relative glutamine (GLN) deficiency may contribute to morbidity and mortality in surgical intensive care unit (SICU) patients. During critical illness, GLN utilization by the immune system, gut mucosa and other tissues exceeds endogenous production and plasma GLN concentrations decrease, which may contribute to cellular dysfunction and increase nosocomial infection risk and mortality. Conventional GLN-free parenteral nutrition (PN) has a limited impact on SICU outcomes and does not repair the GLN deficit. Our recent pilot data show that GLN dipeptide-supplemented PN decreases nosocomial infections and improves clinical outcomes in SICU patients. The process of benefit is poorly understood, but animal and human data suggest that GLN treatment correlates with a) up-regulation of cytoprotective molecules in blood and tissues [e.g, GSH, specific heat shock proteins (HSPs) and GLN]; and b) improved epithelial barrier defenses and immune cell number and function. Properties of L-GLN limit provision in solution, but the GLN dipeptide alanyl-GLN (AG) confers stability and solubility in PN (AG-PN). We propose a multicenter, double-blind, randomized, controlled phase III trial based on our pilot data to test the hypothesis that AG-PN improves clinical outcomes in SICU patients requiring PN after cardiac, vascular or colonic operations. Subjects will receive either standard GLN-free PN or isocaloric, isonitrogenous, AG-PN until enteral feeds are established. Specific Aim 1 is to determine whether AG-PN decreases hospital mortality, nosocomial infection and other important indices of morbidity. Specific Aim 2 is to obtain novel, mechanistically relevant observational data in the Aim 1 subjects on whether AG-PN a) increases serial blood levels of GSH, HSP-70 and -27, and GLN; b) decreases the presence in serum of the bacterial products flagellin and LPS and the adaptive immune response to these mediators; and c) improves key indices of innate/adaptive immunity. This study is designed to delineate the clinical benefit of a major new nutrition support strategy in high-risk SICU patients.

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Condition Intervention Phase
Critical Illness
Drug: Glutamine dipeptide
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Caregiver, Investigator)
Primary Purpose: Treatment
Official Title: Phase III Study on the Efficacy of Glutamine Dipeptide-Supplemented Parenteral Nutrition in Surgical ICU Patients

Resource links provided by NLM:


Further study details as provided by Emory University:

Primary Outcome Measures:
  • Hospital Mortality [ Time Frame: Mortality during the current hospitalization up to 6 months ] [ Designated as safety issue: No ]
    Mortality during the current hospitalization

  • Percent of Patients Who do Not Develop Hospital Infections After Entry [ Time Frame: While the patient is admitted during the current hospitalization up to 6 months ] [ Designated as safety issue: No ]
    Subjects remaining infection-free during the hospitalization.


Secondary Outcome Measures:
  • Blood Cytoprotective Molecules (Glutamine, Heat Shock Protein) [ Time Frame: Within 28 days of enrollment ] [ Designated as safety issue: No ]
    Chemicals in the blood that protect against cellular injury are looked at during study.


Enrollment: 150
Study Start Date: September 2006
Estimated Study Completion Date: October 2014
Primary Completion Date: December 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Glutamine dipeptide
Glutamine dipeptide supplemented nutrition to be given to participants.
Drug: Glutamine dipeptide

Subjects randomized to AG-PN will receive PN containing 0.5 g/kg/day of L alanyl L GLN (AG) dipeptide (Dipeptiven 20%; Fresenius-Kabi) and 1.0 g/kg/day of 15% Clinisol (Baxter Inc., Deerfield, IL) AA solution (total = 1.5 g/kg/day, with AG replacing 1/3 of Clinisol AA). Subjects randomized to STD-PN will receive PN AA as the standard, GLN-free amino acid solution (15% Clinisol). The AA solutions are nearly isonitrogenous; STD-PN provides 2.35 g nitrogen and the AG-PN provides 2.45 g nitrogen per 100 ml 15% AA solution. The amount of GLN dipeptide administered each day will be determined by daily PN volume intake data.

Study subjects will receive a maximum of 28 days of study PN (blinded placebo or GLN-dipeptide-supplemented PN). If the subject continues to require PN after Day 28, study PN and GLN dipeptide will be discontinued.

Other Names:
  • Alanyl-glutamine Dipeptide
  • Dipeptiven
Placebo Comparator: standard
Participants given standard nutrition without glutamine dipeptide
Drug: Glutamine dipeptide

Subjects randomized to AG-PN will receive PN containing 0.5 g/kg/day of L alanyl L GLN (AG) dipeptide (Dipeptiven 20%; Fresenius-Kabi) and 1.0 g/kg/day of 15% Clinisol (Baxter Inc., Deerfield, IL) AA solution (total = 1.5 g/kg/day, with AG replacing 1/3 of Clinisol AA). Subjects randomized to STD-PN will receive PN AA as the standard, GLN-free amino acid solution (15% Clinisol). The AA solutions are nearly isonitrogenous; STD-PN provides 2.35 g nitrogen and the AG-PN provides 2.45 g nitrogen per 100 ml 15% AA solution. The amount of GLN dipeptide administered each day will be determined by daily PN volume intake data.

Study subjects will receive a maximum of 28 days of study PN (blinded placebo or GLN-dipeptide-supplemented PN). If the subject continues to require PN after Day 28, study PN and GLN dipeptide will be discontinued.

Other Names:
  • Alanyl-glutamine Dipeptide
  • Dipeptiven

Detailed Description:

Overview: Relative deficiency of glutamine (GLN) appears to contribute to morbidity and mortality in surgical intensive care unit (SICU) patients, but conventional nutrition support does not repair this deficit. GLN requirements increase during critical illness when utilization by the immune system, gut mucosa and other tissues exceeds endogenous production. GLN depletion under these conditions may contribute to hospital morbidity and mortality. Conventional parenteral nutrition (PN) does not contain GLN and thus does not prevent GLN depletion in catabolic patients. However, our pilot study and other reports strongly suggest that GLN-supplemented PN improves metabolic and clinical outcomes in critically ill patients. Underlying mechanisms for GLN action are poorly understood, but may involve systemic upregulation of the cytoprotective molecules glutathione (GSH), specific heat shock proteins (HSP) and GLN itself, improved gut barrier defenses, and improved innate and/or adaptive immune function. Properties of L-GLN limit provision in PN, but the dipeptide alanyl-glutamine (AG) confers stability and solubility in PN solutions. The P.I.'s pilot study demonstrated a marked decrease in nosocomial infection, improved indices of organ function, and a possible decrease in hospital mortality in SICU patients receiving AG-supplemented PN (AG-PN) versus standard, GLN-free PN (STD-PN). We propose a multi-center, double-blind, controlled, Phase III trial, based on a pilot study, that will determine the effect of parenteral GLN on important clinical outcomes in patients requiring SICU care and PN after cardiac, vascular or colonic surgery. We also propose to obtain needed hypothesis-generating, descriptive data from the Aim 1 study subjects to inform subsequent, truly mechanistic studies of GLN action in animal and human models of surgical critical illness. Study subjects will be randomized on an intent-to-treat basis to receive AG-PN or isonitrogenous, isocaloric STD-PN until enteral feeding is established.

Hypotheses:

  1. SICU patients receiving PN supplemented with GLN dipeptide (AG-PN) will demonstrate improved clinical outcomes compared to patients receiving STD-PN.
  2. Administration of AG-PN in the Aim 1 study subjects: a) increases serial blood levels of specific cytoprotective molecules and improves systemic redox status; b) is associated with decreased serum positivity for the bacterial products flagellin and lipopolysaccharide ( LPS) and the adaptive immune response to these mediators; and c) improves key indices of innate/adaptive immunity.

Specific Aims:

Aim 1: To perform a Phase III randomized controlled trial (RCT) to determine whether AG-PN decreases hospital mortality, nosocomial infections, and other indices of hospital morbidity versus STD-PN in SICU patients. The study will test whether AG-PN: decreases hospital mortality and the incidence of nosocomial infection (primary endpoints) in SICU patients after cardiac, vascular or colonic surgery. We will also determine whether AG-PN decreases total hospital infections, bloodstream infections (BSI), infections due to Staphylococcus aureus or fungal species, the number of days patients require mechanical ventilation, the SICU and total hospital length of stay and the 6-month mortality rate (secondary endpoints).

Aim 2: To determine in the Aim 1 study subjects whether AG-PN: a) increases systemic blood concentrations of the cytoprotective molecules GSH, HSP-70, HSP-27 and GLN and improves systemic GSH and cysteine redox status; b) is associated with decreased serum positivity for the bacterial products flagellin and LPS and titers of anti-flagellin and anti-LPS immunoglobulin M (IgM), immunoglobulin A (IgA) and immunoglobulin G (IgG); and c) improves key indices of innate/adaptive immune cell function.

  Eligibility

Ages Eligible for Study:   18 Years to 90 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion criteria: 1) A signed informed consent is in place on the patient's chart; 2) The patient is at least 18 but not more than 90 years of age at time of surgery; 3) The patient has a body mass index (BMI) < 40 kg/m2 prior to surgery; 4) The patient currently requires SICU care and is within 14 days postoperative from one of the following open (non-laparoscopic) surgical procedures: coronary artery bypass graft(CABG), cardiac valve, vascular (non-neurosurgical), or esophageal gastrointestinal resection of esophagus, stomach, small bowel, colon and/or rectum), or operation to identify the source of peritonitis when there is evidence of a bowel perforation (with or without bowel resection); 5) The patient will require central venous PN for 7+ subsequent days after entry on a clinical basis≠; 6) There is central venous access for administration of the study PN; and 7) The patient's primary physician(s) will allow the investigative team to manage the study PN and enteral feedings during the current hospitalization.

Exclusion Criteria: 1) The patient is pregnant; 2) The patient has clinical sepsis [defined as unstable blood pressure despite pressor support AND mean arterial pressure (MAP) < 60 mm Hg on at least 3 consecutive readings within a 3-hour period during the 24 hours prior to study entry; 3) a) The patient has a current malignancy requiring surgery as the GLND qualifying operation OR b) the patient is currently receiving an active regimen of chemotherapy and/or radiotherapy to treat a previously diagnosed malignancy†; 4) The patient has a history of seizures or pre-existing seizure disorder; 5) The patient has a current encephalopathy*; 6) The patient has a known history of cirrhosis OR a serum total bilirubin level ≥ 10.0 mg/dL); 7) The patient has a history of chronic renal failure requiring dialysis, or has significant renal dysfunction (defined as serum creatinine > 2.5 mg/dL and is not receiving continuous renal replacement therapy (CRRT) or the patient requires acute hemodialysis postoperatively; 8) The patient has a concomitant burn or trauma injury; 9) The patient has previously undergone an organ transplantation;10) the patient has a history of HIV/AIDS; 11) The patient has received any investigational drug within 60 days prior to study entry; 12) The patient has received enteral or parenteral enteral feedings enriched in arginine and/or glutamine within 30 days prior to study entry; and 13) The patient is unable or unwilling to participate in study procedures such as longitudinal blood draws and out patient follow-up visits, etc.

*Encephalopathy for GLND can be diagnosed only in non-chemically sedated patients by the primary critical care physicians or neurologist consultants and is defined as either a comatose state OR severe abnormalities diagnosed by electroencephalogram (EEG), OR if all of the following criteria are met: a) patient goes to sleep but is arousable to verbal and painful stimuli; does not open eyes spontaneously (decreased level of consciousness); b) patient exhibits severe confusion or complete disorientation when aroused (disorientation); c) patient exhibits severe lethargy or bizarre behavior (behavioral dysfunction); and d) patient exhibits inability to cooperate, asterixis, ataxia, clonus, decortication, decerebration, seizures, or rigidity (severe neuromuscular dysfunction).

† Patients with malignant metastasis and terminal untreatable carcinoma will be excluded as per the operational definition agreed upon by the Data Safety and Monitoring Board (DSMB).

≠ Please note that the patient should be in the SICU at the initial PN hang time.

  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00248638

Locations
United States, Colorado
University of Colorado Health Sciences Center
Denver, Colorado, United States, 80262
United States, Georgia
Emory University
Atlanta, Georgia, United States, 30322
United States, Rhode Island
The Miriam Hospital/Brown University
Providence, Rhode Island, United States, 02906
United States, Tennessee
Vanderbilt University
Nashville, Tennessee, United States, 37212-2713
United States, Wisconsin
University Of Wisconsin Hospital
Madison, Wisconsin, United States, 53792
Sponsors and Collaborators
Emory University
Investigators
Principal Investigator: Thomas R Ziegler, MD Emory University
  More Information

No publications provided

Responsible Party: Thomas R. Ziegler, MD, Professor of Medicine, Emory University
ClinicalTrials.gov Identifier: NCT00248638     History of Changes
Other Study ID Numbers: IRB00024944, U01DK069322, DK69322
Study First Received: November 3, 2005
Results First Received: December 19, 2013
Last Updated: December 19, 2013
Health Authority: United States: Food and Drug Administration

Additional relevant MeSH terms:
Critical Illness
Disease Attributes
Pathologic Processes

ClinicalTrials.gov processed this record on August 26, 2014