Prematurity as Predictor of Children's Cardiovascular-renal Health (PREMATCH)
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|ClinicalTrials.gov Identifier: NCT02147457|
Recruitment Status : Completed
First Posted : May 26, 2014
Last Update Posted : May 25, 2016
|First Submitted Date||April 9, 2014|
|First Posted Date||May 26, 2014|
|Last Update Posted Date||May 25, 2016|
|Study Start Date||October 2014|
|Actual Primary Completion Date||December 2015 (Final data collection date for primary outcome measure)|
|Current Primary Outcome Measures
||Endothelial function. [ Time Frame: Baseline measurement. Cross-sectional study. ]
Changes in the macro- and microcirculation of the cardiovascular-renal system:
|Original Primary Outcome Measures||Same as current|
|Current Secondary Outcome Measures||Not Provided|
|Original Secondary Outcome Measures||Not Provided|
|Current Other Pre-specified Outcome Measures||Not Provided|
|Original Other Pre-specified Outcome Measures||Not Provided|
|Brief Title||Prematurity as Predictor of Children's Cardiovascular-renal Health|
|Official Title||Prematurity as Predictor of Children's Cardiovascular-renal Health (PREMATCH)|
Extreme preterm birth interferes with the development of the cardiovascular system. Both macro- as well as microvasculature undergoes extensive, organ specific maturation. Under normal fetal conditions, microvascular growth drives renal development and continues until 34-36 weeks of gestational age, while retinal vascular growth continues until term age. Studies show that there is association between low birth weight and cardiovascular dysfunction. According to the Barker hypothesis, this is due to nutritional shortage. In extreme preterm birth cases, this growth restriction is observed in neonatal life.
In adult life, this suboptimal growth is associated with impaired renal and (micro)vascular function, hypertension, glucose intolerance and cardiovascular disease. According to the Brenner hypothesis, disrupted renal development results in hyperfiltration and hypertension, a process that subsequently promotes itself and leads to renal impairment. We will investigate macro- and microvasculature in different organs, including eye, kidney, heart and sublingual mucosa in former preterm infants, now aged 8-13 years old and age-matched controls.
The expectation is that the results of this project will identify risk factors for cardiovascular-renal disease in the adult life of former preterm infants compared to the controls, while further analysis on mediators in neonatal life of this cardiovascular-renal outcome may provide new information on perinatal risk factors.
STATE OF THE ART The cardiovascular system (both macro- and microcirculation) undergoes extensive maturation throughout fetal, perinatal and pediatric life. Extreme preterm birth interferes with the normal development of the cardiovascular and microcirculatory systems. Disruption in vascular ontogenesis leads to abnormalities in the microvascular structure and circulation in various organs, such as retina (retinopathy of prematurity [O'Connor et al.]), kidney (abnormal glomerulogenesis [Sutherland et al.]) and glycocalyx in sublingual capillaries [Nieuwdorp et al.], among microvascular-driven disruptions observed in other organs (e.g. periventricular leukomalacia [Takashima et al.], bronchopulmonary dysplasia [Gien et al.]). Besides the well known retinopathy of prematurity, microvascular growth drives glomerulogenesis in the kidney and terminates after 34-36 weeks of gestational age under normal fetal conditions.
Perinatal (fetal or neonatal) growth restriction or preterm birth therefore impairs glomerulogenesis [Sutherland et al., Abitbol et al., Barker et al., Faa et al., Gubhaju et al., Zaffanello et al.]. Other cardiovascular abnormalities following from premature birth in later life include decreased heart rate variability [Rakow et al.], endothelial dysfunction [Norman et al.] and hypertension [Abitbol et al., Keijzer-Veen et al.].
Epidemiological observations further confirm that former preterm born infants are indeed at increased risk to develop cardiovascular disease and chronic kidney disease during adulthood [Brenner et al., Carmody et al., Vieux et al., Zandi-Nejad et al.]. The concept that fetal and perinatal conditions affect normal cardiovascular and renal ontogeny is in itself not new. Epidemiological studies showed that there is an association between low birth weight and vascular dysfunction in later life, suggesting that vascular impairment in early life is a harbinger of a poorer long-term prognosis [Sutherland et al., Bacchetta et al., Keijzer-Veen et al., Puddu et al.]. Intra-uterine growth retardation and children small for gestational age can be regarded as a failure of a fetus to reach the genetic potential of growth due to nutritional deprivation, the so-called Barker hypothesis [Barker et al.]. In adult life, this early growth retardation is associated with impaired renal and (micro)vascular function, hypertension, glucose intolerance and cardiovascular disease [Sutherland et al., Abitbol et al., Faa et al., Zaffanello et al., Carmody et al., Keijzer-Veen et al.].
The same sequence of vascular impairment serving as an indicator for long-term prognosis applies to the (early) postnatal life of preterm infants. According to the Brenner hypothesis, the decreased number of nephrons causes hyperfiltration, sodium loss with activation of the renin-angiotensinaldosterone system and hypertension [Brenner et al.], a process that entails further nephron loss, predisposition to develop proteinuria and possibly chronic kidney disease [Vieux et al., Puddu et al.].
MOVING BEYOND THE CURRENT STATE OF THE ART This project aims to move beyond the state-of-the-art by studying association between macro- and microvascular structure and function in children (8-13 years) born prematurely (extremely low birth weights, ELBW, i.e. birth weight below 1000 grams), and sex- and age-matched controls. The specific strengths hereby are that this ELBW cohort has been well characterized on its perinatal aspects [George et al.]. The characterization in the postnatal period includes biometry, perinatal characteristics (e.g. Apgar score, drugs, respiratory support), creatinine trends in the first 6 weeks of postnatal life and psychomotor development (Bayley Scales of Infant Development) at the age of nine months and two years.
The phenotypes of interest for the current project include the micro- and macrocirculation, cardiac structure and function, endothelial function and renal anatomy and function during childhood. We hereby aim to apply state of the art methods (cf methodology section) to assess micro- and macrocirculatory function, combined with state of the art statistics and advanced tools (metabolomics, epigenetics) to explore epidemiological findings and its pathogenesis.
The expectation is that the results of this project will identify and quantify risk factors in former preterm infants for cardiovascular-renal disease when compared to control children, while we can also map early risk factors for cardiovascular-renal disease in adult life and pave the way for a better informed prevention of these complications. Finally, data collected in this specific cohort can be compared to data collected in other cohorts.
HYPOTHESIS We hypothesize that former ELBW infants, compared to controls following term birth, will be associated with changes in the macro- and microcirculation of the cardiovascular-renal system already in young children over and beyond what is currently known. These changes - even if subtle - are probably forerunners of cardiovascular-renal complications in adulthood. In addition, confounders (e.g. neonatal nutrition, neonatal treatment) documented in the early life may identify new approaches for early prevention.
OBJECTIVES Using a case-control design in a 1/2 proportion, this study aims to detect functional and structural changes in children after preterm birth (ELBW) compared with children born after normal gestation with normal weight. The phenotypic aspects considered cover micro- and macrovascular structures and function.
MODULATORS Next, this project will search for host characteristics, life style and environmental factors (see below) that may further modulate the differences in youngsters born either prematurely (case, ELBW) and at term, as well as for circulating and urinary biomarkers that are associated with the observed differences, and may provide insight into the pathogenesis involved.
IDENTIFICATION OF PREDICTORS Based on the existing database of the early perinatal follow-up of the prematurely born infants, this project will attempt to construct models predicting increased risk of potentially clinically significant changes associated with preterm birth and vice versa (mediators in neonatal life may predict cardiovascular-renal outcome in adult life).
INTENTION TO LINK THESE DATASETS WITH OTHER COHORTS WITH SIMILAR OBSERVATIONS Finally, pooling of these cardiovascular phenotypic data in children with other cohorts, either or not former ELBW cases may provide opportunities for additional prediction model development, validation and subsequent secondary preventive strategies.
METHODOLOGY Methodology-related issues include phenotyping, database construction/quality control, modulators, predictors and statistics.
DATABASE CONSTRUCTION/QUALITY CONTROL Trained nurses will code questionnaires, technicians will enter the data. For quality assurance, 10% of questionnaires will be randomly selected and recoded by another nurse. All data will be inputted twice by different technicians. Duplicate datasets will be compared with the PROC COMPARE application (SAS software) to trace input errors. Data coders and SAS programs will check for internal consistency of questionnaire replies. Non-Gaussian distributions will be normalized by proper transformation. As part of the quality control, descriptive statistics will be generated at 6 month intervals.
Measurements of 24h urine samples include volume, electrolytes, creatinine, micro-albumin, and aldosterone. Urinary proteomics will be done in collaboration with Prof Harald Mischak, SME Mosaiques (mosaiques-diagnostics.de) by capillary electrophoresis coupled to mass spectrometry according to standard operating procedures in an environment with proper quality control [Mischak et al.].
- GPS coordinates of residence. Meteorological data and data on airborne pollutants and fine particulate collected from the appropriate sources.
PREDICTORS In our published cohort [George et al.] on creatinemia in ELBW infants in the first 6 weeks of life, raised creatinemia reflected immaturity (e.g. gestational age, weight) and morbidity (Apgar, ventilation, retinopathy of prematurity, intraventricular hemmorrhage), but also treatment modalities (e.g. ibuprofen, steroids, parenteral nutrition). We will link the perinatal covariates and creatinine trends to the dataset of this study to explore to what extent perinatal data predict cardiovascular and renal outcome. Since also treatment modalities are included, this study will provide first data on long term cardiovascular and renal outcome following drug exposure.
|Study Design||Observational Model: Case-Control
Time Perspective: Cross-Sectional
|Target Follow-Up Duration||Not Provided|
|Biospecimen||Retention: Samples With DNA
Urine collection Blood collection
|Sampling Method||Non-Probability Sample|
ELBW (birth weight below 1000 g) neonates and have been well characterized and documented in the postnatal period, survivors (n = 140) will be matched with two controls. One control will be matched to sex, birth year and residential area and will be suggested by the index patient, the second control will be age and sex matched from the area of the field center. All children considered are currently between 8 and 15 years of age.
Based on GCP guidance and national law, parents or custodians will provide informed written consent, while the child has to provide informed assent.
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Original Estimated Enrollment
|Actual Study Completion Date||December 2015|
|Actual Primary Completion Date||December 2015 (Final data collection date for primary outcome measure)|
|Ages||8 Years to 15 Years (Child)|
|Accepts Healthy Volunteers||Yes|
|Contacts||Contact information is only displayed when the study is recruiting subjects|
|Listed Location Countries||Belgium|
|Removed Location Countries|
|Other Study ID Numbers||PREMATCH|
|Has Data Monitoring Committee||No|
|U.S. FDA-regulated Product||Not Provided|
|IPD Sharing Statement||Not Provided|
|Responsible Party||Universitaire Ziekenhuizen Leuven|
|Study Sponsor||Universitaire Ziekenhuizen Leuven|
|PRS Account||Universitaire Ziekenhuizen Leuven|
|Verification Date||November 2015|