Efficacy of Albumin Replacement and Balanced Solution in Patients with Septic Shock (the ALBIOSS-BALANCED Trial): a 2-by-2 Factorial, Investigator-initiated, Open- Label, Multicenter, Randomized, Controlled Trial
Overview
- Phase
- Phase 3
- Intervention
- Albumin
- Conditions
- Septic Shock
- Sponsor
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
- Enrollment
- 1319
- Locations
- 37
- Primary Endpoint
- All-cause 90-day mortality
- Status
- Completed
- Last Updated
- last year
Overview
Brief Summary
Septic shock is a devastating condition often observed in ICU. It is characterized by pro-inflammatory and immune responses, organ failures, high incidence of AKI and lethality. Fluid resuscitation is pivotal as supportive therapy. At present, there are no effective therapies to improve survival of such clinical condition, often characterized by a mortality as high as 40% during the first 90 days from diagnosis.
This project proposes a large 2-by-2 factorial randomized clinical trial testing the efficacy of albumin and the low- chloride balanced crystalloid solutions (either Ringer Lactate, Ringer Acetate, or Crystalsol - BAL) in septic shock.
The investigators have recently concluded a multicenter, randomized trial, the ALBIOS trial, in which, in a post-hoc analysis, albumin, in addition to crystalloids, reduced 90-day mortality in patients with septic shock, as compared to crystalloids alone (Caironi P et al, 2014). Crystalloids with supra-physiological chloride content may deteriorate renal perfusion, increasing the risk of acute kidney injury (AKI) and mortality.
Detailed Description
The project will consist of a 2-by-2 factorial, investigator-initiated, open-label, multicenter, randomized, controlled trial, with PROBE design (Prospective Randomized Open Trial with Blinded Evaluation of Outcomes), in patients with septic shock, as defined according to clinical criteria. Patients will be randomized in a 1:1:1:1 ratio to one of the 4 study groups (Albumin + BAL, Albumin + NS, BAL, NS). Both the primary endpoints will include events evaluated objectively: 90-day mortality and incidence of AKI, as assessed by KDIGO criteria (KDIGO Acute Kidney Injury Work Group, 2012).
Investigators
Eligibility Criteria
Inclusion Criteria
- •Patients with septic shock if they meet the two following criteria:
- •Presence of an infection (known or suspected) in at least one site:
- •Urinary tract
- •Others (blood, skin and soft tissues, central nervous system, bones and joints, cardiac system, reproductive organs).
- •Presence of a severe and acute, sepsis-related cardiovascular failure (as assessed by the SOFA score - see Annex 1), requiring vasopressor to maintain mean arterial pressure \>=65 mmHg, despite adequate volume resuscitation a) Cardiovascular SOFA score \> 2 (3 or 4) If the patient is unable to provide informed consent, she/he can be included in the trial provided that the requirements of ongoing laws are fulfilled; details on this approach are provided in the protocol, par 11.1 and related Annex
- •The patient will be informed about having been included in a clinical trial, as soon as she/he will regain consciousness.
Exclusion Criteria
- •Age \< 18 years
- •Moribund state
- •Known or suspected adverse reaction to albumin administration
- •Septic shock in patients with traumatic brain injury or a clinically active cerebral lesion (known or suspected)
- •Severe congestive heart failure (NYHA III and IV classes)
- •Clinical situations in which the use of albumin is known or supposed to be clinically beneficial (hepatic cirrhosis with ascites, malabsorption syndrome or protein-losing enteropathy, nephrotic syndrome, burns)
- •More than 24 hours after the onset of septic shock
- •Religious objection to the administration of human blood products
- •Presence of chronic end-stage renal disease
- •Severe hyperkalemia (\> 6 mmol/L)
Arms & Interventions
Albumin + Balanced
Human Albumin In parallel with fluid administration for volume resuscitation, patients will receive 400 ml of 20% albumin solution both at randomization (D0) and at day 1 (D1). Subsequently, from day 2 (D2) until day 90 (D90) or ICU discharge (whichever comes first), 20% albumin will be administered on a daily basis, to maintain serum albumin concentration equal to or greater than 30 g/L, based upon serum albumin determination. Balanced crystalloid solutions According to the preference and the standard use of the participating center: * Ringer Lactate * Ringer Acetate * Crystalsol
Intervention: Albumin
Albumin + Balanced
Human Albumin In parallel with fluid administration for volume resuscitation, patients will receive 400 ml of 20% albumin solution both at randomization (D0) and at day 1 (D1). Subsequently, from day 2 (D2) until day 90 (D90) or ICU discharge (whichever comes first), 20% albumin will be administered on a daily basis, to maintain serum albumin concentration equal to or greater than 30 g/L, based upon serum albumin determination. Balanced crystalloid solutions According to the preference and the standard use of the participating center: * Ringer Lactate * Ringer Acetate * Crystalsol
Intervention: Balanced
Albumin + Saline
Human Albumin In parallel with fluid administration for volume resuscitation, patients will receive 400 ml of 20% albumin solution both at randomization (D0) and at day 1 (D1). Subsequently, from day 2 (D2) until day 90 (D90) or ICU discharge (whichever comes first), 20% albumin will be administered on a daily basis, to maintain serum albumin concentration equal to or greater than 30 g/L, based upon serum albumin determination. Normal Saline Na+ 154 mEq/L, Cl- 154 mEq/L (0.9% NaCl).
Intervention: Albumin
Balanced
Balanced crystalloid solutions (Ringer Lactate, Ringer Acetate, Crystalsol)
Intervention: Balanced
Outcomes
Primary Outcomes
All-cause 90-day mortality
Time Frame: Up to 90 days
All-cause death from randomization to 90 days
Combined co-primary endpoint
Time Frame: Up to 90 days
The composite of all-cause death from randomization to 90 days and new occurrence of acute kidney injury (AKI).
Secondary Outcomes
- ICU mortality(Up to ICU discharge, a median of 9 days)
- In-hospital mortality(Up to hospital discharge, a median of 20 days)
- 1-year mortality(Up to 1 year)
- SOFA score(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- Incidence of AKI during ICU stay(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- RRT(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- Need for vasopressors(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- Mechanical ventilation(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- Secondary infections in ICU(Up to 90 days or ICU discharge - a median of 9 days - whichever comes first)
- Duration of stay in ICU(Up to ICU discharge, a median of 9 days)
- Duration of stay in hospital(Up to hospital discharge, a median of 20 days)
- 1-year functional and physical disability(Up to 1 year)