Safety and PK-PD Study of Oral L-CIT in Preterm Infants with BPD±PH and NEC
- Conditions
- BPD - Bronchopulmonary DysplasiaPulmonary HypertensionNEC
- Interventions
- Dietary Supplement: L-Citrulline
- Registration Number
- NCT05636397
- Lead Sponsor
- The Hospital for Sick Children
- Brief Summary
The purpose of this study is to evaluate the safety and explore the PK/PD of L-CIT supplementation in preterm infants to prevent the development of inflammatory pathways initiated by low levels of plasma CIT, specifically in preterm infants with post surgical NEC and BPD±PH.
- Detailed Description
Preterm infants are born with underdeveloped organs and immune systems, placing them at great risk for morbidity. They are more susceptible to inflammatory injury, particularly from conditions of prematurity mediated by inflammatory pathways such as bronchopulmonary dysplasia (BPD) and necrotizing enterocolitis (NEC).
L-CIT, an amino acid, is the first intermediate in the urea cycle as well as a precursor to arginine and nitric oxide (NO), which promotes blood flow. It is made in the intestine and has been shown to exert vasoprotective and anti-inflammatory effects. BPD-PH and NEC are two specific inflammatory diseases of prematurity involving CIT, arginine or NO deficiencies.
Evaluation of the safety and PK/PD of L-CIT supplementation for diseases involving CIT, arginine or NO deficiencies in preterm infants is important. Therefore, in this trial the investigator would like to evaluate the safety and pharmacokinetics/pharmacodynamics (PD) of L-CIT supplementation in preterm infants post surgical NEC and BPD-PH.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 60
- Born ≤ 30 weeks at birth
- Post-menstrual age (PMA) ≥ 34 weeks
- Echocardiographic evidence of PH for infants with BPD+PH
- On invasive or non-invasive ventilation with RSS >2.0 for >12hours/day for at least 48 hours
- Informed written consent (parents/substitute decision maker)
- Congenital Heart Disease [Exceptions: small atrial septal defect (ASD), small ventricular septal defect (VSD), small patent ductus arteriosus (PDA)]
- Infants with pulmonary vein stenosis
- Concurrent sepsis with hemodynamic instability
- Infants considered likely to die within next 7 days
- Any other condition that, in the opinion of the investigator, may adversely affect the infant's ability to complete the study or its measures or pose significant risk to the infant.
Arm 2: surgical NEC
Inclusion Criteria
- Born ≤ 30 weeks at birth
- Recovering from Stage IIIb NEC as per modified Bell's staging (pneumoperitoneum requiring surgery)
- Tolerating 30 ml/kg/day of enteral feeds
- On invasive or non-invasive ventilation (NIPPV/nCPAP) with RSS >2.0 for > 12hours/day for at least 48 hours, 10-14 days post surgery
- Informed written consent (parents/substitute decision maker)
- Considered medically stable by clinical team
Exclusion Criteria:
- Congenital heart disease (except small ASD, small VSD and non hsPDA)
- Pulmonary vein stenosis
- Concurrent sepsis with hemodynamic instability
- Likely to die within next 7 days
- Other condition significantly affecting pulmonary function independent of prematurity or NEC
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description BPD±PH L-Citrulline Arm 1: BPD±PH Total of 12-24 infants; 6-12 at each dose level of oral dosage form of L-Citrulline. (300 or 500 mg/kg/day divided q6 hours). Dose Level 1 = 300 mg/kg/day Dose Level 2 = 500 mg/kg/day Surgical NEC L-Citrulline Arm 2: sNEC A total of 18-36 infants with Stage III NEC; 6-12 at each dose level of oral dosage form of L-Citrulline. (75, 150 or 225 mg/kg/day divided q6 hours) Dose Level 1 = 75 mg/kg/day Dose Level 2 = 150 mg/kg/day Dose Level 3 = 225 mg/kg/day
- Primary Outcome Measures
Name Time Method Safety of oral L-Citrulline administration 5 years The number of patients with adverse events (AE) as a measure of safety and tolerability
- Secondary Outcome Measures
Name Time Method Association of blood pressure as one of the PD outcomes with maximum L-CIT concentration (Cmax) 5 years Blood pressure of the study participants will be associated with PK measures of L-CIT exposure i.e. Cmax using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Association of stoma or nasogastric output as one of the PD outcomes with maximum L-CIT concentration (Cmax) 5 years Stoma or nasogastric output of the study participants will be associated with PK measures of L-CIT exposure i.e. Cmax using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Bayley's scale for infant development 5 years Bayley Scales of Infant and Toddler Development is an extensive formal developmental assessment tool for diagnosing developmental delays in early childhood. BSID is the commonly used abbreviation for Bayley Scales of Infant and Toddler Development. Bayley-III includes a motor score, and fine and gross motor subtest scores. The standardized mean motor score is 100 (SD 15), with scores lower than 85 indicating mild impairment, and lower than 70 indicating moderate or severe impairment.In this particular trial, the investigator would be looking at the correlation between the inflammatory markers (IL-1β, IL-6, IL-8, IL-10, TNFα) and Neurodevelopmental outcomes from Bayley's scale during 18-24M follow up visit in babies received L-Citrulline during their NICU stay.
Association of stool output as one of the PD outcomes with maximum L-CIT concentration (Cmax) 5 years Stool output from the study participants will be associated with PK measures of L-CIT exposure i.e. Cmax using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Association of stoma or nasogastric output with the area under the concentration time curve (AUC) for L-CIT 5 years Stoma or nasogastric output of the study participants will be associated with PK measures of L-CIT exposure i.e. Area under Concentration time curve (AUC) using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen.
Association of stool output with the area under the concentration time curve (AUC) for L-CIT 5 years Stool output from the study participants will be associated with PK measures of L-CIT exposure i.e. Area under Concentration time curve (AUC) using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen.
Association of blood pressure with minimum L-CIT concentration (Cmin) 5 years Blood pressure of study participants will be associated with PK measures of L-CIT exposure i.e. Cmin using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Oxidative stress 5 years Oxidative stress (measured in tracheal aspirates and blood)
Desaturation index 5 years The oxygen desaturation index (ODI) is commonly used to evaluate the severity of nocturnal hypoxemia. The ODI is defined as the number of episodes of oxygen desaturation per hour of sleep with desaturation events of \>=10sec/ sampled hour.
Changes in Blood Pressure 5 years Changes in diastolic and systolic blood pressure prior to and during CIT treatment.
Ventilation 5 years Days on mechanical ventilation, non-invasive ventilation, and supplementary oxygen
BPD 5 years number of days of survival free of BPD
Association of stoma or nasogastric output with minimum L-CIT concentration (Cmin) 5 years Stoma or nasogastric output from study participants will be associated with PK measures of L-CIT exposure i.e. Cmin using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Respiratory Score (RSS) 5 years The respiratory severity score (RSS) is a simplified severity score consisting of the mean airway pressure (MAP) multiplied by the fraction of inspired oxygen (FiO2). This score ranges from 0 to 12, with a higher score indicating more severe lung disease.
Stoma, nasogastric or stool output 5 years Volume of stoma, nasogastric or stool output prior to and during CIT treatment
Postnatal steroid Use 5 years Number of days study participants received postnatal steroids during their NICU stay.
Association of stool output with minimum L-CIT concentration (Cmin) 5 years Stool output from study participants will be associated with PK measures of L-CIT exposure i.e. Cmin using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen. Future larger studies will then be used to examine these relationships with adequately powered studies.
Correlation between CIT and arginine levels 5 years Correlation between changes in CIT and arginine levels with nitrite/nitrate levels
Association of blood pressure with the area under the concentration time curve (AUC) for L-CIT 5 years Blood pressure of the study participants will be associated with PK measures of L-CIT exposure i.e. Area under Concentration time curve (AUC) using univariate correlation approaches. The investigator will then attempt to construct a PK/PD model to link PK and PD measures found to be of significance during the univariate screen.
Biomarkers of inflammation 5 years The levels of IL-1β, IL-6, IL-8, IL-10, TNFα will be measured in tracheal aspirates and blood plasma. The aggregated levels fo these cytokines will reflect the inflammatory status of the study participant.
BPD severity 5 years Moderate to severe BPD based on the different mode of ventilatory support needed at 36 wks PMA.
No BPD = off all oxygen and positive pressure support Moderate BPD = low flow oxygen only Severe BPD= positive pressure support (high flow, CPAP, NIPPV, or ETT)Pre-discharge mortality 5 years Number of study participants who died during NICU admission.
Trial Locations
- Locations (1)
The Hospital For Sick Children
🇨🇦Toronto, Ontario, Canada