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History of Changes for Study: NCT03042143
Repair of Acute Respiratory Distress Syndrome by Stromal Cell Administration (REALIST) (REALIST)
Latest version (submitted May 19, 2022) on ClinicalTrials.gov
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Study Record Versions
Version A B Submitted Date Changes
1 February 2, 2017 None (earliest Version on record)
2 January 16, 2018 Study Status and Contacts/Locations
3 July 24, 2018 Arms and Interventions, Study Status, Eligibility, Study Design and Study Description
4 November 20, 2018 Recruitment Status, Study Status, Contacts/Locations and Oversight
5 November 26, 2018 Sponsor/Collaborators and Study Status
6 January 16, 2019 Study Status
7 April 14, 2020 Study Status, Study Description, Study Identification, Eligibility, Outcome Measures, Study Design and Conditions
8 August 16, 2021 Recruitment Status, Study Status, Contacts/Locations, Study Design, Eligibility, Outcome Measures and Study Description
9 May 19, 2022 Recruitment Status, Study Status, Contacts/Locations, Study Identification, Study Design and Study Description
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Study NCT03042143
Submitted Date:  February 2, 2017 (v1)

Open or close this module Study Identification
Unique Protocol ID: 16154DMcA-AS
Brief Title: Repair of Acute Respiratory Distress Syndrome by Stromal Cell Administration (REALIST) (REALIST)
Official Title: Repair of Acute Respiratory Distress Syndrome by Stromal Cell Administration (REALIST): An Open Label Dose Escalation Phase 1 Trial Followed by a Randomized, Double-blind, Placebo-controlled Phase 2 Trial
Secondary IDs:
Open or close this module Study Status
Record Verification: February 2017
Overall Status: Not yet recruiting
Study Start: September 2017
Primary Completion: September 2020 [Anticipated]
Study Completion: September 2020 [Anticipated]
First Submitted: February 1, 2017
First Submitted that
Met QC Criteria:
February 2, 2017
First Posted: February 3, 2017 [Estimate]
Last Update Submitted that
Met QC Criteria:
February 2, 2017
Last Update Posted: February 3, 2017 [Estimate]
Open or close this module Sponsor/Collaborators
Sponsor: Belfast Health and Social Care Trust
Responsible Party: Principal Investigator
Investigator: Professor Danny McAuley
Official Title: Professor and Consultant of Intensive Care Medicine
Affiliation: Belfast Health and Social Care Trust
Collaborators: Queen's University, Belfast
Northern Ireland Clinical Trials Unit
Open or close this module Oversight
U.S. FDA-regulated Drug: No
U.S. FDA-regulated Device: No
Data Monitoring: Yes
Open or close this module Study Description
Brief Summary: Acute Respiratory Distress Syndrome (ARDS) causes the lungs to fail due to the collection of fluid in the lungs (pulmonary oedema). ARDS is common in severely ill patients in Intensive Care Units and is associated with a high mortality and a high morbidity in those who survive. There is a large economic burden with direct healthcare costs, but also indirectly due to the impact on the carer and patient through the patients inability to return to full time employment. There is little evidence for effective drug (pharmacological) treatment for ARDS. There is increasing information that mesenchymal stem cells (MSCs) might be important in treating ARDS. REALIST will investigate if a single infusion of MSCs will help in the treatment of ARDS. The first step will be to first of all determine what dose of MSCs is safe and then divide patients suffering from ARDS into two groups, one of which will get MSCs and the other a harmless dummy (or placebo) infusion, who will then be followed up to determine if lung function improves. If effective this may lead to further research to determine if MSCs are effective in patients with ARDS. This project will also provide new information about mechanisms in the development of ARDS leading, potentially, to other new treatments
Detailed Description:

The role of MSCs as a novel treatment in ARDS. Mesenchymal Stem Cells (MSCs) are a mononuclear cell population that have the potential to differentiate into multiple lineages, and bone, cartilage and adipocyte cells in particular. Cell-based therapies have been termed the "next pillar of Medicine". MSCs constitute an innovative approach with substantial therapeutic promise for ARDS. MSCs possess several favorable biological characteristics, including convenient isolation, ease of expansion in culture while maintaining genetic stability, minimal immunogenicity and feasibility for allogenic transplantation.

MSCs reduce inflammation and enhance bacterial clearance during rodent and murine bacterial pneumonia, and augment repair of the animal and human lung. Large animal studies have also replicated these beneficial effects. Bone marrow derived (BM) hMSCs decreased acute lung injury (ALI), without producing organ toxicity, in endotoxin injured pigs. Two randomised small phase 1 studies of plastic adherent MSCs in patients with ARDS have taken place. In Japan, investigators used adipose-derived plastic adherent cells in a small cohort (n=12) of patients with ARDS randomized 1:1 to MSCs or placebo: showing that the cells were safe and well-tolerated in this patient group, and were associated with reduced plasma levels of the alveolar epithelial cell injury marker SP-D. In the US Matthay has completed the phase 1 START trial, using a dose escalation study of plastic adherent bone marrow derived MSCs, in patients with moderate to severe ARDS. START showed that marrow derived MSCs at similar doses to those proposed in this study are safe and well-tolerated, (n=9), with a trend to reduced lung injury in the group treated with the highest (10x106cells/kg) compared with the lower doses, 1-5x106cells/kg.

Research hypothesis:

In adult patients with moderate to severe ARDS, human umbilical cord derived CD362 +ve MSCs, (Cyndacel-C cells) are safe and improve important surrogate clinical outcomes.

Trial design:

The phase 1 trial is an open label dose escalation pilot study in which cohorts of subjects with moderate to severe ARDS will receive increasing doses of a single infusion of Cyndacel-C in a 3+3 design. Initially 3 cohorts with 3 subjects/cohort. Planned doses for the 3 cohorts pending absence of safety concerns are 1 x 106 cells/kg, 5 x 106 cells/kg, and 10 x 106 cells/kg.

After 7 days of follow-up for all study subjects in the phase 1 study is available the TMG will review the data and propose a cell dose for the phase 2 trial. This recommendation will be submitted to the DSMB for approval prior to initiating the phase 2 trial. For planning purposes, the phase 2 trial has been designed using the 10 x 106 cells/kg, dose assuming it will be the maximal tolerated dose.

The phase 2 trial is a randomized, double-blind, allocation concealed placebo-controlled study using the 10x106 cell/kg dose of Cyndacel-C or the maximal tolerable dose as determined by the DSMB in patients with moderate to severe ARDS.

Primary objective:

To assess the safety of a single intravenous infusion of Cyndacel-C cells in patients with ARDS.

Secondary objectives:

In patients with moderate to severe ARDS to determine the effect of a single intravenous infusion of Cyndacel-C cells on:

  1. Physiological indices of respiratory dysfunction reflecting severity of ARDS, as measured by oxygenation index (OI), respiratory compliance, and P/F ratio
  2. Sequential organ failure assessment (SOFA) score
  3. Alveolar and systemic markers of inflammatory responses
  4. Alveolar and systemic markers of cell specific injury

Population:

Patients will be prospectively screened daily. All patients with ARDS will be entered into a screening log. If the patient is not recruited the reason will be recorded. A fully anonymised minimal dataset will be recorded on these patients (age, gender, APACHE II score, worst P/F ratio at time of assessment, reasons for non-enrolment and vital status). APACHE II score and vital status will be collected using anonymised linkage to the ICNARC database through a defined CMP number (or equivalent). This will allow comparison to identify that the study population is representative of the overall cohort of patients. This information is required to establish an unbiased study population and to ensure the study can be reported in keeping with CONSORT guidelines (www.consort-statement.org).

Patient consent:

Informed consent procedure:

The study will be conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. The chief investigator (CI) (or designee) is responsible for ensuring that informed consent for trial participation is given by each patient or a legal representative. An appropriately trained doctor or nurse may take consent. The person taking informed consent must be GCP trained, suitably qualified and experienced and have been delegated this duty on the delegation log. Appropriate signatures and dates must be obtained on the informed consent documentation prior to collection of trial data and administration of the trial drug. If no consent is given a patient cannot be randomised into the trial. The incapacitating nature of the condition precludes obtaining prospective informed consent from participants. In this situation informed consent will be sought from a Personal Legal Representative or Professional Legal representative.

Personal legal representative consent:

Informed consent will be sought from the patient's personal legal representative (Per LR) who may be a relative, partner or close friend. The Per LR will be informed about the trial by the responsible clinician or a member of the research team and provided with a copy of the covering statement for the Per LR with an attached participant information sheet (PIS) and asked to give an opinion as to whether the patient would object to taking part in such medical research. If the Per LR decides that the patient would have no objection to participating in the trial the Per LR will be asked to sign the Per LR consent form which will then be countersigned by the person taking consent. The original will be retained in the trial site file and a copy given to the Per LR and another copy placed in the patients' medical records.

Professional legal representative consent:

As the patient is unable to give informed consent and no Per LR is available, a doctor who is not connected with the conduct of the trial may act as a professional legal representative (Prof LR). The doctor will be informed about the trial by the responsible clinician or a member of the research team and given a copy of the PIS. If the doctor decides that the patient is suitable for entry into the trial that doctor will be asked to sign the professional legal representative consent form. The original will be retained in the trial site file and a copy given to the Prof LR and another copy placed in the patients' medical records.

Retrospective patient consent:

Patients will be informed of their participation in the trial by the responsible clinician or a member of the research team once the patient regain capacity to understand the details of the trial. The responsible clinician or a member of the research team will discuss the study with the patient and the patient will be given a copy of the PIS to keep. The patient will be asked for consent to participate in the trial and to sign the consent to continue form which will then be countersigned by the person taking consent. The original will be retained in the trial site file and a copy given to the patient and another copy placed in the patients' medical records. Where consent to continue is not obtained, consent from the legal representative will remain valid. If the patient refuses consent, permission to use data collected to that point and to access medical records for trial data will be requested from the patient.

Withdrawal of consent:

Patients may withdraw or be withdrawn (by Per LR or Prof LR) from the trial at any time without prejudice.

In the event of a request to withdraw from the study, the researcher will determine which elements of the trial are to be withdrawn from the following possibilities and this will be documented:

  • Cyndacel-C administration if ongoing
  • On-going data collection during hospital admission
  • Confirmation of vital status
  • On-going data collection following hospital discharge In the event that the request is to withdraw from all elements of the study, only anonymised data recorded up to the point of withdrawal will be included in the study analysis.

Consent will also be requested to use the samples collected to that point.

Investigational medicinal product:

The investigational MSC product is allogeneic donor CD362+ human umbilical cord-derived mesenchymal stromal cells (CD362+UC-MSC; Cyndacel-C) which is a liquid cell suspension of ex vivo cultured human MSCs.

Storage, thawing and reconstitution of Cyndacel-C cells:

Trial guidelines will provide detailed information regarding the protocol for storage, thawing and reconstitution, and administration of the cell product Cyndacel-C and placebo.

Drug storage:

The study drug will be commenced as soon as possible following reconstitution and within 4 hours.

Study drug termination criteria:

Study drug will be continued until one of the following is met:

  1. Study drug related adverse event
  2. Death or discontinuation of active treatment
  3. Request from Per LR or Pro LR to withdraw the patient from the study
  4. Decision by the attending clinician on safety grounds.

Study drug compliance:

Any omission of the study drug will be recorded in the CRF to monitor compliance.

Study drug accountability:

The clinical trials pharmacist will be responsible for maintaining records of the study drug dispensed to patients in ICU. Drug administration will be recorded on the patient's prescription chart.

Study drug return and destruction:

At the end of the treatment period any remaining unused study drug will be returned to the hospital pharmacy. Destruction of trial medication will be in accordance with pharmacy department's standard operating procedures (SOPs) and hospital waste management policy. A record of destruction will be maintained.

Data Quality:

The NICTU will provide training to site staff on trial processes and procedures including CRF completion and data collection. Within the NICTU the clinical data management process is governed by SOPs to ensure standardisation and adherence to International Conference on Harmonisation Good Clinical Practice (ICH GCP) guidelines and regulatory requirements. Data is to be entered onto the electronic database as per the CRF entry timelines. On-site monitoring visits during the trial will check: (i) the accuracy of the data entered into the CRF, (ii) entries against source documents alongside adherence to the protocol, (iii) trial specific procedures and (iv) Good Clinical Practice (GCP). This monitoring will be carried out as per the trial specific Monitoring Plan. Changes to data will be recorded and fully auditable. Data errors will be documented and corrective actions implemented. Data validation will be implemented and discrepancy reports will be generated following data entry to identify data that may be out of range or inconsistent, or protocol deviations, based on data validation checks programmed into the clinical trial database. For routinely collected clinical data the NHS record will be the source document and for study specific measurements the CRF will be the source document.

Data management:

The PI (or designee) will collect all data and record this in the CRF. Each participant will be allocated a unique participant study number at trial entry, and this, and initials, will be used to identify him or her on the CRF for the duration of the trial. Data will be collected from the time of trial entry until hospital discharge. Trial data will be entered onto a CRF and processed electronically as per NICTU SOPs and the study specific Data Management Plan (DMP). Submitted data will be reviewed for completeness and entered onto a secure, backed-up custom database. Due care will be taken to ensure data safety and integrity, and compliance with the Data Protection Act 1998. Data queries will be raised electronically. The designated site staff will be required to respond to these queries within 2 weeks and send them back to the CTU after the queries have been reviewed and signed by the CI/delegated staff member. Any amended information will then be entered in the study database. A copy of the signed data query form should be retained with the CRF at the investigator site.

If the participant is transferred to another hospital the PI or designated member of the site study team will liaise with the receiving hospital to ensure complete data capture as per CRF instruction. If this is not possible, the primary outcome must be collected as a minimum. CRFs are to be submitted to the CTU as per the CRF submission schedule. Data censorship for each trial will occur 90 days post randomisation.

Data analysis:

The primary analysis will be conducted on all outcome data obtained from all participants regardless of protocol adherence, i.e. intention to treat analysis.

It is possible that some enrolled subjects may not be treated with study drug. Therefore a secondary analysis of the all-treated population analysis will be undertaken.

Statistical methods:

For the Phase 1 trial no formal statistical analysis will be performed on safety data. The primary analysis will be descriptive and will focus on adverse events. The number of pre-specified cell infusion-associated events will also be reported. The maximal tolerated dose up to 10x106cells /kg will be determined by the DSMB and used in the randomized controlled clinical trial.

For the Phase 2 trial, adverse event will be reported as for the phase 1 study. For continuously distributed outcomes, differences between groups will be tested using independent samples t-tests and analysis of covariance with transformations of variables to normality if appropriate, or non-parametric equivalents. Chi-square tests (or Fisher's Exact tests) will be used for categorical variables. A p value of 0.05 will be considered as significant. A single final analysis is planned at the end of the phase 2 trial. A detailed statistical analysis plan will be written before the statistical analysis commences. All the power calculations and methodology for data analysis have been confirmed by TBC, Senior Biostatiscian, Northern Ireland Clinical Trials Unit (NICTU).

Missing data:

Every effort will be made to minimise missing baseline and outcome data in this trial. The level and pattern of the missing data in the baseline variables and outcomes will be established by forming appropriate tables and the likely causes of any missing data will be investigated. This information will be used to determine whether the level and type of missing data has the potential to introduce bias into the analysis results for the proposed statistical methods, or substantially reduce the precision of estimates related to treatment effects. If necessary, these issues will be dealt with using multiple imputation or Bayesian methods for missing data as appropriate.

Sample size:

The phase 1 trial will recruit 9-18 participants. Although the primary focus of the phase 2 trial is safety, there is, however, power to detect a difference in physiological outcomes. The primary efficacy outcome measure will be the difference in OI between the Cyndacel-C and placebo treated groups at day 7. Based on data from a recently completed clinical trial in ARDS, the mean (standard deviation; SD) OI at day 7 in patients with ARDS is 62(51)cmH2O/kPa. To allow 2:1 recruitment (Cyndacel-C vs placebo) a sample size of 63 subjects (42 Cyndacel-C, 21 placebo) will have 80% power at a two-tailed significance level of 0.05 to detect a clinically significant difference of 39 cmH2O/kPa in OI between groups. In a previous phase 2 study of similar size an intervention can demonstrate a change in OI of a similar magnitude confirming a treatment effect of this size can be achieved.

Although few withdrawals or loss to follow-up are anticipated this has been allowed for this in the sample size calculation. In previous UK multicentre studies in the critically ill <3% withdrew consent or were lost to follow-up. Therefore, a conservative drop-out rate of 5% has been estimated and the study will require a total of 66 patients (44 patients in the Cyndacel-C and 22 in the placebo group).

Open or close this module Conditions
Conditions: Acute Respiratory Distress Syndrome
Keywords: Acute respiratory distress syndrome
Human umbilical cord-derived mesenchymal stem cells
Open or close this module Study Design
Study Type: Interventional
Primary Purpose: Treatment
Study Phase: Phase 1/Phase 2
Interventional Study Model: Parallel Assignment

The phase 1 trial is an open label dose escalation pilot study in which cohorts of subjects with moderate to severe ARDS will receive increasing doses of a single infusion of Cyndacel-C in a 3+3 design. Initially 3 cohorts with 3 subjects/cohort.

After 7 days of follow-up for all study subjects in the phase 1 study is available the TMG will review the data and propose a cell dose for the phase 2 trial. This recommendation will be submitted to the DSMB for approval prior to initiating the phase 2 trial.

The phase 2 trial is a randomized, double-blind, allocation concealed placebo-controlled study using the maximal tolerable dose as determined by the DSMB in patients with moderate to severe ARDS.

Number of Arms: 2
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Allocation: Randomized
Enrollment: 75 [Anticipated]
Open or close this module Arms and Interventions
Arms Assigned Interventions
Experimental: Human umbilical cord derived CD362 +ve MSCs
Maximun tolerated dose from the phase 1 trial will be infused over 60 mins
Biological: Human umbilical cord derived CD362 +ve MSCs
Infusion of Human umbilical cord derived CD362 +ve MSCs
Placebo Comparator: Placebo (Plasma-Lyte) infusion
Plasma-Lyte infused over 60 mins
Biological: Placebo (Plasma-Lyte)
Infusion of placebo
Open or close this module Outcome Measures
Primary Outcome Measures:
1. Oxygenation index (OI)
[ Time Frame: Day 7 ]

OI is a physiological index of the severity of ARDS and measures both impaired oxygenation and the amount of mechanical ventilation delivered
2. Incidence of Serious Adverse Events (SAEs)
[ Time Frame: 28 days ]

Incidence of SAEs
Secondary Outcome Measures:
1. Oxygenation index
[ Time Frame: Days 4 and 14 ]

2. Sequential Organ Failure Assessment (SOFA) score
[ Time Frame: Days 4, 7 and 14 ]

SOFA score is a measure of organ failure
3. Respiratory compliance (Crs)
[ Time Frame: Days 4, 7 and 14 ]

Crs is a physiological measure of pulmonary function in ARDS
4. Partial pressure of arterial oxygen to the fraction of inspired oxygen ratio (P/F ratio)
[ Time Frame: Days 4, 7 and 14 ]

P/F ratio is a physiological measure of pulmonary function in ARDS
Open or close this module Eligibility
Minimum Age: 16 Years
Maximum Age:
Sex: All
Gender Based:
Accepts Healthy Volunteers: No
Criteria:

Inclusion Criteria:

  • 1. ARDS as defined by the Berlin definition.
    1. Onset within 1 week of identified insult.
    2. Within the same 24-hour time period i. Hypoxic respiratory failure (PaO2/ FiO2 ratio ≤ 27kPa on PEEP ≥ 5 cmH20) ii. Bilateral infiltrates on chest X-ray consistent with pulmonary oedema not explained by another pulmonary pathology iii. Respiratory failure not fully explained by cardiac failure or fluid overload

Exclusion Criteria:

  • 1. Not receiving invasive mechanical ventilation. 2. More than 96 hours from the onset of ARDS. 3. Age < 16 years. 4. Patient is known to be pregnant. 5. Participation in a clinical trial of an investigational medicinal product within 30 days.

    6. Major trauma in the prior 5 days 7. Presence of any active malignancy (other than non-melanoma skin cancer) that required treatment within the last year.

    8. WHO Class III or IV pulmonary hypertension 9. Pulmonary embolism within past 3 months 10. Currently receiving extracorporeal life support (ECLS) 11. Severe chronic liver disease with Child-Pugh score > 12 12. DNAR (Do Not Attempt Resuscitation) order in place 13. Treatment withdrawal imminent within 24 hours. 14. Consent declined. 15. Prisoners. 16. Non-English speaking patients or those who do not adequately understand verbal or written information unless an interpreter is available.

    17. Previously enrolled in the REALIST trial.

Open or close this module Contacts/Locations
Central Contact Person: Danny F McAuley, MD
Email: d.f.mcauley@qub.ac.uk
Central Contact Backup: Cecilia O'Kane, Ph.D
Email: c.okane@qub.ac.uk
Study Officials: Danny F McAuley, Professor
Principal Investigator
Belfast Health and Social Care Trust
Locations: United Kingdom, Northern Ireland
Belfast Health and Social Care Trust, Royal Hospitals
Belfast, Northern Ireland, United Kingdom, BT12 6BA
Contact:Contact: Danny F McAuley, MD d.f.mcauley@qub.ac.uk
Contact:Contact: Cecilia O'Kane, Ph.D c.okane@qub.ac.uk
Open or close this module IPDSharing
Plan to Share IPD: Yes
Supporting Information:
Time Frame:
Access Criteria:
URL:
Open or close this module References
Links:
Available IPD/Information:

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