To evaluate whether administration of ganciclovir reduces serum IL-6 levels (i.e. reduction between baseline and 14 days post-randomization) in immunocompetent adults with severe sepsis or trauma associated respiratory failure.
- In CMV seropositive adults with severe sepsis or trauma , pulmonary and systemic CMV reactivation amplifies and perpetuates both lung and systemic inflammation mediated through specific cytokines, and contributes to pulmonary injury and multiorgan system failure,
- Prevention of CMV reactivation with ganciclovir decreases pulmonary and systemic inflammatory cytokines that are important in the pathogenesis of sepsis and trauma related complications.
|Acute Lung Injury Acute Respiratory Distress Syndrome Respiratory Failure||Drug: IV Ganciclovir Drug: Placebo||Phase 2|
|Study Design:||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary Purpose: Prevention
|Official Title:||A Randomized Double-Blind Placebo-Controlled Trial of Ganciclovir/Valganciclovir for Prevention of Cytomegalovirus Reactivation in Acute Injury of the Lung and Respiratory Failure (The GRAIL Study)|
The following virologic parameters will be compared between the groups:
Additional cytokines with proven association with ALI and CMV will be compared between the groups.
Cytokines will be analyzed at each time point and over time (area under the curve), and peak levels will be compared between randomization and Day 28 (end of treatment).
|Actual Study Start Date:||March 10, 2011|
|Study Completion Date:||October 28, 2016|
|Primary Completion Date:||June 17, 2016 (Final data collection date for primary outcome measure)|
Experimental: IV Ganciclovir
5mg/kg IV twice daily for 5 days, then followed by either IV ganciclovir or oral valganciclovir once daily until hospital discharge
Drug: IV Ganciclovir
For first 5 days, dosing of intravenous ganciclovir is 10 mg/kg daily, given as 5 mg/kg every 12 hours (adjusted for renal function). After first 5 days (up to 28 days) IV ganciclovir 5 mg/kg QD ( adjusted for renal function). A minimum interval of 6 hours is required between the first and second dose.
Placebo Comparator: Placebo
normal saline IV twice daily for 5 days, then followed by either IV normal saline or oral placebo once daily until hospital discharge
For first 5 days, dosing of intravenous placebo is daily, given every 12 hours. After first 5 days (up to 28 days), IV placebo QD. A minimum interval of 6 hours is required between the first and second dose.
The placebo is an IV solution that does not contain any active medications.
Critical illness due to severe sepsis and trauma are major causes of morbidity and mortality, and a substantial economic burden in the United States and worldwide. Despite advances in clinical care, patients with sepsis and trauma-associated respiratory failure represent specific populations with high rates of adverse outcomes. The etiology of respiratory failure in patients with severe sepsis and trauma is multifactorial, but acute lung injury (ALI) is one of the leading causes, and is associated with prolonged ICU and hospital stays, mortality, and long-term sequelae. Other than general supportive care, few specific interventions other than lung protective ventilation have been shown to improve outcomes in such patients. New approaches for understanding the pathogenesis and developing better therapies are urgently needed.
Acute Lung Injury (ALI) is a syndrome consisting of acute hypoxemic respiratory failure with bilateral pulmonary infiltrates that is associated with both pulmonary and nonpulmonary risk factors (eg. sepsis, trauma) and that is not due primarily to left atrial hypertension. Although a distinction between ALI and a more severe subtype (termed acute respiratory distress syndrome (ARDS) has been made, the pathogenesis, risk factors, and outcomes appear to be similar and for the purposes of this protocol, the term acute lung injury [ALI] will be used to encompass both entities. Accepted consensus definitions of ALI have been introduced and are now widely used for laboratory and clinical investigations of ALI. Acute Lung Injury (ALI) is defined as:
Overly intense, persistent and dysregulated pulmonary and systemic inflammation has emerged as the leading hypothesis for the pathogenesis of ALI and its complications, but the contributory factors and mechanisms are incompletely defined. Several carefully-conducted prospective human studies have shown an association between specific inflammatory biomarkers in blood and BALF (both the initial levels at onset and changes over time) and important clinical outcomes in ALI. [Animal models have also demonstrated an association between inflammatory cytokines and non-pulmonary organ injury and dysfunction] In addition, one of the most important interventions (low-tidal volume ["lung protective"] ventilation) shown to decrease mortality in ALI is associated with reductions in inflammatory cytokines (IL-6, IL-8) in blood and bronchoalveolar lavage fluid [BALF].
Cytomegalovirus (CMV) is a ubiquitous virus in humans worldwide, and has been linked to adverse clinical outcomes including prolongation of mechanical ventilation, increased length of stay, and mortality in multiple studies of critically-ill, apparently immunocompetent, seropositive adults.
Cytomegalovirus (CMV) is a human herpes virus known to infect more than 50-90% of US adults and is known to be a major cause of morbidity and mortality in immunocompromised patients. CMV infection can be acquired through multiple means, including: mother-to-child (in utero, breast milk), infected body fluids (saliva, genital secretions), blood transfusion or organ transplant. The prevalence of CMV infection increases with age throughout life such that by age 90, ~90% of persons will have acquired CMV infection. In immunocompetent persons, following primary infection by any of the routes noted above, CMV is controlled by the immune system and establishes latency ("dormancy") in multiple organs/cell-types for the life of the host. In particular, the lung represents one of the largest reservoirs of latent CMV in seropositive hosts, and may explain the propensity for CMV-associated pulmonary disease in predisposed hosts. During periods of immunosuppression (or as a result of specific stimuli such as TNF-α, LPS, or catecholamines that are commonly associated with critical illness & sepsis [CMV can reactivate from latency (preferentially in the lung) to produce active infection (viral replication). In persons with impaired cellular immunity, reactivation can progress to high-grade CMV replication and commonly leads to tissue injury and clinically-evident disease such as CMV pneumonia. Lower-grade CMV reactivation that is otherwise clinically silent ("subclinical") can also be detected in apparently immunocompetent persons with critical illness using sensitive techniques such as PCR. In addition, even low-level, otherwise asymptomatic subclinical CMV reactivation can produce significant biologic effects both in vitro and in vivo, such as inflammation, fibrosis and immunosuppression. Each of these biologic effects of subclinical CMV infection has either previously been demonstrated (inflammation, fibrosis) or could theoretically be important (immunosuppression) in sepsis-associated ALI and its complications. These biological effects of CMV have been shown to occur through various mediators and other indirect means [Importantly, several important CMV-associated adverse clinical outcomes in transplant populations [allograft rejection, secondary infections] are not necessarily accompanied by overt CMV disease and can only be detected by relatively sensitive means of virus detection such as PCR.
Reactivation of CMV in apparently immunocompetent patients with critical illness due to a broad range of causes has been documented in multiple prior studies using a variety of virologic techniques. The specific triggers for CMV reactivation from latency have been identified and are known to be elevated in patients with sepsis and acute lung injury [A prospective study in intubated patients with sepsis from Germany reported more than 60% rate of CMV DNA detection in tracheal aspirates.
In addition to CMV reactivation in sepsis, CMV reactivation has also been demonstrated specifically in lung and blood of patients with acute lung injury.
Retrospectively testing samples collected in a prospective observational cohort study of patients at risk of developing ARDS, CMV reactivation (ie. CMV DNA by PCR) was detected in BALF and/or plasma of 2/5 [40%] of subjects who developed ARDS, in sequential samples from 7/20 [35%] patients with ARDS, but not in patients at risk but who did not develop ARDS (0/5) [Limaye 2009 unpublished data]. In a separate study, CMV reactivation was retrospectively assessed by PCR in BALF of 88 subjects enrolled in a randomized trial of fish oil for treatment of ALI. Seropositivity at baseline (ie. evidence of latent CMV infection) in the cohort was 65% (similar to prior age-related estimates), and CMV reactivation (ie. CMV DNA by PCR) was detected in BALF of 12/57 [21%] patients [Limaye unpublished data 2009].
Several lines of evidence have linked CMV reactivation with adverse clinical outcomes in non-immunosuppressed adults with critical illness. In a recent meta-analysis, CMV reactivation (compared to no reactivation) was associated with a 2-fold increased odds of mortality in ICU patients.
In addition to mortality, recent studies have demonstrated a strong and independent association between CMV reactivation and increased hospital and ICU length of stay and duration of mechanical ventilation.
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01335932
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01335932
|United States, Colorado|
|University of Colorado / National Jewish Health / Swedish Medical Center|
|Denver, Colorado, United States, 80206|
|United States, Illinois|
|Chicago, Illinois, United States, 60611|
|United States, Massachusetts|
|Baystate Critical Care Medicine / Tufts University School of Medicine|
|Springfield, Massachusetts, United States, 01199|
|United States, Michigan|
|University of Michigan|
|Ann Arbor, Michigan, United States, 48109-5360|
|United States, North Carolina|
|Wakeforest University, School of Medicine|
|Winston-Salem, North Carolina, United States, 27157|
|United States, Ohio|
|The Cleveland Clinic Foundation|
|Cleveland, Ohio, United States, 44195|
|Ohio State University Medical Center|
|Columbus, Ohio, United States, 43210|
|United States, Oregon|
|The Oregon Clinic|
|Portland, Oregon, United States, 97220|
|United States, Pennsylvania|
|University of Pennsylvania Medical Center|
|Philadelphia, Pennsylvania, United States, 19104-6160|
|University of Pittsburgh Medical Center|
|Pittsburgh, Pennsylvania, United States, 15261|
|United States, Vermont|
|University of Vermont College of Medicine|
|Burlington, Vermont, United States, 05405|
|United States, Virginia|
|University of Virginia|
|Charlottesville, Virginia, United States, 22908-0546|
|United States, Washington|
|Harborview Medical Center|
|Seattle, Washington, United States, 98104|
|University of Washington Medical Center / Harborview Medical Center|
|Seattle, Washington, United States, 98195|
|Principal Investigator:||Michael Boeckh, MD||Fred Hutchinson Cancer Research Center|
|Principal Investigator:||Ajit Limaye, MD||University of Washington|
|Study Director:||Louise Kimball, PhD, RN||Fred Hutchinson Cancer Research Center|