Study Results
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View full resultsBasic Information
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TERMINATED
NA
21 participants
INTERVENTIONAL
2018-05-01
2024-01-16
Brief Summary
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Detailed Description
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SOS is most commonly defined by two clinical criteria: the modified Seattle criteria and the Baltimore criteria (Table 2). The modified Seattle criteria state that at least two of the following criteria must be present within 20 days of BMT: bilirubin \> 2mg/dL; hepatomegaly and/or ascites; and/or weight gain \> 5% above baseline weight. Pediatric SOS incidence in BMT is 20% and is higher compared to adults. Death or multi-organ dysfunction affects 30-60% children who develop SOS. The most common definition of severe SOS is retrospective, namely death from SOS-related causes or persistent multi-organ dysfunction at 100 days post BMT. However, the European Society for Blood and Marrow Transplantation has proposed a new prospective SOS grading scheme that will likely become standard of care since it is pediatric patient specific and it is can be performed prospectively and thus can guide treatment.
Recently, a promising drug for SOS treatment has been discovered, defibrotide, which is a DNA derivative from porcine intestine that protects and repairs endothelial cells. Prior trials showed that defibrotide decreased the incidence of multi-organ failure and death from SOS. The main caveat is that treatment must be initiated very close to the time of clinical diagnosis using the Baltimore criteria to be effective. A study showed that 31/33 (94%) patients had complete remission of their SOS when treated with defibrotide \<3 days after diagnosis, whereas only 3/12 (25%) patients had complete remission when treated \>3 days of diagnosis. However, universal prophylaxis is infeasible due to high drug costs ($155,000 for patient) (2016). There is a critical need for an early and effective SOS diagnostic test that can identify patients who would benefit from defibrotide treatment.
Several adult and pediatric prospective studies have evaluated the efficacy of grayscale and Doppler ultrasound (US) in diagnosing SOS and have concluded that the clinical criteria are superior to US criteria for SOS diagnosis. The main reason for this conclusion is that conventional US is able to diagnose SOS only after the clinical diagnosis. This research has resulted in multiple recent guidelines recommending US only for confirming clinical diagnoses or following disease progression and not for primary diagnosis. Ultrasound shear wave elastography (SWE) has been shown to effectively diagnose passive hepatic congestion. Fontan physiology is the best studied example. SWE values markedly increased after the Fontan operation. This surgery connects the hepatic venous circulation to the pulmonary arteries exposing the liver to increased resistance from the pulmonary circulation thereby increasing hepatic venous congestion. Additionally, the effect sizes in the Fontan studies are large compared with the effect sizes in hepatic fibrosis studies. The common thread of hepatic venous congestion between Fontan physiology and SOS physiology led us to hypothesize that SWE could be useful in SOS diagnosis. Additionally, preliminary SWE studies in adults showed that it might be useful in the setting of SOS.
Data Collection Procedures Candidates for the study will be identified by a BMT physician taking care of the patient and will be identified as a potential candidate for the study. Subjects will be approached for consent by a member of the research team prior to start of conditioning regimen. Consented subjects will have demographic, laboratory and clinical data collected from the chart at each ultrasound time point.
Ultrasound Examinations and Timeline After enrollment and within two weeks prior to starting their conditioning regimen, a limited abdominal US with Doppler measurements of the hepatic arteries, hepatic and portal veins, as well as SWE will be performed.
Subjects will be undergo US examinations based on disease course as outlined below:
1. All Patients: Patients will undergo limited abdominal US with Doppler and SWE once a week upon admission for conditioning until the patient day +30 BMT or discharge, whichever comes first.
2. Inpatient SOS: patients will undergo limited abdominal US with doppler and SWE once a week upon admission for conditioning until resolution of SOS.
3. Late Onset SOS: patients will undergo limited abdominal US with Doppler and SWE once a week upon admission for conditioning until resolution of SOS.
Clinically indicated US and SWE exams for suspicion for SOS will be included in our analysis. All imaging will be performed using General Electric Logiq E9 US machines by dedicated pediatric sonographers and interpreted by board-certified pediatric radiologists. Twelve shear wave velocity measurements will be taken 2-3 cm below the liver capsule at the mid-clavicular line in the right hepatic lobe and another 12 will be taken in the left hepatic lobe near midline avoiding areas of vasculature. By necessity, the sonographer and interpreting radiologist will not be blinded to the clinical status of the patient. US and clinical data will be collected weekly and managed using REDCap electronic data capture tools hosted at Children's Mercy Hospital.
Conditions
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Study Design
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NA
SINGLE_GROUP
DIAGNOSTIC
NONE
Study Groups
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All Patients Enrolled
All patients will undergo limited abdominal US with Doppler and SWE once a week upon admission for conditioning until the patient day +30 BMT or discharge, whichever comes first. Additional ultrasounds will also be performed if SOS is suspected.
Ultrasound Examination
Grayscale ultrasound, Doppler ultrasound, ultrasound elastography with or without ultrasound intravenous contrast will be performed.
Interventions
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Ultrasound Examination
Grayscale ultrasound, Doppler ultrasound, ultrasound elastography with or without ultrasound intravenous contrast will be performed.
Eligibility Criteria
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Inclusion Criteria
Exclusion Criteria
* Inability to properly image patient by ultrasound (e.g. uncooperative)
1 Month
21 Years
ALL
No
Sponsors
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Children's Mercy Hospital Kansas City
OTHER
Responsible Party
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Sherwin Chan MD PhD
Physician, MD
Principal Investigators
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Shewin Chan, MD, PhD
Role: PRINCIPAL_INVESTIGATOR
Children's Mercy Hospital Kansas City
Locations
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Children's Mercy Hospital
Kansas City, Missouri, United States
Countries
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References
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Provided Documents
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Document Type: Study Protocol
Document Type: Informed Consent Form
Related Links
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D'Souza A ZX. Current Uses and Outcomes of Hematopoietic Cell Transplantation (HCT): CIBMTR Summary Slides, 2016.
Cozadd B (2018) Jazz Pharmaceuticals. 36th Annual JP Morgan Annual Healthcare Conference, San Francisco, California.
(2016) In Brief: Defibrotide (Defitelio) for Hepatic Veno-Occlusive Disease. The Medical Letter
Other Identifiers
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17110684
Identifier Type: -
Identifier Source: org_study_id
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