UremiaPhase 4NCT00388648
Very Low Protein Diet or Dialysis in Uremic Elderly?
A Phase 4 study testing mixture of amino and keto acids in people with Uremia and Elderly (Aged >70), run by Università degli Studi di Brescia at 1 site in Italy.
Trial summary
There are no solid data on the real advantage of an early start of dialysis, as suggested by the DOQI guidelines. Uremic patients frequently have a poor nutritional status. However, we cannot distinguish between the detrimental effect on nutrition of too low a residual renal function or too long a period of low… Read more about this study
- Who is it for?
- Ages 70 to 95 years
- Conditions the study is for
- Uremia, Elderly (Aged >70), Dialysis
- What is being tested?
- mixture of amino and keto acids
- How many people
- 160 participants
- Where
- 1 siteItaly
- Study dates
- Jan 2000to Jul 2005
- Phase
- Phase 4
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 70 to 95 years
- All sexes
- No healthy volunteers
- Older adult
Who may be able to join
- males or females >= 70 years of age
- RRF 5-7 ml/min/1.73 m2
- left ventricular ejection fraction >40%
- signed informed written consent
Who cannot join
- diabetes
- severe cerebral disease
- proteinuria >3 g/24 h
- severe hepatic failure
- active malignancy
- COPD requiring supplementary oxygen
- AIDS, or HIV-positive
Trial locations and contacts
1 site in 1 country.
About this study
Official title: Efficacy and Safety of a Very Low Protein Diet in Postponing Dialysis in Elderly: a Prospective Randomized Multicenter Controlled Study
There are no solid data on the real advantage of an early start of dialysis, as suggested by the DOQI guidelines. Uremic patients frequently have a poor nutritional status. However, we cannot distinguish between the detrimental effect on nutrition of too low a residual renal function or too long a period of low protein-diet, per se. However, it appears that a very-low-protein diet (VLPD) supplemented with essential amino acids and keto-analogs of amino acids, and with an adequate quantity of calories, can prevent hypoalbuminemia at the start of dialysis and can slow the progression of chronic renal failure.
EDTA and USRDS data suggest that most patients starting dialysis nowadays are elderly, who also have the highest incidence of morbidity and mortality. Moreover, hospitalization rate becomes higher after the start of dialysis compared to the pre-dialysis period.
Can an aminoacid-supplemented VLPD, prolonged beyond the GFR limits suggested by DOQI, offer elderly patients better survival and better quality of life than dialysis? The answer can only come from a prospective, randomized trial, in elderly patients, starting at the GFR values suggested by the NKF-DOQI for starting dialysis, comparing outcomes with a vegetarian VLPD supplemented with a mixture of keto-analogs of amino acids and essential amino acids, and with dialysis.
Read the detailed description
An adequate dose of dialysis is needed, in order to improve patient outcome, in both peritoneal dialysis (PD) and extracorporeal dialysis (HD). The debate, however, has renewed interest in when to start dialysis. The NKF-DOQI group suggested using the amount of solute clearance for regular dialysis as a value for starting dialysis treatment, i.e. creatinine clearance 9-14 ml/min.
Elderly patients on dialysis have a low survival rate.In fact, according to the lombard Registry(a italian region), patients 70-75 years old survive 2.9/3.6 years (male/female) after the start of dialysis, those 75-80 years old 2.7/2.7 years, and those 80-85 years old 2.4/1.4 years. This low survival is largely due to the combined effects of aging and comorbidities, on which an early start of dialysis has no or very limited positive effects.
Moreover, the hemodialytic treatment might have more negative effects in the elderly: intermittent hemodynamic stress, continuous fluctuation of electrolytes, metabolites, acid-base equilibrium, and the bioincompatibility of the membrane. In PD patients, the negative effects are also related to episodes of peritonitis and to daily loss of protein and a higher frequency of malnutrition.
An early start of dialysis should improve survival and well-being, and reduce morbidity. But a rapid decline of residual renal function (RRF) is observed after the start of dialysis. Maintenance of RRF as long as possible is very important, because the kidneys do some things a dialysis membrane cannot do: tubular and endocrine function, larger clearances of middle molecules, some of them potentially toxic such as parathyroid hormone, granulocyte inhibitory protein, and substances inducing anorexia.
In a prospective study on CAPD patients, for every increase of 1 ml/min of GFR, the relative risk (RR) of death decreased 50%. In the CanUsa study, using the time-dependent Cox multivariate analysis, a 5% reduction in RR of death was observed for each 5L/week of residual renal GFR at baseline (7). These results suggest that, at least in elderly patients, the fast decline of GFR observed after the start of dialysis could be another cause of the low survival rate.
In our center, 42 elderly patients started a very-low-protein diet (VLPD: 0.3 g of protein/kg body weight), supplemented with a mixture of keto acids and amino acids when their creatinine clearance reached values usually considered as a parameter for starting dialysis. The survival of this group of patients was compared with that of 71 patients directly put onto dialysis with the same creatinine clearance at which we started the VLPD. Subsequently, 24 patients in the diet group started dialysis when their mean GFR was 3.9 ml/min, i.e. lower than the 7 ml/min usually considered adequate in PD patients and much lower than 9-14 ml/min suggested by the NKF-DOQI group.
In this retrospective, non-randomized study, survival was better in the patients treated with diet than patients with dialysis. This seems to bear out that RRF does more than a dialytic membrane and must be preserved as long as possible.
- Conditions
- Uremia, Elderly (Aged >70), Dialysis, Low Protein Diet, Survival
- Being tested
- mixture of amino and keto acids
- Keywords
- Dialysis, Vegan Diet, Mortality, Morbidity, Treatment outcome
- Medical subject headings
- Uremia
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
mixture of amino and keto acidsDrug
What is being measured
The primary outcome is the main question the study is designed to answer.
The primary hypotheses to be tested are whether, at least in the elderly:
the supplemented Very Low Protein Diet (VLPD) does not increase the risk of morbidity and mortality,
a prolonged period of VLPD can postpone the need for dialysis in elderly patients, and dialysis can start at a RRF lower than usually suggested.
Secondary outcomes (1)
the VLPD does not induce malnutrition.
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted17 Oct 2006 (estimated)
- Study startJan 2000
- Study completionJul 2005
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (2)Papers the sponsor has linked to this study.
- Other trials for UremiaStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 4
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 160 participants
Sponsor and investigators
- Lead sponsor
- Università degli Studi di Brescia
- Sponsor type
- University, hospital or other
- Investigators
- Giovanni c Cancarini, Prof, Study chair, University of Brescia (Italy)
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT00388648
- Sponsor's protocol ID
- NBs2000
- Status last verified
- Oct 2006
- First submitted
- 16 Oct 2006
- Last updated
- 17 Oct 2006
- Results posted
- No
Publications
Maiorca R, Brunori G, Viola BF, Zubani R, Cancarini G, Parrinello G, De Carli A. Diet or dialysis in the elderly? The DODE study: a prospective randomized multicenter trial. J Nephrol. 2000 Jul-Aug;13(4):267-70.
PubMed 10946805Brunori G, Viola BF, Parrinello G, De Biase V, Como G, Franco V, Garibotto G, Zubani R, Cancarini GC. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis. 2007 May;49(5):569-80. doi: 10.1053/j.ajkd.2007.02.278.
PubMed 17472838
Study at a glance
From the registry record, last updated by the sponsor on 17 Oct 2006. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Efficacy and Safety of a Very Low Protein Diet in Postponing Dialysis in Elderly: a Prospective Randomized Multicenter Controlled Study
- ClinicalTrials.gov ID
- NCT00388648
- Acronym / sponsor ID
- NBs2000
- Conditions
- Uremia, Elderly (Aged >70), Dialysis, Low Protein Diet, Survival
- Keywords
- Dialysis, Vegan Diet, Mortality, Morbidity, Treatment outcome
- Phase
- Phase 4
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 160 participants
- Lead sponsor
- Università degli Studi di BresciaUniversity, hospital or other
- Study start
- Jan 2000
- Study completion
- Jul 2005
- First posted
- 17 Oct 2006 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
There are no solid data on the real advantage of an early start of dialysis, as suggested by the DOQI guidelines. Uremic patients frequently have a poor nutritional status. However, we cannot distinguish between the detrimental effect on nutrition of too low a residual renal function or too long a period of low protein-diet, per se. However, it appears that a very-low-protein diet (VLPD) supplemented with essential amino acids and keto-analogs of amino acids, and with an adequate quantity of calories, can prevent hypoalbuminemia at the start of dialysis and can slow the progression of chronic renal failure.
EDTA and USRDS data suggest that most patients starting dialysis nowadays are elderly, who also have the highest incidence of morbidity and mortality. Moreover, hospitalization rate becomes higher after the start of dialysis compared to the pre-dialysis period.
Can an aminoacid-supplemented VLPD, prolonged beyond the GFR limits suggested by DOQI, offer elderly patients better survival and better quality of life than dialysis? The answer can only come from a prospective, randomized trial, in elderly patients, starting at the GFR values suggested by the NKF-DOQI for starting dialysis, comparing outcomes with a vegetarian VLPD supplemented with a mixture of keto-analogs of amino acids and essential amino acids, and with dialysis.
Detailed description
An adequate dose of dialysis is needed, in order to improve patient outcome, in both peritoneal dialysis (PD) and extracorporeal dialysis (HD). The debate, however, has renewed interest in when to start dialysis. The NKF-DOQI group suggested using the amount of solute clearance for regular dialysis as a value for starting dialysis treatment, i.e. creatinine clearance 9-14 ml/min.
Elderly patients on dialysis have a low survival rate.In fact, according to the lombard Registry(a italian region), patients 70-75 years old survive 2.9/3.6 years (male/female) after the start of dialysis, those 75-80 years old 2.7/2.7 years, and those 80-85 years old 2.4/1.4 years. This low survival is largely due to the combined effects of aging and comorbidities, on which an early start of dialysis has no or very limited positive effects.
Moreover, the hemodialytic treatment might have more negative effects in the elderly: intermittent hemodynamic stress, continuous fluctuation of electrolytes, metabolites, acid-base equilibrium, and the bioincompatibility of the membrane. In PD patients, the negative effects are also related to episodes of peritonitis and to daily loss of protein and a higher frequency of malnutrition.
An early start of dialysis should improve survival and well-being, and reduce morbidity. But a rapid decline of residual renal function (RRF) is observed after the start of dialysis. Maintenance of RRF as long as possible is very important, because the kidneys do some things a dialysis membrane cannot do: tubular and endocrine function, larger clearances of middle molecules, some of them potentially toxic such as parathyroid hormone, granulocyte inhibitory protein, and substances inducing anorexia.
In a prospective study on CAPD patients, for every increase of 1 ml/min of GFR, the relative risk (RR) of death decreased 50%. In the CanUsa study, using the time-dependent Cox multivariate analysis, a 5% reduction in RR of death was observed for each 5L/week of residual renal GFR at baseline (7). These results suggest that, at least in elderly patients, the fast decline of GFR observed after the start of dialysis could be another cause of the low survival rate.
In our center, 42 elderly patients started a very-low-protein diet (VLPD: 0.3 g of protein/kg body weight), supplemented with a mixture of keto acids and amino acids when their creatinine clearance reached values usually considered as a parameter for starting dialysis. The survival of this group of patients was compared with that of 71 patients directly put onto dialysis with the same creatinine clearance at which we started the VLPD. Subsequently, 24 patients in the diet group started dialysis when their mean GFR was 3.9 ml/min, i.e. lower than the 7 ml/min usually considered adequate in PD patients and much lower than 9-14 ml/min suggested by the NKF-DOQI group.
In this retrospective, non-randomized study, survival was better in the patients treated with diet than patients with dialysis. This seems to bear out that RRF does more than a dialytic membrane and must be preserved as long as possible.
Study design
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
Who may qualify
- Ages
- 70 to 95 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (4 listed)
- males or females >= 70 years of age
- RRF 5-7 ml/min/1.73 m2
- left ventricular ejection fraction >40%
- signed informed written consent
Key exclusion criteria (7 listed)
- diabetes
- severe cerebral disease
- proteinuria >3 g/24 h
- severe hepatic failure
- active malignancy
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| mixture of amino and keto acids | Drug | – |
Primary outcome
The primary hypotheses to be tested are whether, at least in the elderly:
the supplemented Very Low Protein Diet (VLPD) does not increase the risk of morbidity and mortality,
a prolonged period of VLPD can postpone the need for dialysis in elderly patients, and dialysis can start at a RRF lower than usually suggested.
1 secondary outcome
the VLPD does not induce malnutrition.
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 17 Oct 2006.
- Results publication: PubMed 10946805Maiorca R, Brunori G, Viola BF, Zubani R, Cancarini G, Parrinello G, De Carli A. Diet or dialysis in the elderly? The DODE study: a prospective randomized multicenter trial. J Nephrol. 2000 Jul-Aug;13(4):267-70.
- Derived from this study: PubMed 17472838Brunori G, Viola BF, Parrinello G, De Biase V, Como G, Franco V, Garibotto G, Zubani R, Cancarini GC. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis. 2007 May;49(5):569-80. doi: 10.1053/j.ajkd.2007.02.278.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Giovanni c Cancarini, Prof study chair
University of Brescia (Italy)
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 4 study testing mixture of amino and keto acids in people with Uremia and Elderly (Aged >70), run by Università degli Studi di Brescia at 1 site in Italy.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 7 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 17 Oct 2006. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Italy. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 4 studies take place after a treatment is approved, to learn more about its long-term benefits and risks in everyday use.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
The primary hypotheses to be tested are whether, at least in the elderly:. The study lists 3 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT00388648, which also lists 2 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 17 Oct 2006.