Vitamin K to Attenuate Coronary Artery Calcification in Hemodialysis Patients

Study Overview
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Brief Summary
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The purpose of this study is to see if vitamin K supplementation three times per week reduces the progression of coronary artery calcification over 12 months in dialysis patients compared to placebo.

Detailed Description
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At every stage of chronic kidney disease (CKD), the leading cause of mortality is cardiovascular disease. This is due, in part, to vascular calcification (VC) of the coronary arteries. The extent of VC in the coronary arteries of patients with CKD is commonly determined by high resolution CT scan. The total coronary artery calcium (CAC) score, measured in Agatston units (AUs), reflects the calcium burden in the three major coronary arteries and is the current standard for determining extent of vascular calcification in hemodialysis patients. Matrix Gla protein (MGP), a vitamin K dependent protein, is a key inhibitor of vascular calcification and is present in the arterial wall. It is established that MGP becomes up-regulated adjacent to sites of calcification and that vitamin K is critical to its function. Therefore vitamin K status may be critical to the extent of vascular calcification in this patient group. However, to date, no trial has examined whether vitamin K supplementation prevents the progression of coronary artery calcification in patients with kidney failure, a group in which high risk has been established. Therefore, our primary research question is: Does vitamin K supplementation with 10 mg of phylloquinone thrice weekly reduce the progression of coronary artery calcification (as measured by CAC score) over 12 months in prevalent hemodialysis patients with a baseline CAC score of ≥ 30 Agatston Units compared to placebo?

Official Title
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Inhibit Progression of Coronary Artery Calcification With Vitamin K in HemoDialysis Patients: The iPACK-HD Study

Conditions
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End-stage Kidney Disease

Intervention / Treatment
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* Drug: Vitamin K1
* Drug: Microcrystalline Methylcellulose


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Able to provide signed informed consent ≥18 years of age Expected to survive one year Have end-stage kidney disease and require hemodialysis Have a baseline coronary artery calcification score ≥30 Agatston units (AUs) Exclusion Criteria: Have a medical condition that requires warfarin Require hemodialysis for acute kidney injury Are Pregnant Have other severe co-morbid conditions (e.g. malignancy, disabling stroke) with life expectancy less than one year Have undergone coronary artery bypass grafting or have stents placed in their coronary arteries Are currently enrolled in another interventional trial

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Placebo<br>Microcrystalline Methylcellulose | Drug: Microcrystalline Methylcellulose<br>* 10mg orally three times a week for 12 months<br>|
| Active Comparator: Vitamin K1<br>Vitamin K1 | Drug: Vitamin K1<br>* 10mg orally three times a week for 12 months<br>* Other names: Phylloquinone;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recruitment rate | Number of participants recruited per month at each site) and an overall crude average of each site's rate. | 12 months | 
| Compliance with study medication | Proportion of prescribed doses received. | 12 months | 
| Dropout rate | Proportion of participants who dropped out from the trial. | 12 months | 
| Adherence to study protocol | Proportion of participants who adhered to the study protocol. | 12 months | 
| Rates of eligible patients consented and randomized | Proportion of eligible patients consented and randomized. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Coronary artery calcification (Agatston calcium scores) progression | A)The percent and absolute change of the Agatston calcium scores (CT scan) will be assessed at study exit vs. baseline. Included measures will be: Total CAC, Left Main CAC, Right Coronary Artery CAC, Left Anterior Descending CAC, Circumflex CAC, and Posterior Descending Artery CAC. B) The proportion of participants with a 15% or greater increase in Agatston calcium scores will be assessed at study exit vs baseline. | 12 months | 
| Coronary artery calcification (volume calcium scores) progression | A) The percent and absolute change of the volume calcium scores (CT scan) will be assessed at study exit vs. baseline. Included measures will be: Total CAC, Left Main CAC, Right Coronary Artery CAC, Left Anterior Descending CAC, Circumflex CAC, and Posterior Descending Artery CAC. B) The proportion of participants with a 15% or greater increase in volume calcium scores will be assessed at study exit vs baseline. | 12 months | 
| Coronary artery calcification (Agatston calcium scores) regression | The proportion of participants with a 10% or greater decrease in Agatston calcium scores will be assessed at study exit vs baseline. | 12 months | 
| Coronary artery calcification (volume calcium scores) regression | The proportion of participants with a 10% or greater decrease in volume calcium scores will be assessed at study exit vs baseline. | 12 months | 
| Aortic valve calcification (Agatston calcium scores) progression | The absolute and percentage change of the Agatston calcium scores (CT scan) will be assessed at study exit vs. baseline. | 12 months | 
| Aortic valve calcification (volume calcium scores) progression | The absolute and percentage change of the volume calcium scores (CT scan) will be assessed at study exit vs. baseline. | 12 months | 
| Mitral valve calcification (Agatston calcium scores) progression | The absolute and percentage change of the Agatston calcium scores (CT scan) will be assessed at study exit vs. baseline. | 12 months | 
| Mitral valve calcification (volume calcium scores) progression | The absolute and percentage change of the volume calcium scores (CT scan) will be assessed at study exit vs. baseline. | 12 months | 
| Abdominal aortic calcification (AAC) scores | The AAC score (mean score in L1-L4, mean number of positive segments, mean total severity using lateral lumbar spine radiographs) will be assessed at study exit vs. baseline. | 12 months | 
| Levels of biomarkers of vitamin K status | Gas6, PK, MK4, osteocalcin Gla, osteocalcin Glu, osteocalcin Gla to Glu ratio, percent of osteocalcin undercarboxylated, and dpucMGP will be assessed at baseline, four, eight and study exit. Protein induced by vitamin K absence or antagonist II (PIVKA-II) will be assessed at baseline and study exit. | 12 months | 
| Prevalence and incidence of thoracic vertebral fractures | The prevalence and incidence of thoracic vertebral fractures (anterior and lateral radiographs) will be assessed at baseline and study exit. | 12 months | 
| Prevalence and incidence of lumbar vertebral fractures | The prevalence and incidence of lumbar vertebral fractures (anterior and lateral radiographs) will be assessed at baseline and study exit. | 12 months | 
| Presence/absence and total hospitalizations | The presence or absence and total hospitalizations will be assessed across the study duration per patient. | 12 months | 
| Presence/absence and total cardiovascular events | The presence or absence and total cardiovascular events (acute coronary syndrome, congestive heart failure, stroke, transient ischemic attack, amputation, and cardiac [symptom-driven] [cerebral or peripheral] revascularization procedure, or cardiac arrest) will be assessed across the study duration per patient. | 12 months | 
| Presence/absence and total thrombotic events | The presence or absence and total thrombotic events (deep vein thrombosis and pulmonary embolism) will be assessed across the study duration per patient. | 12 months | 
| Presence/absence and total hemodialysis access thrombotic events | The presence or absence and total hemodialysis access thrombotic events (fistula and/or graft thrombosis or dialysis catheter thrombosis) will be assessed across the study duration per patient. | 12 months | 
| Presence/absence and total mortality | The presence or absence and total all-cause and cardiovascular cause mortality will be assessed across the study duration per patient. | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Vitamin K, Chronic Kidney Disease, Vascular Calcification, Hemodialysis, Coronary Artery Calcification