Ascorbic Acid Administration in the Treatment of Anemia in Chronic Hemodialysed Patients

Study Overview
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Brief Summary
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The administration of ascorbic acid seemed to increase the iron available for erythropoiesis, thus improving the anemia response to the treatment. The investigators therefore aimed to evaluate the effects of intravenous ascorbic acid administration in hemodialysed patients with iron overload.

Detailed Description
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Renal anemia is a complex condition in which chronic inflammation, among other factors, can change the iron distribution by locking it in deposits, and also, iron metabolism parameters. Thus, is hard to separate the iron functional deficit from overload. The ascorbic acid is a hydrosoluble vitamin capable of reduction and hydrolysis. As a reduction agent, the ascorbic acid supports the transformation of ferric iron to ferrous iron. For instance, the ascorbic acid can increase digestive absorption and taking over the iron without transferrin, helps iron release from ferritin and hemosiderin and delays ferritin conversion to hemosiderin; therefore, the administration of ascorbic acid can increase the quantity of iron available for erythropoiesis by realising it from the deposits. Consequently, the antioxidant function of ascorbic acid can increase the red cells' lifetime, reducing the inflammation and improving erythropoietin response Following these premises, recent studies have examined the effect of administrating ascorbic acid to hemodialysed patients with erythropoiesis stimulating agents (ESA) hyporesponsiveness anemia and functional deficit or iron overload markers. The results of administering ascorbic acid revealed an increased level of hemoglobin and transferrin saturation (TSAT) combined with the decrease of ESA doses. The major limitations of these studies are the short amount of time for observation (<6months) and the limited number of participants which hampered neither the complete evaluation of the goals, nor the adverse effects of supplementary administration of vitamin C. Until now, the Clinical practice guidelines of Kidney Disease do not recommend currently using of high doses of vitamin C, considering the risk of a high level of oxalemia and the limited information about the benefits. Considering this background, we intended to evaluate the benefits of intravenous administration of ascorbic acid in hemodialysed patients with iron balance markers suggestive for iron overload.

Official Title
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Effects of Ascorbic Acid Administration in the Treatment of Anemia in Chronic Hemodialysed Patients With Iron Overload

Conditions
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Anaemia Response to the Treatment, Peripheral Iron Indices, Oxalemia

Intervention / Treatment
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* Drug: Ascorbic Acid


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age above 18 years old At least 6 months on hemodialysis at the time of randomization; Kt/V≥1.2; average of the last three serum ferritin levels > 500 ng/mL AND Average of the last three TSAT levels > 20% and increasing ERI in the 4th quartile of the group Exclusion Criteria: Active bleeding or other cause of anemia Serum level of intact parathyroid hormone (iPTH)>800 pg/mL Actual neoplasia HIV, Hepatitis B or C infections Significant inflammation (CRP>12mg/L) or acute infection Venous central catheter Severe hepatic, cardiovascular, psychic disease or other severe comorbidities Moderate or severe malnutrition Blood transfusions in the 2 months prior to screening Pregnancy or breastfeeding Inclusion in another clinical trial in the past month

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 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: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Ascorbic acid<br>Patients will receive a 300 mg intravenous ascorbic acid, 3 times a week, postdialysis, except for the dialysis sessions when iv iron is administered. | Drug: Ascorbic Acid<br>* 300 mg of intravenous ascorbic acid will be given 3 times a week, postdialysis, in 100 mL saline solution, except for the dialysis sessions when iv iron is administered<br>|
| Placebo Comparator: Control group<br>Patients will receive 100 mL saline solution, 3 times a week, with associated medication, except but the dialysis sessions when iv iron is administered. | Drug: Ascorbic Acid<br>* 300 mg of intravenous ascorbic acid will be given 3 times a week, postdialysis, in 100 mL saline solution, except for the dialysis sessions when iv iron is administered<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Variation of erythropoetin resistance index (ERI) | Erythropoietin resistance index: the dose of ESA divided by the level of Hb - will be calculated monthly. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of patients with Hb in the target range | Percentage of patients with stable the hemoglobin in the target range (10.5-12g/dL), without any change in the weekly dose of ESA | 12 months | 
| Changes in ESA dose | The number of reductions or increases in the ESA dose during the study | 12 months | 
| Variation in ESA dose | The difference between the actual ESA dose and the one at baseline will be calculated monthly. | 12 months | 
| Variation of iron dose | The difference between the actual iron dose and the one at baseline will be calculated monthly. | 12 months | 
| Percentage of patients with hemoglobin within target | Percentage of patients with 10<Hb<12.1 g/dL will be calculated monthly. | 12 months | 
| Percentage of patients with target iron status | Percentage of patients with 100<serum ferritin<800 ng/mL and 19<transferrin saturation<51% will be calculated monthly. | 12 months | 
| Variation of serum hepcidin | Variation of serum hepcidin will be calculated every 3 months | 12 months | 
| Oxalemia | Serum oxalate level will be calculated every 3 months | 12 months | 
| Local and general tolerance to vitamin C | Local and general tolerance to vitamin C will be evaluated monthly | 12 months | 
| Adverse events | Adverse events will be evaluated monthly | 12 months | 
| The number of withdrawals and dropouts | The number of withdrawals and dropouts will be calculated monthly | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Renal anaemia, Intravenous ascorbic acid, Intravenous iron administration