Dysbiosis, Hepatic Encephalopathy
Conditions
Brief summary
This interventional study aims to evaluate the safety and efficacy of oral capsule fecal microbiota transplantation (FMT) for treating hepatic encephalopathy refractory to conventional rifaximin and lactulose therapy in patients with liver cirrhosis. Patients diagnosed with hepatic encephalopathy refractory to rifaximin and lactulose therapy will be randomized into three groups. While continuing conventional therapy, the first group receives FMT via colonoscopy and oral capsule administration, the second group receives only oral capsule administration, and the third group serves as a control, receiving only conventional therapy. The aims of the study are: To evaluate the efficacy and safety of FMT by oral capsules in cirrhotic patients with hepatic encephalopathy refractory to standard therapy. To evaluate changes in the gut microbiota composition and in the intestinal and systemic inflammatory condition occurring after FMT and if they can be associated with clinical improvement. To evaluate metabolic modifications occurring after FMT and if they can be associated with clinical improvement.
Interventions
PROCEDUREFecal microbiota transplantation delivery through colonoscopy
Patients will receive 4 L of macrogol and salts solution the afternoon before FMT and remain fasting the night before the scheduled treatment. During colonoscopy, about 350 mL of donor fecal preparation will be infused in the cecum.
DRUGFecal microbiota transplantation delivery through oral capsules
Intestinal gastro-resistant capsules (capacity 0.91 mL, overall 10\^8-9 bacteria per capsule) will be filled with the fecal slurry. From each donation weighing 100 g, it is expected to obtain 150 cps, which will be promptly frozen and stored at -80°C. At each monthly visit, the patient will receive 60 capsules, to be stored at -20°C at home. Capsules will be administered orally at the dose of 1 cps twice a day from month 1 post-colonoscopy to patients in the FMT group 1 (colonoscopy plus capsules), and from day 1 to patients in the FMT group 2 (capsules only).
Sponsors
Fondazione Policlinico Universitario Agostino Gemelli IRCCS
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
* Diagnosis of liver cirrhosis * Hepatic encephalopathy of grade \>1 or higher according to West Haven classification, persistent or recurrent despite treatment with lactulose/lactitol and rifaximin at adequate doses started at least 30 days before the Hepatic encephalopathy episode
Exclusion criteria
* Na \<130 meq /l * Creatinine \> 1.3 mg / dl * Presence of grade 3 ascites * Presence of esophagogastric varices at risk of haemorrhage in the absence of adequate prophylaxis * Presence of other possible causes of encephalopathy (cerebral vascular disease, known neurodegenerative or cognitive disorders) * Known psychiatric disorders or other causes of brain dysfunction (e.g. hypoglycemia, hyponatremia) * Alcohol consumption * Diagnosis of hepatocellular carcinoma * Contraindication to fecal microbiota transplantation (e.g. pregnancy or breastfeeding) * Presence of known intestinal diseases * Any clinical condition that, in the opinion of the investigators, may contraindicate the enrollment in the study
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Evaluation of safety of fecal microbiota transplantation by oral capsules in the treatment of cirrhotic patients with hepatic encephalopathy refractory to conventional therapy | 12 months | Number of patients with treatment associated adverse events as assessed by CTCAE v5.0 |
| Evaluation of efficacy of fecal microbiota transplantation by oral capsules in the treatment of cirrhotic patients with hepatic encephalopathy refractory to conventional therapy | 12 months | Number of patients with an improvement or no worsening of hepatic encephalopathy after treatment administration as clinically assessed by West-Haven classification and psychometric tests (portosystemic hepatic encephalopathy syndrome test and inhibitory control test) and through laboratory measurement of ammonia serum levels. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Evaluation of changes in the intestinal inflammatory following the fecal microbiota transplantation | 12 months | Changes in the intestinal inflammatory condition will be assessed by the quantification of fecal calprotectin concentration (mg/dl). |
| Comparison between protein metabolites concentration (ppm) in serum, urine and feces before and after microbiota transplantation | 12 months | Quantification of amino acides will be performed before the microbiota transplantation and every three months after by the examination of serum, urine and fecal samples through liquid chromatography tandem mass spectrometry methods. |
| Evaluation of changes in the gut microbiota composition following the fecal microbiota transplantation | 12 months | DNA and RNA microbiota sequencing on fecal samples will be performed every three months after treatment initiation to define changes in the abundance of bacteria and alpha diversity (by the Simpson's Index of Diversity). |
| Comparison between carbohydrates metabolites concentration (ppm) in serum, urine and feces before and after microbiota transplantation | 12 months | Quantification of tricarboxylic acid cycle compounds, sugars and sugar phosphates will be performed before the microbiota transplantation and every three months after by the examination of serum, urine and fecal samples through liquid chromatography tandem mass spectrometry methods. |
| Comparison between lipid metabolites concentration (ppm) in serum, urine and feces before and after microbiota transplantation | 12 months | Quantification of fatty acids, acyl carnitine, tryglicerides, dyacil glycerols and phospholipides will be performed before the microbiota transplantation and every three months after by the examination of serum, urine and fecal samples through liquid chromatography tandem mass spectrometry methods. |
| Evaluation of changes in the systemic inflammatory following the fecal microbiota transplantation | 12 months | Changes in the systemic inflammatory condition will be assessed by the quantification of serum cytokines, chemokines, and bacterial fragments concentrations (units/ml): Interleukin1 beta, tumor necrosis factor alpha, Interleukin2, Interleukin6, Interleukin17, interferon gamma, Chemokine C-C motif ligand 2, Chemokine C-C motif ligand 3, Chemokine C-C motif ligand 4, Chemokine C-C motif ligand 5, Chemokine C-C motif ligand 10, Chemokine C-X-C motif ligand 10, lipopolysaccharides |
Countries
Italy
Outcome results
None listed