Aapkes et al. BMC Gastroenterology (2022) 22:82 https://doi.org/10.1186/s12876-022-02142-y STUDY PROTOCOL Open Access Protocol for a randomized controlled multicenter trial assessing the efficacy of leuprorelin for severe polycystic liver disease: the AGAINST‑PLD study S. E. Aapkes1, L. H. P. Bernts2, A. P. van den Berg3, M. van den Berg4, H. Blokzijl3, A. E. P. Cantineau4, M. D. A. van Gastel1, R. J. de Haas5, P. Kappert5, R. U. Müller6, F. Nevens7, R. Torra8, A. Visser9, J. P. H. Drenth2 and R. T. Gansevoort1* Abstract Background: In patients with severe polycystic liver disease (PLD), there is a need for new treatments. Estrogens and possibly other female sex hormones stimulate growth in PLD. In some patients, liver volume decreases after meno- pause. Female sex hormones could therefore be a target for therapy. The AGAINST-PLD study will examine the efficacy of the GnRH agonist leuprorelin, which blocks the production of estrogen and other sex hormones, to reduce liver growth in PLD. Methods: The AGAINST-PLD study is an investigator-driven, multicenter, randomized controlled trial. Institutional review board (IRB) approval was received at the University Medical Center of Groningen and will be collected in other sites before opening these sites. Thirty-six female, pre-menopausal patients, with a very large liver volume for age (upper 10% of the PLD population) and ongoing liver growth despite current treatment options will be randomized to direct start of leuprorelin or to 18 months standard of care and delayed start of leuprorelin. Leuprorelin is given as 3.75 mg subcutaneously (s.c.) monthly for the first 3 months followed by 3-monthly depots of 11.25 mg s.c. The trial duration is 36 months. MRI scans to measure liver volume will be performed at screening, 6 months, 18 months, 24 months and 36 months. In addition, blood will be drawn, DEXA-scans will be performed and questionnaires will be collected. This design enables comparison between patients on study treatment and standard of care (first 18 months) and within patients before and during treatment (whole trial). Main outcome is annualized liver growth rate compared between standard of care and study treatment. Secondary outcomes are PLD disease severity, change in liver growth within individuals and (serious) adverse events. The study is designed as a prospective open-label study with blinded endpoint assessment (PROBE). Discussion: In this trial, we combined the expertise of hepatologist, nephrologists and gynecologists to study the effect of leuprorelin on liver growth in PLD. In this way, we hope to stop liver growth, reduce symptoms and reduce the need for liver transplantation in severe PLD. *Correspondence: r.t.gansevoort@umcg.nl 1 Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 2 of 11 Trial registration Eudra CT number 2020-005949-16, registered at 15 Dec 2020. https://​www.​clini​caltr​ialsr​egist​er.​eu/​ctr-​ search/​search?​query=​2020-​005949-​16. Keywords: Polycystic liver disease, GnRHa, Estrogen Background Polycystic liver disease (PLD) is a rare disease, charac- terized by the presence of > 10 liver cysts [1]. Autoso- mal Dominant Polycystic Liver Disease (ADPLD) leads to PLD only and is caused by a mutation in PRKCSH, SEC63, LRP5, ALG8 or SEC61B [1]. Autosomal Domi- nant Polycystic Kidney Disease (ADPKD) can cause PLD but also leads to kidney cysts and renal function decline [1–3] and is most frequently caused by a mutation in the PKD1 or PKD2 gene [4, 5]. The PKD1 and PKD2 genes encode for ciliary proteins polycystin 1 and polycystin 2, respectively, while the mutations in ADPLD affect mat- uration and trafficking of polycystin 1 [3, 4]. The preva- lence of ADPLD is < 1:10.000 [6], the point prevalence of clinically relevant ADPKD approximately 1:2500 [7], but not all ADPKD patients suffer from PLD [8]. PLD patients have a normal liver function in general, but large liver volumes can lead to serious physical and psychosocial complaints [1, 9]. The large liver can com- press the stomach and bowels, leading to early satiety, decreased food intake, weight loss, sarcopenia and con- stipation [1, 9]. The increased intra-abdominal volume Fig. 1 MRI scan (coronal T2-weighted image) of a patient with severe can lead to pain, and diaphragmatic, umbilical and ingui- PLD and ongoing liver growth despite somatostatin analogue use, nal herniation [1] and compression of vascular structures that would be eligible for the AGAINST-PLD study can lead to ascites, portal vein thrombosis or hepato- venous outflow obstruction [10]. The large, protruding abdomen may cause psychological problems, because of distorted body image and confronting questions about performed in Europe to treat PLD [12]. Therefore, there possible pregnancy [1, 9]. This can result in decreased is a continuing unmet need for new therapies in PLD. quality of life, and sometimes liver transplantation is the only and last resort treatment option [11, 12]. Female hormones in PLD Female sex is the most important risk factor for PLD [14]. An unmet need for new treatments About 90% of patients is female [14, 15]. Several factors Dependent on the cyst distribution, different treatments indicate that female sex hormones stimulate cyst growth. are possible. In case of several dominant liver cysts, First, estrogen supplementation leads to enhanced liver aspiration or fenestration is used [1, 9]. If liver cysts are growth [16, 17] and after menopause, when estrogen and clustered in a few liver segments, a hemihepatectomy progesterone levels fall, liver volumes sometimes decrease can be performed [1]. In case of numerous liver cysts in spontaneously [18]. Second, estrogen receptors are pre- all segments, surgical interventions are not possible and sent on hepatic cyst epithelium and in vitro, liver growth the mainstay of treatment is to halt natural growth [1, increases after estrogen supplementation and decreases 9]. The only treatment now available to halt growth of after administration of estrogen blockers [19–22]. In a liver cysts are somatostatin analogues, but in about 40% recent review paper, we explained in detail how the female of patients treated with these drugs liver growth con- sex hormones estrogen and progesterone may affect liver tinues (Fig. 1) [13]. In these patients, the only treatment growth and how these hormones could be a target for option that remains is a liver transplantation [1, 9, 12]. In therapies [22]. While there is a lot of evidence that estro- the last 15 years, 1293 liver transplantations have been gen affects liver cyst growth, it is difficult to disentangle the Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 3 of 11 contributions of the individual sex hormones, like estrogen Methods and design and progesterone, on PLD. Oral contraceptives mostly con- Study design tain estrogen as well as progesterone and menopause also The AGAINST-PLD study (A GnRH Agonist IN premen- affects both hormones. Therefore, it is unclear whether opausal women Study to Treat Polycystic Liver Disease) other sex hormones than estrogen, such as progesterone, is a 3-year lasting, investigator driven, phase 2b rand- affect liver growth. omized controlled trial. Participants will be randomized An ideal therapy should block all estrogen receptors and between direct start or delayed start (18 months later) of should block also other sex hormones, such as progester- leuprorelin treatment (Figs. 2, 3). Patients randomized one. For estrogen only, three different estrogen receptors to delayed start will receive standard of care in the first [22] are present on hepatic cyst epithelium: ER-α, ER-β 18 months of the trial. Therefore, in the first 18 months and the G-coupled protein estrogen receptor 1 (GPER-1) of the trial, we can distinguish between the effect of [19–23]. Selective estrogen receptor modulators (SERM), treatment and the natural course of disease by compar- such as tamoxifen, act as agonist or antagonist on ER-α and ing both treatment arms. Using data obtained during the ER-β, dependent on the surrounding tissue [24, 25]. Cur- second 18 months of the trial, when all patients are sub- rently it is not possible to predict the effects of SERMs in jected to active treatment, we can compare liver growth PLD. Besides, the effect on the GPER-1 receptor (inhibition rates within individuals before start of treatment and or stimulation) is unclear. Therefore, in this trial, we aim to during treatment and obtain more information about reduce liver growth in patients suffering from severe PLD safety and tolerability. using the Gonadotropin Releasing Hormone (GnRH) ago- nist leuprorelin. This drug leads to cessation of the produc- Study setting tion of estrogen as well as progesterone and other female The trial will be conducted according to the International hormones, aiming to stop liver growth, but with medically Conference of Harmonization Good Clinical Practice induced menopause as logical adverse event [26]. Guidelines and adheres to the Declaration of Helsinki. IRB approval will be obtained in all participating cent- Objectives ers. All participants must give their voluntary and written The main trial objective is: informed consent before any study related procedures could take place. Individuals who meet the entry criteria • To determine whether lowering estrogen and pro- and complete the baseline visit will be enrolled in one of gesterone levels with the GnRH agonist leuprorelin the five participating University Medical Centers: Gron- decreases liver growth rates (%/y) in pre-menopausal ingen and Nijmegen, (the Netherlands), Cologne (Ger- women with severe PLD when compared to similar many), Leuven (Belgium) and Barcelona (Spain). women not receiving this treatment. Patient selection Secondary objectives are: Detailed inclusion criteria are given in Table 1, of which the most important are: 1. To assess the effect of leuprorelin on PLD disease severity, measured with the PLD-Questionnaire • Female patients, pre-menopausal (PLD-Q) • Anti Mullerian Hormone (AMH) level > 0.3 (a lower 2. To assess the change in liver growth within individu- level indicates upcoming menopause) als before and during leuprorelin treatment • Age 18–45 years (inclusive) 3. To assess the tolerability and incidence of (serious) • PLD with a very large liver for age, based on the adverse events. upper 10% of volumes in our PLD registry (n = 1600) [27]. Exploratory outcomes are: • One historical MRI or CT scan, performed 1–5 years before baseline, available to calculate liver growth 1. To assess estrogen and progesterone levels before start of the study 2. To assess differences in short term and long term • Ongoing liver growth, confirmed using a historical effects of treatment scan (a) obtained in routine clinical care and the scan 3. In case of ADPKD, to assess the effect on kidney at screening (b) with the liver volume in ml from growth and renal function decline. scan b–a > 0. Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 4 of 11 Fig. 2 Infographic about the AGAINST-PLD study • Use of a somatostatin analogue (only proven effective for somatostatin analogue use (yes/no) and age (< 40 therapy currently available) or reason not to use such and ≥ 40 years). drug (e.g. not tolerated, ineffective, not available) Intervention Most important exclusion criteria are: Leuprorelin is a synthetical analogue of GnRH and strongly stimulates the pituitary resulting in desensitiza- • Symptoms of (upcoming) menopause, e.g. hot flushes tion. Thus, the production of luteinizing hormone (LH) • Active desire to have children during study period and follicle stimulating hormone (FSH) by the pituitary • Use of exogenous estrogen and/or progesterone stops, which leads to cessation of the production of estro- • Contra-indication for leuprorelin gen and progesterone by the ovaries. Leuprorelin will be started using monthly injections of 3.75 mg, and if tolerated after 3 months, treatment regi- Randomization men will be switched to 3-monthly injections of 11.25 mg. Participants will be randomized 1:1 between direct and Depending on patients’ preferences, participants will be delayed start (after 18 months) of treatment using an trained to self-administer the injections at home or injec- online Interactive Response System (IXRS) tool, stratified tions will be administered by study personnel. Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 5 of 11 Fig. 3 Study design of the AGAINST-PLD study. Patients are randomized between direct and delayed start (after 18 months) of treatment. a Historical scan, b baseline scan, a, b historical growth. Primairy outcome, comparison between growth on treatment and without treatment in the first 18 months is b, c versus b, e. Secondary outcome, growth within individuals before and during treatment is b, c versus c, d and a, b versus b, e Concomitant medication Secondary outcomes For massive PLD, somatostatin analogues are currently the only evidence-based treatment. Therefore, soma- 1. Change in PLD disease severity, assessed by the vali- tostatin analogues should be used, tried, or have been dated PLD-Q questionnaire, calculated over the first considered before inclusion in the AGAINST-PLD trial. 18 months of the trial and compared between the Patients are thus allowed to use a somatostatin analogue direct start group (on treatment) and delayed start during the trial (see inclusion criteria, Table 1). During group (on standard of care). the study, start or stop of somatostatin analogues as well 2. Liver growth rates within individuals compared as surgical procedures to reduce liver volume should before treatment and during treatment. In the direct be avoided unless there are important reasons to do so, start group, historical growth rates (Fig. 3a, b) will because this could interfere with the assessment of the be compared with growth rate during 18 months primary outcome, liver growth. of treatment (b–e) and in the delayed start group, Use of estrogen- and or progesterone contain- growth rates during the first 18 months of the trial ing medication is not allowed during the trial period, (untreated, b–c) will be compared with the last because it could interfere with the effect of the study 18 months of the trial (treated, c–d). treatment. Blood pressure treatment is targeted below 3. The incidence of (serious) adverse events, compared 130/80 mmHg with RAAS-inhibitors as the first- between the direct and delayed start group in the choice agents. Calcium vitamin D (500 mg/800 IE) will first 18 months of treatment. be prescribed to all patients in the study to prevent osteoporosis. Outcome parameters Exploratory outcomes Primary outcome • Height adjusted liver volumes, compared between • Liver growth (%/y), calculated over the first the direct and delayed start group after 18 months 18 months of the trial and compared between the • Estradiol, progesterone, AMH, LH and FSH levels at direct start group (on treatment) and delayed start baseline, 6, 18, 24 and 36 months group (on standard of care), b–e versus b–c, Fig. 3. Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 6 of 11 Table 1 Overview of in- and exclusion criteria for the AGAINST-PLD study Inclusion criteria Female Diagnosis of PLD (presence of > 10 cysts) Age 18–45 (inclusive) years Very large liver for age:   18–30 y hTLV > 2.0 L/m   30–35 y hTLV > 2.2 L/m   25–40 y hTLV > 2.5 L/m   40–45 y hTLV > 3.0 L/m 1 historical MRI or CT scan of the liver available, made 5-1 y before baseline Ongoing liver growth, confirmed using the historical scan and MRI scan at screening Use of somatostatin analogues OR a reason not to use them (e.g. tried in de past but stopped because of side effects, not effective, no acces, patient does not want to) Voluntary written informed consent Exclusion criteria Post menopausal status or (vasomotor) symptoms indicating upcoming menopause AMH < 0.03 ng/ml at screening Active desire to have children, pregnancy or breast-feeding Contra-indications for leuprorelin, such as cardiovascular disease or osteoporosis Liver transplantation expected within 1.5 years Use of oral estrogen or progesterone containing medication Contra-indications for MRI Chronic use of immunosupressive agents Severe hypertension (systolic pressure ≥ 160 and/or diastolic pressure ≥ 100 mmHg) Clinically significant uncontrolled medical condition that, in the opinion of the investigator, would put the safety of the patient at risk though participation, or which would affect efficacy or safety analysis, such as, but not limited to, recurrent cholangitis, recurrent ascites, hepato-venous outflow obstruction, (history of ) depression Participation in other interventional studies at the same time Exclusion criteria related to the historical MRI/CT scan Start or stop of liver volume reducing therapy (medication e.g. somatostain analogues or surgical interventions) between the historical scan and screening Historical scan is performed < 3 months after start or stop of volume reducing therapy (either a somatostatin analogue or surgical treatments) • Difference between acute and chronic effects of • Bone density: T-score on Dual Energy X-ray treatment on liver growth as assessed by a mixed Absorptiometry (DEXA) scans will be compared models analysis comparing liver growth rate in the between direct start group and delayed start group first 6 months of treatment compared to the next after 18 months. 12 months of treatment. For patients with polycystic kidney disease (PKD) also: With respect to tolerability: • Kidney growth (%/y) calculated over the first • Quality of life, using the validated 36-Item Short 18 months of the trial compared between direct Form Health Survey (SF-36) and the Beck Depres- and delayed start group sion Inventory II (BD-II) questionnaires • Kidney growth rates within individuals compared • Menopause related complaints: using the Menopause before treatment and during treatment Specific Quality of Life (MENQOL) questionnaire • Differences between acute and chronic effects of treatment on kidney growth Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 7 of 11 • Renal function decline before and during treat- Data collection and management ment. The study consists of one or two screening visits, nine hospital visits and one phone call. During short visits (3, 12, 15, 21 months), a small set of local laboratory meas- Sample size calculation urements, vital signs, AEs and concomitant medica- In our own DIPAK 1 trial [13], the mean liver tion will be assessed. At larger visits (BL, 6, 18, 24 and growth rate in patients meeting the inclusion criteria 36 months) in addition MRI scans, extensive lab and was + 5.8% ± 2.8% per 18 months. Since the information questionnaires will be performed. DEXA scans are made on liver growth rate in this specific group is scarce, we at baseline, halfway and end of the study (Figs. 3, 4). Data conservatively doubled the SD to ensure enough power. will be entered in a web-based electronic case report We aim at fully stopping liver growth. Using β = 80%, form to ensure correct and timely data collection in a α = 0.05, and incorporating a 20% drop-out rate, inclu- central database. sion of 36 patients is needed to show this effect. In other proof-of-concept studies in PLD, similar numbers of MRI scans patients were included [28, 29]. Liver and kidney volumes (the latter in ADPKD patients only) will be measured using an MRI scan at screening, 6, Recruitment 18, 24 and 36 months. MRI scans will be performed using Patients will be recruited from outpatient clinics of the a standardized protocol, including a coronal T2-weighted participating centers or referred by other centers. All par- single-shot fast gradient spin-echo sequence with fat- ticipating centers are expertise centers on polycystic liver saturation with a slice thickness of 3 mm which is the and/or polycystic kidney disease and see many patients primary sequence to determine liver volumes. In addi- that meet the inclusion criteria for the trial. We planned tion, a transversal T2-weighted single shot fast gradient 24 months for the recruitment period. spin-echo sequence with fat suppression and a coronal T1-DIXON-VIBE spoiled gradient echo sequence will be obtained. After pseudonymization, MRI scans will be sent to the central reading facility, where images will Fig. 4 Visit schedule. S = screening, BL = baseline, V = visit, P = phone call. Screening procedures can take place in one visit or with MRI and DEXA apart, as preferred by site and patient. Patients are randomized to direct start (at BL) or delayed start (at V5). A phone cal (P) takes place one month after first leuprorelin injection. More extensive visits with MRI, questionnares and extensive lab take place at BL, 6, 18, 24 and 36 months. Extensive lab consists also of biobanking (samples stored at − 80 °C and shipping to core laboratory for measurement of female sex hormones in one run) and in case of ADPKD, 24 h urine collection. Between visits, site personnel will remind patients to administer the leuprorelin injections by phone or email Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 8 of 11 be analyzed blinded for patient, time and treatment by transplant offer, this patient will also be withdrawn from trained observers using an automated MRI program [30]. the trial. To ensure that valid MR images are obtained, quality control will be performed within 72 h by trained person- Statistics nel. In case a scan is rejected, it will be repeated. Statistical analysis Analyses are performed after completion of the study. For the primary outcome, liver growth during the first Laboratory measurements 18 months of the trial compared between direct and For a detailed overview of collected samples, see Fig. 4. delayed starters, an unpaired t-test will be used. In case At all visits, a limited set of laboratory measurements of missing data, last information will be used adjusted for will be performed. At baseline and the visits at month 6, the duration of follow up. For questionnaires, the delta in 18, 24 and 36, more extensive laboratory measurements, scores during the first 18 months of the trial will be com- biobanking and in ADPKD patients, 24-h urine sam- pared between direct and delayed starters. To compare ples will be collected. Except form biobanking samples, liver growth within individuals before and during treat- laboratory samples will be analyzed locally. Biobanking ment, a paired t-test will be used. Adverse events will be samples will be stored at − 80 °C and shipped to the core categorized and the number of adverse events per cate- laboratory at the end of the trial to measure estrogen, gory will be compared between direct and delayed start- progesterone, AMH, FSH and LH in one run, to mini- ers using an unpaired t-test. mize interlaboratory and interassay variation. For all primary and secondary analyses, we will per- form pre-defined sensitivity analysis to adjust for age, Vital signs disease type (ADPKD vs. ADPLD), total liver volume at During every visit we will measure blood pressure, baseline, total kidney volume at baseline, use of somato- weight and abdominal circumference. Height will be statin analogues, and test differences in treatment effects collected at baseline. Upper arm circumference of among these variables (interaction). In a sensitivity anal- the non-dominant arm will be measured every visit ysis we will test for differences in the outcome variables because this is one of the exception criteria for the between the first 18 months of the trial and the second MELD score [31]. 18 months of the trial in the direct start group, using a breakpoint analysis. All analyses will be performed based Questionnaires on an intention to treat principle. As a sensitivity analy- Questionnaires will be sent digitally to the patient at sis, we will perform a per-protocol analysis. screening, 6, 18, 24 and 36 months. Quality of life will be In an additional analysis we will explore whether liver assessed using the SF-36 and BD-II questionnaires, PLD growth is linear and whether the liver growth rate during disease severity using the validated PLD-Q questionnaire treatment is different in the first 6 months of treatment and menopause related complaints using the MENQOL compared to the 12 months thereafter, using a multiple questionnaire [32, 33]. mixed model. Criteria for withdrawal Discussion Subjects can leave the study at any time for any reason The AGAINST-PLD study will assess the effect of the if they wish to do so without any consequences. Patients GnRH-agonist leuprorelin on liver growth in pre-men- that drop-out from the trial within the first 3 months opausal patients with severe PLD. If effective, leuprore- from baseline will be replaced and not be part of the lin may help to stop disease progression in female PLD intention to treat analysis. Patients that drop-out from patients at risk of rapid disease progression. Ultimately, the trial later on will not be replaced by new patients and this may avoid liver transplantations, which is desirable will be asked for an early-end of treatment. The investi- in view of the donor shortage and the procedure related gator can withdraw a subject from the study for urgent morbidity and mortality [12]. medical reasons, such as (but not limited to): occur- We study the effect of anti-estrogenic therapy in PLD, a rence of a concomitant disease in which leuprorelin is novel and promising target, using a broad proof-of-con- contra-indicated, pregnancy, need of treatment that is cept approach. To reiterate a recent literature review [22], contra-indicated during the trial (such as estrogens), lost- estrogens have a cyst growth promoting effect and the to-follow up or, by the opinion of the treating physician, idea to study estrogen inhibition in female PLD patients high need for surgical volume reducing treatments. If has been coined several times [3, 20, 22, 34]. To inhibit a patient that is registered on the waiting list receives a the effect of estrogens, several approaches could be used [22]. We chose for a GnRH-agonist, because this is the Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 9 of 11 only way currently available to inhibit all three types of used to treat side effects, such as clonidine in case of hot estrogen receptors and also block the effects of other flushes and venlafaxine in case of mood swings. In addi- female hormones such as progesterone. For other treat- tion, also at the request of the patients in the focus group, ments, such as tamoxifen (a selective estrogen recep- a gynecologist will be available at all study sites to coun- tor modulator) it is so far unclear whether they would sel patients before and during the study, at some sites inhibit, stimulate or either have no effect on estrogen supported by a trained nurse as “menopause coach”. receptors in PLD and they would not block other female On the longer term, estrogen depletion could lead to hormones which possibly also affect liver growth [22]. an increased risk of osteoporosis and a slightly enhanced Since the study treatment ceases the menstruation cardiovascular risk [26, 35, 36]. With a treatment dura- and can lead to menopause-related complaints, blinding tion of 18 or 36 months, we do not expect large detrimen- is not possible and as a consequence we adopted a pro- tal effects on the long term. However, to ensure optimal spective open-label with blinded endpoint assessment safety, patients with a history of cardiovascular disease (PROBE) design. Randomization between direct and and a low bone-density at screening will be excluded delayed start of treatment makes it possible to compare from the trial and during the trial blood pressure, choles- treated and untreated patients, but also to compare liver terol levels and bone-density will be monitored (Fig. 4). growth before and during treatment within patients, In addition, all patients will receive advise on healthy and it will render additional safety and tolerability data. food intake and calcium and vitamin D supplementation. Finally, the design meets the urgency felt by patients, stating that they would not participate if they could be in a control group without treatment. Interim analysis To safeguard a favorable efficacy–safety ratio during Efficacy–safety ratio the trial, a Data Safety and Monitoring Board will meet Leuprorelin blocks the production of all female sex hor- regularly to discuss the progress and interim results. A mones and can have several side effects that we know formal interim analysis for safety and futility will be per- from menopause, such as hot flushes, night sweats, mood formed when 50% of the patients (n = 18) have reached swings, vaginal dryness and disturbed sleep [26]. On the 18 months, the time point at which the primary outcome long term, estrogen depletion could increase the risk of is assessed. osteoporosis and cardiovascular events [35, 36]. We tried to enhance the tolerability and the efficacy- Perspective safety ratio of the study medication in several ways. First, In case the trial is positive, leuprorelin treatment will at only patients with the highest need for new treatment first be especially indicated in patients suffering from options are included in this study. The target popula- severe, symptomatic PLD given the nature of the inter- tion consist of patients who, despite current treatment vention and the expected side-effects. However, when options, will mostly need a liver transplantation in the more experience is gained, and leuprorelin also shows a future if the course of the disease cannot be altered. We good efficacy–safety ratio in a real life setting, the use of discussed the design of this trial in a focus group with this drug could be extended to patients with less severe eight patients meeting the inclusion criteria and with de forms of PLD, that notwithstanding are symptomatic. Dutch Liver Patient Foundation. They felt that the bur- With the AGAINST-PLD study, we venture outside the den of the disease is high and the perspective grim, and somatostatin analogue era and explore a promising new most patients thought that the potential of efficacy of a target for intervention to stop PLD progression: inhibi- new treatment outweighs side effects. tion of female sex hormones. In this trial we will include Second, with the help of patient focus groups we patients with the highest need for treatment. In this way adjusted the study design to the preferences and needs we hope to be able to reduce liver growth, and associated of patients to be included, especially to limit adverse symptoms, an urgent unmet need in PLD. events related to the mechanism of action of GnRH ago- nists. A potential option to reduce side effects would be Abbreviations to add a low-dose estrogen and/or progesterone as “add- ADPKD: Autosomal Dominant Polycystic Kidney Disease; ADPLD: Autosomal back therapy”, as is used in GnRH agonist treatment for Dominant Polycystic Liver Disease; AMH: Anti Mullerian Hormone; BD-II: Beck endometriosis [26]. However, because this is a proof-of- Depression Inventory Questionnaire; CT: Computed tomography; DEXA: Dual Energy X-ray Absorptiometry; DIPAK: Developing Intervention strategies concept trial testing whether estrogen depletion curtails to halt Progression of Autosomal Dominant Polycystic Kidney Disease; ER: liver growth, we decided to not allow add-back therapy. Estrogen receptor; FSH: Follicle stimulating hormone; GnRH: Gonadotropin Instead, we added that non-hormonal treatments can be receptor hormone; GPER: G-coupled protein estrogen receptor; LH: Lutein- izing hormone; MENQOL: Menopause Specific Quality of Life; MRI: Magnetic resonance imaging; PLD: Polycystic liver disease; PLD-Q: Polycystic Liver Aapkes et al. BMC Gastroenterology (2022) 22:82 Page 10 of 11 Disease Questionnaire; PROBE: Prospective open label study with blinded References endpoint assessment. 1. Van Aerts RMM, Van De Laarschot LFM, Banales JM, Drenth JPH. Clinical management of polycystic liver disease. J Hepatol. 2018;68:827–37. Acknowledgements 2. Bae KT, Zhu F, Chapman AB, Torres VE, Grantham JJ, Guay-Woodford LM, We thank J. Willemse, director of the Dutch Liver Patient Foundation, for her et al. Magnetic resonance imaging evaluation of hepatic cysts in early commitment in the preparations of this trial. autosomal-dominant polycystic kidney disease: the Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease cohort. Clin J Am Authors’ contributions Soc Nephrol. 2006;1:64–9. Study design and protocol development: SEA, LHPB, JPHD and RTG. Gyneco- 3. Barten TRM, Bernts LHP, Drenth JPH, Gevers TJG. New insights into target- logical aspects of study design: MvdB and AEPC. Imaging aspects of study ing hepatic cystogenesis in autosomal dominant polycystic liver and design: PK, RJdH and MDAvG. Patient involvement: AV. Local investigators kidney disease. Expert Opin Ther Targets. 2020;24:589–99. participating in the design and conduct of the trial: APvdB, HB, RUM, FN and 4. Harris PC, Torres VE, Harris PC, Torres VE. Genetic mechanisms and signal- RT. All authors read and approved the final manuscript. ing pathways in autosomal dominant polycystic kidney disease. J Clin Investig. 2014;124:2315–24. Funding 5. Cornec-Le Gall E, Torres VE, Harris PC. Genetic complexity of autoso- The AGAINST-PLD study is funded by unrestricted grants from the Dutch mal dominant polycystic kidney and liver diseases. J Am Soc Nephrol. Government (ZonMW grant 10140261910001) and Abbvie (SA-003047 (ACA- 2018;29:13–23. NETH-20-01)) (providing study medication free of charge). Neither organiza- 6. Suwabe T, Chamberlain AM, Killian JM, King BF, Gregory AV, Madsen CD, tion had any role in the conception of this study, nor in the writing of the et al. Epidemiology of autosomal-dominant polycystic liver disease in study protocol and this manuscript. Olmsted county. JHEP Rep. 2020;2:100166. 7. Willey CJ, Blais JD, Hall AK, Krasa HB, Makin AJ, Czerwiec FS. Prevalence of Availability of data and materials autosomal dominant polycystic kidney disease in the European Union. De-identified individual participant data collected during the trial will be Nephrol Dial Transplant. 2017;32:1356–63. made available upon request to researchers who provide a methodologi- 8. Meijer E, Visser FW, Van Aerts RMM, Blijdorp CJ, Casteleijn NF, D’Agnolo cally sound proposal and whose use of the data has been approved by the HMA, et al. Effect of lanreotide on kidney function in patients with AGAINST-PLD Steering Committee. autosomal dominant polycystic kidney disease the DIPAK 1 randomized clinical trial. JAMA. 2018;320:2010–9. 9. Cnossen WR, Drenth JPH. Polycystic liver disease: an overview of patho- Declarations genesis, clinical manifestations and management. Orphanet J Rare Dis. 2014;9:69. Ethics approval and consent to participate 10. Bernts LHP, Drenth JPH, Tjwa ETTL. Management of portal hypertension Ethics approval was obtained before start of the trial by the Internal Review and ascites in polycystic liver disease. Liver Int. 2019;39:2024–33. Board (IRB) from the University Medical Center of Groningen, METC number 11. Neijenhuis MK, Kievit W, Verheesen SMH, D’Agnolo HM, Gevers TJG, METc 2021/119. All participants must give their voluntary and written Drenth JPH. Impact of liver volume on polycystic liver disease-related informed consent before any study related procedures could take place. symptoms and quality of life. United Eur Gastroenterol J. 2018;6:81–8. 12. Adam R, Karam V, Cailliez V, O Grady JG, Mirza D, Cherqui D, et al. 2018 Consent for publication annual report of the European Liver Transplant Registry (ELTR)—50-year Not applicable. evolution of liver transplantation. Transpl Int. 2018;31:1293–317. 13. van Aerts RMM, Kievit W, D’Agnolo HMA, Blijdorp CJ, Casteleijn NF, Dek- Competing interests ker SEI, et al. Lanreotide reduces liver growth in patients with autoso- Dr. Gansevoort received grant support and fees for serving on advisory boards mal dominant polycystic liver and kidney disease. Gastroenterology. and steering committees from Galapagos, IPSEN, Otsuka Pharmaceuticals 2019;157:481–91. and Sanofi-Genzyme. In addition, Dr. Gansevoort holds the Orphan Medicinal 14. van Aerts RMM, Kievit W, de Jong ME, Ahn C, Bañales JM, Reiterová J, Product Designation status at the European Medicines Agency for lanreo- et al. Severity in polycystic liver disease is associated with aetiology tide as treatment for kidney function decline in ADPKD (EMA/OD/027/15). and female gender: results of the International PLD Registry. Liver Int. Dr. Drenth has received grant support and fees for serving on advisory 2019;39:575–82. boards and consultancy from IPSEN and Novartis. All money is paid to their 15. Van Keimpema L, De Koning DB, Van Hoek B, Van Den Berg AP, Van Oijen institutions. No other potential conflict of interest relevant to this article was MGH, De Man RA, et al. Patients with isolated polycystic liver disease reported. The Dept. 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Long-term effects on bone mineral density and bone metabolism of 6 months’ treatment with gonadotropin-releasing hormone analogues in Japanese women: comparison of buserelin acetate with leuprolide acetate. J Bone Miner Metab. 2005;23:389–94. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Ready to submit your research ? Choose BMC and benefit from: • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations • maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions