Paracetamol Effect on Oxidative Stress and Renal Function in Severe Malaria
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Purpose
Blackwater fever, characterized by intravascular haemolysis and hemoglobinuria, is an important cause of renal impairment and mortality in severe malaria caused by Plasmodium falciparum. The largest malaria clinical trials report blackwater incidences of 5-7% in Asian adults and 4% in African children with severe malaria treated with artesunate or quinine. The prevalence of blackwater fever in Chittagong, Bangladesh is 15% with associated rates of renal failure and mortality of 42.9% and 14.2% respectively.
The fundamental characteristic of blackwater fever is the presence of intravascular hemolysis of both infected and uninfected erythrocytes and release of free haemoglobin. The cytotoxic free haemoglobin present can cause severe oxidative damage as a result of haem redox cycling yielding ferric and ferryl heme, which generate radical species that induce lipid peroxidation and subsequent production of F2-isoprostanes (F2-IsoPs). Evidence suggests that F2-IsoPs generated by the hemoprotein-catalyzed oxidation of lipids are responsible for the oxidative damage and vasoconstriction associated with renal injury in haemolytic disorders and rhabdomyolysis.
A novel mechanism of paracetamol was recently demonstrated, showing that paracetamol is a potent inhibitor of hemoprotein-catalyzed lipid peroxidation by reducing ferryl heme to its less toxic ferric state and quenching globin radicals. In a recent proof of concept trial, paracetamol at therapeutic levels was shown to significantly decrease oxidant kidney injury, improve renal function and reduce renal damage by inhibiting the hemoprotein-catalyzed lipid peroxidation in a rat model of rhabdomyolysis-induced renal injury. Since adults with severe malaria demonstrate increased concentrations of cell-free haemoglobin, and urinary F2-IsoPs, the investigators hypothesize that this novel inhibitory mechanism of paracetamol may provide renal protection in this population by reducing the hemoprotein-induced lipid peroxidation. As there is currently no consensus that exists concerning adequate medical treatment for blackwater fever, the potential application of this safe and extensively used drug would be of great benefit.
| Condition | Intervention |
|---|---|
|
Malaria |
Drug: Paracetamol Drug: No Paracetamol |
| Study Type: | Interventional |
| Study Design: | Allocation: Randomized Endpoint Classification: Efficacy Study Intervention Model: Parallel Assignment Masking: Open Label Primary Purpose: Treatment |
| Official Title: | Paracetamol Effect on Oxidative Stress and Renal Function in Severe Falciparum Malaria With Intravascular Haemolysis: A Randomised Controlled Clinical Trial |
- Effect of paracetamol concentrations [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]Compare the effect of therapeutic paracetamol concentrations compared with absent or low paracetamol concentration on renal function, defined as the peak creatinine levels or trough creatinine clearance, in patients with severe falciparum malaria stratified by the level of intravascular haemolysis.
- Compare treatment arm with control arm with respect to duration of Acute Kidney Injury (AKI) and development of AKI. [ Time Frame: 7 days ] [ Designated as safety issue: No ]Duration of AKI will be defined as the length of time elapsed until serum creatinine returns to normal (<1mg/dL) in the absence of renal replacement therapy. Plasma paracetamol concentration will be measured daily by high performance liquid chromatography (HPLC).
- Oxidative stress assessed by measuring F2-isoprostanes (F2-IsoPs) [ Time Frame: 3 days ] [ Designated as safety issue: No ]Cell free haemoglobin measured as plasma concentration by HPLC and by enzyme linked immunosorbant assay (ELISA) on admission then daily for 72hours. Cell free haem measured in plasma using a chromogenic assay on admission then daily for 72hours. Haem-to-protein cross-links measured by HPLC on admission and daily for 72hours.
- Assessment of Blackwater fever [ Time Frame: 7 days ] [ Designated as safety issue: No ]Blackwater fever assessed using a standardized urine colour chart and urine haemoglobin every 6 hours until clinical recovery.
- Mortality trends [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]To compare mortality trends between groups and evaluate if mortality correlates with level of oxidative stress, cell free haemoglobin and Acute Kidney Injury (AKI).
- Intravascular Haemolysis [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]Intravascular haemolysis according to G6PD status
- Fever clearance time [ Time Frame: 7 days ] [ Designated as safety issue: No ]Fever clearance time defined as the time taken for the tympanic temperature to fall below 37.5°C and remain there for at least 24hours); Fever time defined as the duration in hours of an individuals temperature above 37.5°C; Area above the 37.5°C temperature versus time curve (AUC-T°) within first 24hours of treatment. Aural temperature will be measured every 6 hours until fever clearance.
- Parasite clearance time [ Time Frame: 7 days ] [ Designated as safety issue: No ]Parasite clearance time assessed by microscopy of peripheral blood films will be assessed every 6hours for the presence of asexual parasitaemia until negative on 2 consecutive blood films. Parasites will also be staged to assess if sequestration is inhibited due to temperature reduction.
- Parasite sequestration [ Time Frame: 7 days ] [ Designated as safety issue: No ]Parasite sequestration assessed by capillary flow in the rectal microcirculation using Orthogonal Polarization Spectral (OPS) imaging.
- Assessment of Acute Kidney Injury [ Time Frame: 7 days ] [ Designated as safety issue: No ]Acute kidney injury: assessed by blood and urine biomarkers of pre-renal and renal injury including neutrophil gelatinase-associated lipocalcin (NGAL) and kidney injury molecule (KIM).
- Creatinine clearance [ Time Frame: 4 weeks ] [ Designated as safety issue: No ]Urine colour will be assessed by standardized urine colour charts. Urine colour will be correlated with urine specific gravity, urine osmolality, urine haemoglobin and creatinine clearance.
- Safety assessment [ Time Frame: 4 weeks ] [ Designated as safety issue: Yes ]Safety assessed by the number of patients with serious adverse events (SAEs) and by changes from baseline in vital signs and laboratory measurements.
| Estimated Enrollment: | 50 |
| Study Start Date: | July 2012 |
| Estimated Study Completion Date: | December 2015 |
| Estimated Primary Completion Date: | December 2015 (Final data collection date for primary outcome measure) |
| Arms | Assigned Interventions |
|---|---|
|
Experimental: Paracetamol
>50kg: Paracetamol 1gm PO/NG q6hourly plus intravenous Artesunate <50kg: Paracetamol 12.5-15mg/kg/dose q6hourly plus intravenous Artesunate
|
Drug: Paracetamol
>50kg: Paracetamol 1gm PO/NG q6hourly plus intravenous Artesunate <50kg: Paracetamol 12.5-15mg/kg/dose q6hourly plus intravenous Artesunate
|
|
Active Comparator: No Paracetamol
No paracetamol + Intravenous Artesunate
|
Drug: No Paracetamol
No paracetamol + Intravenous Artesunate
|
Show Detailed Description Eligibility| Ages Eligible for Study: | 12 Years and older |
| Genders Eligible for Study: | Both |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- Patient age >12 years
- Presence of severe P. falciparum malaria, with and without blackwater fever, confirmed by positive blood smear with asexual forms of P. falciparum
- Temperature >38 degrees Celsius on admission or fever during the preceding 24hours
- Written informed consent from patient or attending relative able to and willing to give informed consent. Consent form and information sheets will be translated into Bangla and copies provided to the patient.
Exclusion Criteria:
- Patient or relatives unable or unwilling to give informed consent
- History of chronic liver disease
- History of alcohol use (>3drinks per day)
- Contraindication or allergy to paracetamol or artesunate therapy
- Contraindication to nasogastric tube insertion i.e. facial fracture, bleeding diathesis
- Pregnancy
Contacts and Locations| Contact: Katherine Plewes, MD | +6683-821-4103 | katherine@tropmedres.ac |
| Bangladesh | |
| Chittagong Medical College Hospital | Recruiting |
| Chittagong, Bangladesh | |
| Contact: Katherine Plewes, MD +6683-821-4103 katherine@tropmedres.ac | |
| Sub-Investigator: Katherine Plewes, MD | |
| Principal Investigator: | Katherine Plewes, MD | University of Oxford |
More Information
No publications provided
| Responsible Party: | University of Oxford |
| ClinicalTrials.gov Identifier: | NCT01641289 History of Changes |
| Other Study ID Numbers: | BAKMAL1201 |
| Study First Received: | May 23, 2012 |
| Last Updated: | July 24, 2012 |
| Health Authority: | United Kingdom: Research Ethics Committee |
Keywords provided by University of Oxford:
|
Falciparum malaria Paracetamol Blackwater fever |
Additional relevant MeSH terms:
|
Malaria Malaria, Falciparum Protozoan Infections Parasitic Diseases Acetaminophen Artesunate Antipyretics Physiological Effects of Drugs Pharmacologic Actions Analgesics, Non-Narcotic |
Analgesics Sensory System Agents Peripheral Nervous System Agents Central Nervous System Agents Therapeutic Uses Amebicides Antiprotozoal Agents Antiparasitic Agents Anti-Infective Agents Antimalarials |
ClinicalTrials.gov processed this record on May 16, 2013