Effect of Paracetamol on Renal Function in Plasmodium Knowlesi Malaria (PACKNOW)

• ClinicalTrials.gov Identifier: NCT03056391
• Recruitment Status: Completed
• First Posted: February 17, 2017
• Last Update Posted: December 19, 2019
• Sponsor: Menzies School of Health Research
• Information provided by (Responsible Party): Menzies School of Health Research

Study Description

Brief Summary:

Acute kidney injury is a common complication of severe Plasmodium knowlesi malaria, and an important contributor to mortality.

The exact pathogenic mechanisms of AKI in knowlesi malaria are not known, however it is hypothesised that haemolysis of red blood cells and subsequent release of cell-free haemoglobin leads to oxidative stress and lipid peroxidation in the renal tubules.

A novel mechanism of paracetamol was recently demonstrated, showing that paracetamol acts as a potent inhibitor of hemoprotein-catalyzed lipid peroxidation. In a proof of concept trial, paracetamol at therapeutic levels was shown to significantly decrease oxidative kidney injury and improve renal function by inhibiting the hemoprotein-catalyzed lipid peroxidation in a rat model of rhabdomyolysis-induced renal injury.

The investigators hypothesize that this novel inhibitory mechanism of paracetamol may provide renal protection in adults with knowlesi malaria by reducing the hemoprotein-induced lipid peroxidation that occurs in haemolytic conditions. As there is currently no consensus that exists concerning adequate medical treatment for severe malaria complicated by intravascular haemolysis and AKI, the potential application of paracetamol would be of benefit, especially as it is safe and widely available.

Condition or disease	Intervention/treatment	Phase
Malaria	Drug: Paracetamol	Phase 3

Detailed Description:

Plasmodium knowlesi is the most common cause of malaria, and malaria deaths, in Sabah, Malaysia. Acute kidney injury (AKI) is a common feature of severe knowlesi malaria; however the mechanisms of AKI in knowlesi malaria are unknown. In falciparum malaria, recent evidence suggests that oxidative stress from haemolysis-related cell-free haemoglobin (CFHb) may contribute to pathogenesis of AKI.

Cell-free haemoglobin and oxidative stress: CFHb is released during intravascular haemolysis, and when exceeding the binding capacity of plasma haptoglobin, is filtered by the glomeruli and enters the renal tubules. CFHb is pathogenic as the ferrous heme can be oxidized to the ferric state, conferring peroxidase activity to the hemoglobin. Consequently, the hemoglobin can reduce hydroperoxides, such as hydrogen peroxide (H2O2) and lipid hydroperoxides, which generate the ferryl state of heme (FeIV=O) and a protein radical. The ferryl heme and protein radical can then generate lipid radicals by oxidation of free and phospholipid-esterified unsaturated fatty acids. The arachidonic side chains of membrane phospholipids are particularly vulnerable to this free radical-mediated damage in the complex cascade of lipid oxidation leading to the generation of F2-isoprostanes (F2-IsoPs) and isofurans (IsoFs). F2-IsoPs and IsFs are increased in severe falciparum malaria, and have been shown to induce vasoconstriction associated with renal injury in other haemolytic conditions including rhabdomyolysis, sepsis and post-operatively.

Paracetamol and oxidative stress: A novel mechanism of paracetamol was recently demonstrated, showing that paracetamol acts as a potent inhibitor of hemoprotein-catalyzed lipid peroxidation by reducing ferryl heme to its less toxic ferric state and quenching globin radicals. In a proof of concept trial, paracetamol at therapeutic levels was shown to significantly decrease oxidative kidney injury and improve renal function by inhibiting the hemoprotein-catalyzed lipid peroxidation in a rat model of rhabdomyolysis-induced renal injury. In a retrospective study of patients with sepsis, receiving paracetamol in the setting of raised CFHb was associated with reduced lipid peroxidation, and reduced risk of death. More recently, in a randomized placebo-controlled trial, paracetamol was associated with a reduction in F2-IsoPs and improved renal function in adults with sepsis and detectable CFHb.

Rationale: The investigators hypothesize that paracetamol may provide renal protection in patients with severe knowlesi malaria by reducing the hemoprotein-induced lipid peroxidation that occurs in haemolytic conditions. As there is currently no consensus that exists concerning adequate medical treatment for severe malaria complicated by intravascular haemolysis and AKI, the potential application of paracetamol would be of great benefit, especially as it is safe and widely available.

Proposed activities: The main activity proposed is a randomised, open label, controlled trial of regularly-dosed paracetamol, versus no paracetamol, in patients with knowlesi malaria, to assess the effect of paracetamol on renal function and oxidative stress.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 360 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Effect of Paracetamol on Renal Function in Plasmodium Knowlesi Malaria: A Randomised Controlled Clinical Trial
• Study Start Date: October 2016
• Actual Primary Completion Date: February 1, 2018
• Actual Study Completion Date: February 1, 2018

Arms and Interventions

Arm	Intervention/treatment
Experimental: Paracetamol; >50kg: Paracetamol 1gm PO/NG 6 hourly for 72 hours (maximum dose 4g/24h) plus IV artesunate or oral artemether/lumefantrine. <50kg: Paracetamol 12.5-15mg/kg/dose 6 hourly for 72 hours (maximum total dose 5doses/24hours;75mg/kg) plus IV artesunate or oral artemether/lumefantrine.	Drug: Paracetamol; >50kg: Paracetamol 1gm PO/NG 6 hourly for 72 hours (maximum dose 4g/24h) plus IV artesunate or oral artemether/lumefantrine. <50kg: Paracetamol 12.5-15mg/kg/dose 6 hourly for 72 hours (maximum total dose 5doses/24hours;75mg/kg) plus IV artesunate or oral artemether/lumefantrine.; Other Name: acetaminophen
No Intervention: No Paracetamol; No Paracetamol plus IV artesunate or oral artemether/lumefantrine. If temperature >39.5°C, tepid sponging and mechanical antipyresis will be performed by research staff and/or relatives.

Outcome Measures

Primary Outcome Measures :

1. Effect of Paracetamol on kidney function [ Time Frame: 72 hours ]
   Change in creatinine concentration (umol/L) at 72 hours from enrolment in patients receiving regularly-dosed paracetamol compared to those not receiving regular paracetamol, stratified by the level of intravascular haemolysis (cell-free haemoglobin).

Secondary Outcome Measures :

1. Longitudinal change in creatinine [ Time Frame: 72 hours ]
   Longitudinal change in creatinine, as measured by the area under the creatinine-time curve, with creatinine measured 12 hourly from enrolment to 72 hours; and the effect of enrolment cell-free haemoglobin on longitudinal change in creatinine
2. Change in creatinine in severe malaria [ Time Frame: 72 hours ]
   Change in creatinine at 72 hours and longitudinal change in creatinine over 72 hours, including the effect of enrolment CFHb, in patients with severe knowlesi malaria.
3. Development of AKI [ Time Frame: 72 hours ]
   Development of AKI over 72 hours: i) an absolute increase in serum creatinine of >26.5 umol/L from enrolment creatinine; ii) a percentage increase in serum creatinine of >50% from enrolment; iii) post-enrolment onset of oliguria of less than 0.5ml/kg/hour for more than 6 hours; iv) 24 hour urine output of <400ml after rehydration and urinary obstruction excluded. AKI on enrolment will also be described by the Kidney Disease Improving Global Outcomes (KDIGO) criteria (with baseline creatinine estimated using the MDRD equation).
4. Duration of AKI [ Time Frame: 28 days ]
   Length of time elapsed until serum creatinine returns to normal (estimated using MDRD equation) in the absence of renal replacement therapy in those with AKI on enrolment and those that develop AKI after enrolment.
5. Longitudinal changes in haemolysis: plasma cell-free haemoglobin [ Time Frame: 72 hours ]
   Longitudinal changes in plasma cell-free haemoglobin over 72 hours.
6. Longitudinal changes in haemolysis: plasma cell-free haem [ Time Frame: 72 hours ]
   Longitudinal changes in plasma cell-free haem over 72 hours.
7. Longitudinal changes in haemolysis: haem-to-protein cross-links [ Time Frame: 72 hours ]
   Longitudinal changes in haem-to-protein cross-links over 72 hours.
8. Longitudinal changes in markers of oxidative stress: F2-IsoP [ Time Frame: 72 hours ]
   Longitudinal changes in plasma F2-isoprostanes [F2-IsoP] over 72 hours.
9. Longitudinal changes in markers of oxidative stress: IsoF [ Time Frame: 72 hours ]
   Longitudinal changes in plasma isofurans [IsoF]) over 72 hours.
10. Longitudinal changes in F2-IsoPs according to G6PD enzyme activity [ Time Frame: 72 hours ]
    Longitudinal changes in F2-IsoPs according to G6PD enzyme activity, assessed qualitatively by fluorescent spot test.
11. Longitudinal changes in IsoFs according to G6PD enzyme activity [ Time Frame: 72 hours ]
    Longitudinal changes in IsoFs and CFHb according to G6PD enzyme activity, assessed qualitatively by fluorescent spot test.
12. Longitudinal changes in CFHb according to G6PD enzyme activity [ Time Frame: 72 hours ]
    Longitudinal changes in CFHb according to G6PD enzyme activity, assessed qualitatively by fluorescent spot test.
13. Longitudinal changes in F2-IsoPs according to G6PD genotype [ Time Frame: 72 hours ]
    Longitudinal changes in F2-IsoPs according to G6PD genotype
14. Longitudinal changes in IsoFs according to G6PD genotype [ Time Frame: 72 hours ]
    Longitudinal changes in IsoFs according to G6PD genotype
15. Longitudinal changes in CFHb according to G6PD genotype [ Time Frame: 72 hours ]
    Longitudinal changes in CFHb according to G6PD genotype
16. Population pharmacokinetics of paracetamol: Cmax [ Time Frame: 72 hours ]
    Peak plasma concentration (Cmax)
17. Population pharmacokinetics of paracetamol: Tmax [ Time Frame: 72 hours ]
    Time to peak plasma concentration (Tmax)
18. Population pharmacokinetics of paracetamol: AUC [ Time Frame: 72 hours ]
    Area under the plasma drug concentration-time curve (AUC)
19. Population pharmacodynamics of paracetamol [ Time Frame: 72 hours ]
    Paracetamol dose-response curve
20. Fever clearance time [ Time Frame: 72 hours ]
    Defined as the time taken for the aural temperature to fall below 37.5°C, and the time taken for the temperature to fall below 37.5°C and remain there for at least 24hours
21. Fever duration [ Time Frame: 72 hours ]
    Defined as the duration in hours that an individual's temperature is above 37.5°C
22. Area above the fever versus time curve (AUC-T°) [ Time Frame: 72 hours ]
    Area above the 37.5°C temperature versus time curve (AUC-T°) within first 24 hours of treatment.
23. Parasite clearance time (hours) [ Time Frame: 72 hours ]
    Parasite clearance time, defined as (i) the time from commencement of antimalarial treatment to the first of 2 consecutive negative blood films, with blood films assessed by microscopy every 6 hours for the presence of asexual parasitaemia, and (ii) the linear portion of the slope of the log-parasitemia versus time relationship.
24. Blood and urine biomarkers of pre-renal and renal injury [ Time Frame: 72 hours ]
    Neutrophil gelatinase-associated lipocalcin (NGAL), kidney injury molecule (KIM), urinalysis, urine microscopy, urine electrolytes, and urine creatinine.
25. Longitudinal urine colour [ Time Frame: 72 hours ]
    Longitudinal urine colour (assessed by standardized urine colour charts). The proportion of patients with enrolment urine pH less than 6 together with a urine color of 6 or greater who develop AKI will be compared between groups.
26. Longitudinal urine pH [ Time Frame: 72 hours ]
    Longitudinal urinalysis dipstick test-strip: urine pH. The proportion of patients with enrolment urine pH less than 6 together with a urine color of 6 or greater who develop AKI will be compared between groups.
27. Longitudinal urine specific gravity [ Time Frame: 72 hours ]
    Longitudinal urinalysis dipstick test-strip: urine specific gravity
28. Longitudinal urine haemoglobin [ Time Frame: 72 hours ]
    Longitudinal urinalysis dipstick test-strip: urine haemoglobin
29. Change in creatinine (umol/L) between therapeutic concentrations of paracetamol vs those with absent or low. [ Time Frame: 72 hours ]
    Change in creatinine at 72 hours and longitudinal change in creatinine over 72 hours in patients with therapeutic concentrations of paracetamol, compared to patients with absent or low concentrations of paracetamol
30. Number of participants with treatment-related adverse events as assessed by CTCAE v4.0 [ Time Frame: 28 days ]
    Reporting of any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with paracetamol administration
31. Longitudinal red cell deformability [ Time Frame: 72 hours ]
    Longitudinal red cell deformability, as measured by laser-assisted optical rotational red cell analyser (LORCA) elongation index.
32. Longitudinal changes in markers of endothelial dysfunction [ Time Frame: 72 hours ]
    Longitudinal changes in markers of weibel palade body exocytosis including angiopoietin-2

Eligibility Criteria

• Ages Eligible for Study: 5 Years and older (Child, Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Patient age ≥ 5 years
2. Presence of P. knowlesi malaria, confirmed by positive blood smear with asexual forms of P. knowlesi.
3. Temperature >38C on admission or fever during the preceding 48 hours
4. Enrolled within 18 hours of commencing antimalarial treatment
5. 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 Malay and copies provided to the patient.

Exclusion Criteria:

1. Patient or relatives unable or unwilling to give informed consent
2. Contraindication or allergy to paracetamol or artesunate therapy
3. Known cirrhosis, or >6 standard alcoholic drinks/day
4. Pregnancy

Contacts and Locations

Locations

Malaysia

Keningau District Hospital

Keningau, Sabah, Malaysia, 88200

Queen Elizabeth Hospital

Kota Kinabalu, Sabah, Malaysia, 88200

Kota Marudu District Hospital

Kota Marudu, Sabah, Malaysia, 89100

Ranau District Hospital

Ranau, Sabah, Malaysia, 89300

Sponsors and Collaborators

Menzies School of Health Research

Investigators

• Principal Investigator: Giri M Rajahram, MD; Clinical Research Center, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
• Study Director: Bridget Barber, MBBS; Menzies School of Health Research
• Study Director: Nicholas Anstey, PhD; Menzies School of Health Research
• Study Director: Matthew Grigg, MBBS; Menzies School of Health Research
• Study Director: Timothy William, MBBS; Jesselton Medical Centre
• Study Director: Jayaram Menon, MBBS; Ministry of Health, Malaysia
• Study Director: Tsin Yeo, MBBS; Menzies School of Health Research
• Study Director: Katherine Plewes, MD; Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
• Study Director: Arjen Dondorp, MD; Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
• Study Director: Daniel Cooper, MBChB; Menzies School of Health Research

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Cooper DJ, Plewes K, Grigg MJ, Rajahram GS, Piera KA, William T, Chatfield MD, Yeo TW, Dondorp AM, Anstey NM, Barber BE. The effect of regularly dosed paracetamol versus no paracetamol on renal function in Plasmodium knowlesi malaria (PACKNOW): study protocol for a randomised controlled trial. Trials. 2018 Apr 24;19(1):250. doi: 10.1186/s13063-018-2600-0.

• Responsible Party: Menzies School of Health Research
• ClinicalTrials.gov Identifier: NCT03056391
• Other Study ID Numbers: NMRR-16-356-29088
• First Posted: February 17, 2017
• Last Update Posted: December 19, 2019
• Last Verified: December 2019

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

Keywords provided by Menzies School of Health Research:

knowlesi malaria; paracetamol; renal function; haemolysis; oxidative stress

Additional relevant MeSH terms:

Malaria; Protozoan Infections; Parasitic Diseases; Acetaminophen; Artesunate; Lumefantrine; Artemether; Artemether, Lumefantrine Drug Combination; Analgesics, Non-Narcotic; Analgesics; Sensory System Agents; Peripheral Nervous System Agents; Physiological Effects of Drugs; Antipyretics; Antimalarials; Antiprotozoal Agents; Antiparasitic Agents; Anti-Infective Agents; Antineoplastic Agents; Antiviral Agents; Schistosomicides; Antiplatyhelmintic Agents; Anthelmintics