Paracetamol Effect on Oxidative Stress and Renal Function in Severe Malaria
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|ClinicalTrials.gov Identifier: NCT01641289|
Recruitment Status : Completed
First Posted : July 16, 2012
Last Update Posted : June 14, 2018
|First Submitted Date ICMJE||May 23, 2012|
|First Posted Date ICMJE||July 16, 2012|
|Last Update Posted Date||June 14, 2018|
|Actual Study Start Date ICMJE||July 10, 2012|
|Actual Primary Completion Date||September 13, 2014 (Final data collection date for primary outcome measure)|
|Current Primary Outcome Measures ICMJE
||Effect of paracetamol concentrations [ Time Frame: 72 hours ]
Compare the effect of therapeutic paracetamol concentrations compared with absent or low paracetamol concentration on renal function, peak creatinine levels or trough creatinine clearance, defined as the change at 72 hours compared to baseline, in patients with severe and moderately severe falciparum malaria stratified by the level of intravascular haemolysis (cell-free haemoglobin).
|Original Primary Outcome Measures ICMJE
||Effect of paracetamol concentrations [ Time Frame: 4 weeks ]
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.
|Current Secondary Outcome Measures ICMJE
|Original Secondary Outcome Measures ICMJE
|Current Other Pre-specified Outcome Measures||Not Provided|
|Original Other Pre-specified Outcome Measures||Not Provided|
|Brief Title ICMJE||Paracetamol Effect on Oxidative Stress and Renal Function in Severe Malaria|
|Official Title ICMJE||Paracetamol Effect on Oxidative Stress and Renal Function in Severe Falciparum Malaria With Intravascular Haemolysis: A Randomised Controlled Clinical Trial|
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.
Mortality in severe malaria remains ~15% despite the best available parasiticidal antimalarial therapy, intravenous artesunate. Adjunctive therapies in combination with anti-parasitic drugs have the potential to improve outcomes. However, currently there are no proven adjunctive therapies for the treatment of severe malaria, which can improve case-fatality when used in combination with anti-parasitic drugs. This research proposal focuses on exploring if paracetamol prevents renal dysfunction caused by free haemoglobin induced oxidative damage in severe malaria.
Blackwater fever epidemiology As early as the 1800s, blackwater fever complicating severe malaria caused by Plasmodium falciparum was recognized as an important cause of morbidity and mortality, with a 25-30% mean mortality rate. The etiology and pathogenesis is poorly understood but it is characterized by massive intravascular haemolysis and passage of black or red urine, which can lead to renal impairment and death. This manifestation was linked to quinine therapy as its occurrence nearly disappeared during the chloroquine era from 1950 to 1980. Since 1990, the resurgence in the number of cases noted in both malaria-free and malarious areas in non-immune and immune individuals has generated renewed interest into this manifestation of severe malaria. The largest malaria clinical trials report blackwater fever incidences of 7% and 4% in Asian adult patients with severe malaria treated with artesunate and quinine, respectively and 4% in African children treated with either drug. The prevalence of blackwater fever in Chittagong, Bangladesh was recently determined in a pilot study to be 15% with associated renal failure and mortality rates of 42.9% and 14.2% respectively.
Blackwater fever pathogenesis Although the exact mechanism linking falciparum malaria and blackwater fever is uncertain, numerous explanations have been suggested. It has been proposed to occur in 4 specific circumstances: (1) in case patients with G6PD deficiency with or without malaria who take oxidant drugs (primaquine) (2) in case patients with G6PD deficiency and malaria untreated and treated with quinine (3) when patients (normal G6PD) with severe malaria are treated with quinine (4) when people exposed to malaria self-medicate with quinine or related amino-alcohol drugs. However, new circumstances of blackwater fever have emerged, occurring in patients with normal G6PD levels with severe malaria who have received artesunate rather than quinine.
Role of oxidative stress and free haem The fundamental characteristic of blackwater fever is the presence of massive haemolysis of both infected and uninfected erythrocytes and release of free haemoglobin. The free haem is highly cytotoxic, and an important scavenger of nitric oxide, promoting endothelial damage and is proposed to be involved in the pathogenesis of renal injury and cerebral malaria. When the degree of intravascular haemolysis exceeds the capacity of plasma haptoglobin to bind the haemoglobin released from red blood cells, free haemoglobin is then filtered by the glomeruli and enters the renal tubules. In a series of renal biopsies, fine and coarse haemoglobin granules are present in the proximal tubules, while haemoglobin casts and granular casts predominate in the distal and collecting tubules in patients with blackwater fever and intravascular haemolysis. This classic theory of renal damage by tubular precipitation is challenged by recent findings of reversing oxidative properties of free haem can prevent renal damage. The free haemoglobin present is pathogenic as the ferrous haem can be oxidized to the ferric state (FeIII) subsequently conferring peroxidase activity to the haemoglobin. Consequently, the haemoglobin can reduce hydroperoxides, such as hydrogen peroxide (H2O2) and lipid hydroperoxides, which generate the ferryl state (FeIV=O) of haemoglobin and a globin protein radical.
Haem Fe(III) protein + H2O2 --> haem [Fe(IV)=O] protein• + H+ + H2O The ferryl haem 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). Evidence suggests that F2-isoPs generated by the haemoprotein-catalyzed oxidation of lipids are responsible for the oxidative damage and vasoconstriction associated with renal injury in the setting of hemolytic disorders and rhabdomyolysis.
Paracetamol and oxidative stress A novel mechanism of paracetamol was recently demonstrated, showing that paracetamol acts as a potent inhibitor of haemoprotein-catalyzed lipid peroxidation by reducing ferryl haem to its less toxic ferric state and quenching globin radicals. This effect is enhanced 14-fold in an acidic milieu. In a recent proof of concept trial, paracetamol at therapeutic levels was shown to significantly decrease oxidant injury in the kidney, improve renal function and reduce renal damage by inhibiting the haemoprotein-catalyzed lipid peroxidation, mediated by redox cycling of the haem moiety of myoglobin, in a rat model of rhabdomyolysis-induced renal injury.
Rationale Since adults with severe malaria and blackwater fever associated with haemolysis demonstrate increased concentrations of cell-free haemoglobin, severe acidosis and urinary F2-IsoPs, the investigators hypothesize that this novel inhibitory mechanism of paracetamol may provide renal protection in this population by reducing the haemoprotein-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.
Proposed activities The main activity proposed is a randomised open label controlled study of paracetamol in patients with severe falciparum malaria to assess its modulating effect on renal function and oxidative stress.
|Study Type ICMJE||Interventional|
|Study Phase ICMJE||Not Applicable|
|Study Design ICMJE||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
|Study Arms ICMJE||
|Publications *||Plewes K, Kingston HWF, Ghose A, Wattanakul T, Hassan MMU, Haider MS, Dutta PK, Islam MA, Alam S, Jahangir SM, Zahed ASM, Sattar MA, Chowdhury MAH, Herdman MT, Leopold SJ, Ishioka H, Piera KA, Charunwatthana P, Silamut K, Yeo TW, Lee SJ, Mukaka M, Maude RJ, Turner GDH, Faiz MA, Tarning J, Oates JA, Anstey NM, White NJ, Day NPJ, Hossain MA, Roberts Ii LJ, Dondorp AM. Acetaminophen as a Renoprotective Adjunctive Treatment in Patients With Severe and Moderately Severe Falciparum Malaria: A Randomized, Controlled, Open-Label Trial. Clin Infect Dis. 2018 Sep 14;67(7):991-999. doi: 10.1093/cid/ciy213.|
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Status ICMJE||Completed|
|Actual Enrollment ICMJE
|Original Estimated Enrollment ICMJE
|Actual Study Completion Date ICMJE||September 21, 2014|
|Actual Primary Completion Date||September 13, 2014 (Final data collection date for primary outcome measure)|
|Eligibility Criteria ICMJE||
|Ages ICMJE||12 Years and older (Child, Adult, Older Adult)|
|Accepts Healthy Volunteers ICMJE||No|
|Contacts ICMJE||Contact information is only displayed when the study is recruiting subjects|
|Listed Location Countries ICMJE||Bangladesh|
|Removed Location Countries|
|NCT Number ICMJE||NCT01641289|
|Other Study ID Numbers ICMJE||BAKMAL1201|
|Has Data Monitoring Committee||No|
|U.S. FDA-regulated Product||Not Provided|
|IPD Sharing Statement ICMJE||Not Provided|
|Current Responsible Party||University of Oxford|
|Original Responsible Party||Same as current|
|Current Study Sponsor ICMJE||University of Oxford|
|Original Study Sponsor ICMJE||Same as current|
|Collaborators ICMJE||Not Provided|
|PRS Account||University of Oxford|
|Verification Date||June 2018|
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP