1
|
Humphries C, Addison M, Aithal G, Boyd J, Briody L, Campbell JDM, Candela ME, Clarke E, Coulson J, Downing-James N, Fontana RJ, Geddes A, Grahamslaw J, Grant A, Heye A, Hutchinson JA, Jones A, Mitchell F, Moore J, Riddell A, Rodriguez A, Thomas A, Tucker G, Walker K, Weir CJ, Woods R, Zahra S, Forbes SJ, Dear JW. Macrophage Therapy for Acute Liver Injury (MAIL): a study protocol for a phase 1 randomised, open-label, dose-escalation study to evaluate safety, tolerability and activity of allogeneic alternatively activated macrophages in patients with paracetamol-induced acute liver injury in the UK. BMJ Open 2024; 14:e089417. [PMID: 39653576 PMCID: PMC11628987 DOI: 10.1136/bmjopen-2024-089417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 11/04/2024] [Indexed: 12/12/2024] Open
Abstract
INTRODUCTION Acute liver failure (ALF) has no effective treatment other than liver transplantation and is commonly caused by paracetamol overdose. New treatments are needed to treat and prevent ALF. Alternatively-activated macrophages (AAMs) can promote resolution of liver necrosis and stimulate hepatocyte proliferation. Using AAMs in unscheduled care requires the use of an allogeneic product. A clinical trial is needed to determine the safety and tolerability of allogeneic AAMs. METHODS AND ANALYSIS A single-centre, open-label, dose-escalation, phase 1 randomised trial to determine whether there is dose-limiting toxicity of AAMs in patients with paracetamol-induced acute liver injury. Randomisation will occur at higher doses. Between 17 and 30 patients will receive treatment, subject to dose-limiting toxicity and an adaptive trial design which aims to reduce the risk of allocation bias through blinding and randomisation. ETHICS AND DISSEMINATION The trial will be conducted according to the ethical principles of the Declaration of Helsinki 2013 and has been approved by North East-York Research Ethics Committee (reference 23/NE/0019), National Health Service Lothian Research and Development department, and the UK Medicines and Healthcare products Regulatory Agency. When the trial concludes, results will be shared by presentation and publication. TRIAL REGISTRATION NUMBER ISRCTN12637839.
Collapse
Affiliation(s)
- Christopher Humphries
- Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, UK
| | - Melisande Addison
- Centre for Regenerative Medicine, University of Edinburgh, 5 Little France Drive, Edinburgh, UK
| | - Guruprasad Aithal
- MAIL Trial Data Monitoring Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Derby Road, Nottingham, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Lesley Briody
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - John D M Campbell
- Scottish National Blood Transfusion Service, Jack Copland Centre, 52 Research Avenue North, Edinburgh, UK
| | - Maria Elena Candela
- Centre for Regenerative Medicine, University of Edinburgh, 5 Little France Drive, Edinburgh, UK
| | - Ellise Clarke
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - James Coulson
- MAIL Trial Data Monitoring Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Nicholas Downing-James
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Robert John Fontana
- MAIL Trial Steering Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Ailsa Geddes
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Julia Grahamslaw
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Alison Grant
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Anna Heye
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - James A Hutchinson
- MAIL Trial Steering Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Ashley Jones
- MAIL Trial Data Monitoring Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Fiona Mitchell
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Joanna Moore
- MAIL Trial Data Monitoring Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Alice Riddell
- MAIL Trial Steering Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Angela Thomas
- MAIL Trial Steering Committee, Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Garry Tucker
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Kim Walker
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, 3 Little France Road, Edinburgh, UK
| | - Rachel Woods
- Edinburgh Clinical Research Facility, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Sharon Zahra
- Scottish National Blood Transfusion Service, Jack Copland Centre, 52 Research Avenue North, Edinburgh, UK
| | - Stuart J Forbes
- Centre for Regenerative Medicine, University of Edinburgh, 5 Little France Drive, Edinburgh, UK
- Centre for Precision Cell Therapy for the Liver, Lothian Health Board, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, UK
| | - James W Dear
- Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, UK
- Centre for Precision Cell Therapy for the Liver, Lothian Health Board, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, UK
| |
Collapse
|
2
|
Mikulski D, Kościelny K, Dróżdż I, Mirocha G, Nowicki M, Misiewicz M, Perdas E, Strzałka P, Wierzbowska A, Fendler W. Serum Levels of miR-122-5p and miR-125a-5p Predict Hepatotoxicity Occurrence in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation. Int J Mol Sci 2024; 25:4355. [PMID: 38673940 PMCID: PMC11050045 DOI: 10.3390/ijms25084355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Hepatic complications are an acknowledged cause of mortality and morbidity among patients undergoing hematopoietic stem cell transplantation. In this study, we aimed to evaluate the potential role in the prediction of liver injury of five selected microRNAs (miRNAs)-miR-122-5p, miR-122-3p, miR-15b-5p, miR-99b-5p, and miR-125a-5p-in the setting of autologous hematopoietic stem cell transplantation (ASCT). A total of 66 patients were included in the study: 50 patients (75.8%) with multiple myeloma (MM) and 16 (24.2%) with lymphoma. Blood samples were collected after the administration of the conditioning regimen, on the day of transplant (day 0). The expression levels of selected miRNAs were quantified by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) using the miRCURY LNA miRNA Custom PCR Panels (QIAGEN). In a multivariate logistic regression analysis adjusted for age, sex, and the administered conditioning regimen, two miRNAs, hsa-miR-122-5p (odds ratio, OR 2.10, 95% confidence interval, CI: 1.29-3.42, p = 0.0029) and hsa-miR-125a-5p (OR 0.27, 95% CI: 0.11-0.71, p = 0.0079), were independent for hepatic toxicity occurrence during the 14 days after transplant. Our model in 10-fold cross-validation preserved its diagnostic potential with a receiver operating characteristics area under the curve (ROC AUC) of 0.75, 95% CI: 0.63-0.88 and at optimal cut-off reached 72.0% sensitivity and 74.4% specificity. An elevated serum level of miR-122-5p and decreased level of miR-125a-5p on day 0 are independent risk factors for hepatotoxicity in ASCT recipients, showing promise in accurately predicting post-ASCT complications. Identifying patients susceptible to complications has the potential to reduce procedure costs and optimize the selection of inpatient or outpatient procedures.
Collapse
Affiliation(s)
- Damian Mikulski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (D.M.); (K.K.); (G.M.); (E.P.)
- Department of Hematooncology, Copernicus Memorial Hospital in Lodz, 93-513 Lodz, Poland
| | - Kacper Kościelny
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (D.M.); (K.K.); (G.M.); (E.P.)
| | - Izabela Dróżdż
- Department of Clinical Genetics, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Grzegorz Mirocha
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (D.M.); (K.K.); (G.M.); (E.P.)
| | - Mateusz Nowicki
- Department of Hematology, Medical University of Lodz, 92-215 Lodz, Poland; (M.N.); (M.M.); (P.S.); (A.W.)
- Department of Hematology and Transplantology, Copernicus Memorial Hospital in Lodz, 93-513 Lodz, Poland
| | - Małgorzata Misiewicz
- Department of Hematology, Medical University of Lodz, 92-215 Lodz, Poland; (M.N.); (M.M.); (P.S.); (A.W.)
| | - Ewelina Perdas
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (D.M.); (K.K.); (G.M.); (E.P.)
| | - Piotr Strzałka
- Department of Hematology, Medical University of Lodz, 92-215 Lodz, Poland; (M.N.); (M.M.); (P.S.); (A.W.)
- Department of Hematology and Transplantology, Copernicus Memorial Hospital in Lodz, 93-513 Lodz, Poland
| | - Agnieszka Wierzbowska
- Department of Hematology, Medical University of Lodz, 92-215 Lodz, Poland; (M.N.); (M.M.); (P.S.); (A.W.)
- Department of Hematology and Transplantology, Copernicus Memorial Hospital in Lodz, 93-513 Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (D.M.); (K.K.); (G.M.); (E.P.)
| |
Collapse
|
3
|
Bateman DN, Dart RC, Dear JW, Prescott LF, Rumack BH. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila) 2023; 61:1020-1031. [PMID: 38197864 DOI: 10.1080/15563650.2023.2293452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Fifty years ago, basic scientific studies and the availability of assay methods made the assessment of risk in paracetamol (acetaminophen) poisoning possible. The use of the antidote acetylcysteine linked to new methods of risk assessment transformed the treatment of this poisoning. This review will describe the way in which risk assessment and treatments have developed over the last 50 years and highlight the remaining areas of uncertainty. METHODS A search of PubMed and its subsidiary databases revealed 1,166 references published in the period 1963-2023 using the combined terms "paracetamol", "poisoning", and "acetylcysteine". Focused searches then identified 170 papers dealing with risk assessment of paracetamol poisoning, 141 with adverse reactions to acetylcysteine and 114 describing different acetylcysteine regimens. To manage the extensive literature, we focused mainly on contributions made by the authors during their time in Edinburgh and Denver. DOSE AND CONCENTRATION RESPONSE The key relationship between paracetamol dose and toxicity risk was established in 1971 and led to the development of the Rumack-Matthew nomogram from data collected in Edinburgh. MECHANISMS OF TOXICITY A series of papers on the mechanisms of toxicity were published in 1973, and these showed that paracetamol hepatotoxicity was caused by the formation of a toxic intermediate epoxide metabolite normally detoxified by glutathione but which, in excess, was bound covalently to hepatic enzymes and proteins. An understanding of the relationship between the rate of paracetamol metabolism, paracetamol concentration, and toxic hazard in humans soon followed. ANTIDOTE DEVELOPMENT AND EFFICACY IN PATIENTS These discoveries were followed by the testing of a range of sulfhydryl-donors in animals and "at risk" patients. Acetylcysteine was developed as the lead intravenous antidote in the United Kingdom. The license holder in the United States refused to make an intravenous formulation. Thus, oral acetylcysteine became the antidote trialed in the United States National Multicenter Study. Intravenous acetylcysteine regimens used initially in the United Kingdom and subsequently in the United States used loading doses of 150 mg/kg over 15 minutes or one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours. These regimens were associated with adverse drug reactions (nausea, vomiting and anaphylactoid reactions) and hence, treatment interruption. Newer dosing regimens now give loading doses more slowly. One, the Scottish and Newcastle Anti-emetic Pretreatment protocol, using an acetylcysteine regimen of 100 mg/kg over two hours followed by 200 mg/kg over 10 hours, has been widely adopted in the United Kingdom. A cohort comparison study suggests this regimen has comparable efficacy to standard regimens and offers opportunities for selective higher acetylcysteine dosing. RISK ASSESSMENT AT PRESENTATION No dose-ranging studies with acetylcysteine were done, and no placebo-controlled studies were performed. Thus, there is uncertainty regarding the optimal dose of acetylcysteine, particularly in patients ingesting very large overdoses of paracetamol. The choice of intervention concentration on the Rumack-Matthew nomogram has important consequences for the proportion of patients treated. The United States National Multicenter Study used a "treatment" line starting at 150 mg/L (992 µmol/L) at 4 hours post overdose, extending to 24 hours with a half-life of 4 hours, now standard there, and subsequently adopted in Australia and New Zealand. In the United Kingdom, the treatment line was initially 200 mg/L (1,323 µmol/L) at 4 hours (the Rumack-Matthew "risk" line). In 2012, the United Kingdom Medicines and Healthcare products Regulatory Agency lowered the treatment line to 100 mg/L (662 µmol/L) at 4 hours for all patients, increasing the number of patients admitted and treated at a high cost. Risk assessment is a key issue for ongoing study, particularly following the development of potential new antidotes that may act in those at greatest risk. The development of biomarkers to assess risk is ongoing but has yet to reach clinical trials. CONCLUSION Even after 50 years, there are still areas of uncertainty. These include appropriate acetylcysteine doses in patients who ingest different paracetamol doses or multiple (staggered) ingestions, early identification of at-risk patients, and optimal treatment of late presenters.
Collapse
Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Medical Toxicology, University of CO School of Medicine, Aurora, CO, USA
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Laurie F Prescott
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Barry H Rumack
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|