Phlebotomy in Blood Donors and Polycythemia Vera Patients- The Effect on Physiology: An Orienting Case-Cross Over Study
Conditions: Polycythemia
Sponsor: Leiden University Medical Center

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Phlebotomy in Blood Donors and Polycythemia 
Vera Patients– The Effect on Physiology: An 
Orienting Case-Cross Over Study  
 
 
 
 
 
 
 
 
 
Short title 
NOSFERATU  
Coordinating investigator: Drs. R.P.B. Tonino 
Primary investigator: Prof. Dr. J.J. Zwaginga  
Other project members: Dr. M.R. Schipperus 
 
V1.0 28-04-2022 
 
 

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Short title 
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Version 
1.0 
 
Date 
28-04-2022 
 
Coordinating investigator  Drs. Rik Tonino, PhD student.  
r.p.b.tonino@lumc.nl  
LUMC, Haga Teaching Hospital, TRIP 
 
Principal investigator: 
Prof dr. J. J. Zwaginga, Hematologist.  
j.j.zwaginga@lumc.nl  
LUMC, TRIP 
Local coordinators 
 
LUMC: 
 
Prof dr. J. J. Zwaginga, Hematologist  
j.j.zwaginga@lumc.nl  
Subsidising party 
LUMC, TRIP 
Independent experts 
Prof. Dr. H.C.J. Eijkenboom 
h.c.j.eikenboom@lumc.nl, internal medicine 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
 
1. 
RATIONALE ...................................................................................................................... 7 
2. 
OBJECTIVES .................................................................................................................... 9 
3. 
STUDY DESIGN ............................................................................................................... 9 
4. 
Study POPULATION ....................................................................................................... 10 
4.1 
Population ................................................................................................................ 10 
4.2 
Inclusion criteria ....................................................................................................... 10 
4.3 
Exclusion criteria ...................................................................................................... 10 
4.4 
Sample size calculation ........................................................................................... 11 
5. 
INVESTIGATIONAL PRODUCT ..................................................................................... 11 
5.1 
Phlebotomies ........................................................................................................... 11 
6. 
METHODS ...................................................................................................................... 11 
6.1 
Study parameters/endpoints .................................................................................... 11 
6.2 
Study procedures ..................................................................................................... 12 
6.3 
Withdrawal of individual subjects ............................................................................. 13 
6.4 
Replacement of individual subjects after withdrawal ............................................... 13 
6.5 
Follow-up of subjects withdrawn from treatment ...................................................... 13 
7. 
SAFETY REPORTING .................................................................................................... 13 
7.1 
AEs, SAEs and SUSARs ......................................................................................... 13 
7.2 
Follow-up of adverse events .................................................................................... 14 
7.3 
Data Safety Monitoring ............................................................................................ 14 
8. 
STATISTICAL ANALYSIS ............................................................................................... 14 
8.1 
Primary study parameters ........................................................................................ 15 
8.2 
Secondary study parameters ................................................................................... 15 
8.3 
Other study parameters ........................................................................................... 15 
9. 
ETHICAL CONSIDERATIONS ........................................................................................ 16 
9.1 
Regulation statement ............................................................................................... 16 
9.2 
Recruitment and consent ......................................................................................... 16 
9.3 
Benefits and risks assessment ................................................................................ 16 
9.4 Incentives ...................................................................................................................... 16 
10. 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION .......................... 16 
10.1 
Handling and storage of data and documents ......................................................... 16 
10.2 
Monitoring and Quality Assurance ........................................................................... 17 
10.3 
Amendments ............................................................................................................ 17 
10.4 
Public disclosure and publication policy ................................................................... 17 
11. 
REFERENCES ............................................................................................................ 18 

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PROTOCOL SIGNATURE SHEET 
 
 
  
 
 

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LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS  
 
ABR 
General Assessment and Registration form (ABR form), the application 
form that is required for submission to the accredited Ethics Committee; 
in Dutch: Algemeen Beoordelings- en Registratieformulier (ABR-
formulier) 
AE 
Adverse Event 
AR 
Adverse Reaction 
DSMB 
EQ5D 
Data Safety Monitoring Board 
EuroQol 5D 
GCP 
Good Clinical Practice 
GDPR 
 
Hb 
General Data Protection Regulation; in Dutch: Algemene Verordening 
Gegevensbescherming (AVG) 
Haemoglobin 
ICF 
MDS 
Informed Consent Form 
Myelodysplastic Syndrome 
METC  
 
Medical research ethics committee (MREC); in Dutch: medisch-ethische 
toetsingscommissie (METC) 
RBC 
(S)AE 
SoC 
Red Blood Cells  
(Serious) Adverse Event  
Standard of care 
Sponsor 
The sponsor is the party that commissions the organisation or 
performance of the research, for example a pharmaceutical 
company, academic hospital, scientific organisation or investigator. A 
party that provides funding for a study but does not commission it is not 
regarded as the sponsor, but referred to as a subsidising party 
UAVG 
Dutch Act on Implementation of the General Data Protection Regulation  
WMO 
Medical Research Involving Human Subjects Act 
 
 

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SUMMARY 
 
Rationale: Little is known about the effect of a hemoglobin-shift on patients, anaemic, non-
anaemic or even polycythaemic. It has been established that severe anaemia has 
deteriorating effects on the patient, which can be (partially) reversed by treatments like 
transfusion, ESAs or iron/vitamin supplements, depending of the etiology of the anaemia. 
However, we have yet to determine the optimal haemoglobin target and threshold for such 
treatments. We therefore need to evaluate what the exact effect of various haemoglobin 
levels, and a shift therein, is on the physiology of patients. Only then can we properly weigh 
the benefits against the risk for individual patients when considering treatment for anaemia, 
safety of blood donation, or expected effect of phlebotomy for polycythaemia.  
 
Primary Objective:  
- 
Compare the per individual and per group effects of a reduction in Hb mass on physical 
functional outcomes (heart rate; activity parameters; QoL) in patients with 
polycythaemia vera. 
 
Secondary Objectives:  
- 
Compare the primary outcomes to data from the REMOTE-2 and FAINT-study 
(similar measurements in transfusion dependent patients and whole blood donors)  
Study design: Case-cross over study. Patients will be remotely monitored one week before 
phlebotomy until one week after. 
 
Study population: Adult patients with a polycythaemia requiring phlebotomies on a regular 
basis. 
 
Main study parameters:  heart rate, blood pressure, activity parameters and quality of life. 
 
Nature and extent of the burden and risks associated with participation, benefit and 
group relatedness: No medical benefits, besides contributing to knowledge regarding their 
disease; No relevant risks. There is, however, the burden of 1) filling out the EQ5D forms (2 
minutes a day); 2) measuring the bloodpressure (2 minutes a day) and wearing the 
smartwatch for two weeks per phlebotomy, three phlebotomies. 
 
 
 
 

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1. RATIONALE  
We have very little knowledge of what effect a shift in haemoglobin (Hb) mass has in any 
person, anemic, polycythemic or normemic. Assessing functional outcomes at various Hb 
levels may help to better understand what effect changes in Hbmass have on the physiology. 
While a reduction in Hb level from 16 to 15 g/dL may not be clinically relevant for the subject 
itself, observing and properly documenting its effect will help put the puzzle of Hb 
optimization together. Because of the ready availability of patients with polycythaemia vera 
that undergo phlebotomies on a regular basis, we want to start by evaluating physiological 
parameters in these subjects. Parallel to this study, Sanquin will evaluate whole blood donors 
in a similar study (FAINT-study, https://www.sanquin.nl/over-sanquin/donorstudies) and 
myelodysplastic syndrome patients with chronic transfusion dependency receiving various 
amounts of red blood transfusions are monitored in the REMOTE 2 study (NL73847.58.20). 
Assessing the Hbmass-and-physiology question from different perspectives and comparing 
these outcomes will increase our understanding of the matter.  
 
Our theoretic basis for this study starts with the function of haemoglobin, the main 
component of red blood cells (RBC), which transports oxygen. In healthy persons, the human 
body regulates the haemoglobin levels to maintain a level between 12.1 and 15.1 g/dL in 
females 13.8 and 17.2 g/dL in males. This Hb concentration, or level, is a result of the 
Hbmass (Total intravascular mass of Hb) and the plasma volume: 
Hb𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐≈
Hb𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚
Plasma volume +  Hb𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚  
Several diseases can cause this level of haemoglobin to decrease to levels below 8 g/dL, 
requiring patients to receive RBC transfusions. In these anaemic patients, the shortage of 
oxygen delivery in tissues causes symptoms like fatigue, dyspnea and lack of concentration, 
leading to a reduced quality of life.1–3 On the other hand, altitude training and drugs like 
RhuEPO are used to increase the maximum oxygen transport capacity (VO2max) in order to 
enhance athletic performance.4–6 A somewhat linear association between Hbmass and 
absolute O2 transport capability may be assumed. The less Hb, the less O2 transport. In 
terms of VO2max, which is the maximum amount of O2 a subjects’ body can transport, this 
will be limited for rheological reasons with high Hb levels. For instance, patients with 
polycythaemia vera (PV) suffer from hyperviscosity issues, which again may restrict oxygen 
transport capacity.  
 
In daily life however, we are not that often dependent on our VO2max, but more on our 
‘’VO2usual’’. When our erythropoiesis for some reason is unable to maintain normal Hb 
levels, the human body has many compensation strategies to maintain basic O2 delivery, like 

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increasing the cardiac output, vasoconstriction, and adjusting the plasma volume to increase 
the Hb concentration. A subject will probably not notice slight changes in Hbmass. At some 
point, however, the compensation mechanisms may be noticeable (higher heart 
rate/palpitations/fatigue).  
 
We know that in patients with anaemia, red blood cell transfusions improve walk test 
distances and fatigue scores7, and preliminary results show that heart rate is inversely 
correlated with changes in Hb level by transfusion. For these patients, it is clear that the 
change in Hbmass has an effect on their daily physiology. What we do not know, is the 
magnitude of this effect at different levels of Hb level. Do these effects correlate linearly to 
the change in Hb level? Or, is there a certain level above which an extra increase in Hb will 
not exert a beneficial effect on the patient? 
Effects of changes in Hbmass on daily physiology in non-anaemic subjects have not yet 
been studied properly. In the past, studies showed a decrease in VO2max following 
isovolemic Haemodilution and an increase in VO2max following transfusions.8 Studies 
evaluating donors have shown that donation increases resting heart rate 24 hours after 
donation,9 and decreases VO2max. A systematic review, however, shows no significant 
difference in VO2max, power or, heart rate, up until 48 hours after donation.10 It also 
concludes that there are not enough studies regarding cardiorespiratory outcomes following 
blood donation. However, While the blood volume returns to normal within 24-48 hours after 
donation due to an increase in plasma volume, Hb restoration takes as much as up to 12 
weeks. Therefore, to adequately measure the effect of the decrease in Hb level on 
physiological outcomes without the increased cardiac output due to the lower blood volume, 
evaluation of these outcomes should not start before 48 hours after donation.  
The same goes for patients with PV that undergo phlebotomies: no proper physiological 
evaluation has been documented yet. This makes this study new and important for both the 
PV-patient group as well as for our general understanding of the effect of Hb-shifts on the 
physiology of the human body.   
 
Tools for measuring the impact of change in Hb mass on the subjects well-being: vital 
signs, physical function. 
We intent to evaluate vital signs and physical function of PV-patients with the Withings BPM 
connect and the Withings Steel HR. We have chosen to use the generic EQ5D for the PV-
group and have also added a visual analog scale (VAS) 0-100 slider question: how active have 
you been today?‘.  
 

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2. OBJECTIVES 
Primary Objective:  
- 
Compare the per individual and per group effects of a reduction in Hb mass on physical 
functional outcomes (heart rate; activity parameters; QoL) in patients with 
polycythaemia. 
 
Secondary Objectives:  
- 
Compare the primary outcomes to data from the REMOTE-2 and FAINT-study 
(similar measurements in transfusion dependent patients and whole blood donors)  
3. STUDY DESIGN 
This an observational case-crossover study: Ten patients with polycythemia will be remotely 
monitored a week before until a week after they receive a phlebotomy. We will remotely monitor 
their 1) heart rate, 2) blood pressure 3) activity and 4) QoL of life. Participating subjects will be 
asked to measure their blood pressure and heart rate with the Withings BPM Connect on a 
daily basis during this study period. Furthermore, they will be asked to fill out an EQ5D 
questionnaire (5 questions) and a 0-100 visual analog scale question ‘how active they have 
been that day’, every day. Lastly, they will wear a Withings Steel HR smartwatch continuously, 
which will measure their heart rate and activity measures continuously.  
The data in the week prior to the phlebotomy is meant to generate baseline data to which the 
data after the phlebotomy will be compared. Hospital staff will be provided access to a platform 
to monitor subject data. Withings data security is in accordance with the GDPR 
(https://www.withings.com/fr/en/legal/privacy-policy).  
Both the questionnaires and vital parameters can be monitored remotely. Subjects missing a 
measurement will be sent a reminder to make up for a missed task. Detailed description of 
study procedures can be found in table 3.1. We will measure each patient during three 
phlebotomies.  
 
 

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Table 3.1. Study procedures  
 
Screening >7 days before 
phlebotomy 
 
Day  
-70 
(+/-1) 
Day 0 
 
Day 07 
(+/-1) 
Day 7 
 
Obtain informed 
consent  
X 
 
 
 
 
Eligibility criteria 
X 
 
 
 
 
Baseline data 
collection 
X 
 
 
 
 
Handout BPM 
Connect, Withings 
HR steel  
And deployment 
X1 
 
 
 
 
Physiologic data  
training period 
X 
First 48 hrs 
 
 
 
 
Phlebotomy/donation 
 
 
X 
 
 
Hb measurement 
 
 
X2 
 
 
EQ5D, daily 
 
X 
 
X 
 
Record AEs3 
 
 
 
X 
 
X 
1 Data quality and continuity will be monitored. 
2 Hemoglobin measurement will be venepuncture for PV and POC measurement for donors 
3 Infusion reactions and AEs related to the Withings Steel HR will be collected. 
 
4. Study POPULATION 
4.1 Population   
• 
Ten patients with polycythaemia, requiring phlebotomy on a regular basis (at least 
every 4 months)  
4.2 Inclusion criteria 
In order to be eligible to participate in this study, a subject must meet all of the following criteria: 
• 
Subjects aged ≥18 years  
• 
In possession of a smartphone 
• 
Life expectancy ≥ 3 months  
4.3 Exclusion criteria 
A potential subject who meets any of the following criteria will be excluded from participation 
in this study: 
• 
Poor performance/functional status (Eastern Cooperative Oncology Group system 
ECOG ≥3, see appendix) 

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• 
Participants with known arrhythmias or other significant cardiological conductivity 
disorders (Paroxysmal atrial fibrillation is allowed) 
• 
Hospitalized subjects 
• 
Subjects with a pacemaker. 
• 
Subjects with a secondary polyglobulia due to eg smoking or other pulmonary 
issues. 
• 
Scheduled oncological treatments or surgery during the study period. 
Subjects currently participating in other clinical studies will be evaluated if those studies would 
interfere, which would make the subject ineligible.  
 
4.4 Sample size calculation 
The difference in heart rate after phlebotomy as primary outcome has not yet been studied at 
all. In respect to a change in Hb mass in the opposite direction: preliminary research showed 
a difference of 4 bpm before and after a transfusion. Because there is no other data, we 
anticipate the mean difference in heart rate to be 4 bpm with a standard deviation of 3.  
Considering subjects will be compared to themselves as their own controls, with an α of 0.05 
and a β of 0.20 this makes a sample size of 9 per group. With the explorative nature in mind, 
we chose to set the sample size for this initial case-cross over pilot at 10 subjects per group. 
We will measure each subject during three phlebotomies to reduce the intrapatient variability. 
 
5. INVESTIGATIONAL PRODUCT  
5.1 Phlebotomies 
The investigational product in this trial is the phlebotomy. We will not change anything about 
the standard care.  
 
6. METHODS 
6.1 Study parameters/endpoints 
6.1.1 Main study parameter/endpoint 
• 
Data gathered by the Withings BPM Connect 
o Heart rate 
 
 
 
 
 
resting  
o Blood pressure 
 
 
 
 
resting  
6.1.2 Secondary study parameters/endpoints  
• 
Data gathered by the Withings Steel HR  
o Steps  
 
 
 
 
 
daily total 

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o Exercise time  
 
 
 
 
daily total 
o Distance Walking or Running 
 
 
daily total 
o Heart rate 
 
 
 
 
 
median, resting 
 
 
 
 
 
 
• 
Hb-level pre-phlebotomy (standard of care)  
 
continuous 
• 
EQ5D  
 
 
 
 
 
 
score  
• 
0-100 VAS activity slider 
 
 
 
 
score 
6.1.3 Other study parameters  
• 
Co-morbidity (heart failure, kidney disease, diabetes, 
yes/no, which  
splenectomy)  
• 
Beta-blockers  
 
 
 
 
 
which 
• 
Adverse reactions 
 
 
 
 
 
which, extent 
 
 
6.2 Study procedures 
An overview of study procedures can be found in table 3.1. 
 
Heart rate monitoring via the Withings BPM connect 
The BPM connect is a clinically validated blood pressure and heart rate meter which patients 
will be using themselves at home. They will take their blood pressure and heart rate on a daily 
basis during the study. Patients will be trained in using the clinically validated BPM Connect. 
They will also be asked to measure their blood pressure, <2hr before and <2hr after 
phlebotomy. 
 
Continuous monitoring via the Withings Steel HR 
Patients will wear the CE marked Withings Steel HR continuously from one week before the 
phlebotomy until one week after the phlebotomy. Heart rate measurements of the Steel HR 
will be validated by comparing the Steel HR data to the heart rate data of the clinically validated 
BPM connect.  
 
Quality of life measurements via EQ5D 
Each day for the duration of the study, patients will fill out an EQ5D questionnaire (2min). The 
EQ5D is a generic 6-item quality of life questionnaire. The CASTOR-based questionnaire will 
be sent to the patient via an e-mail. Because of direct entry of the questionnaires in CASTOR 
by the patients, there will be no other source material.  
 

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Phlebotomy and donation 
All phlebotomies will be scheduled and performed as usual. No interventions are used in this 
observative study. 
 
6.3 Withdrawal of individual subjects 
Subjects can leave the study at any time for any reason if they wish to do so without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent 
medical reasons. 
6.3.1 Specific criteria for withdrawal  
● Withdrawal of consent by patient 
● Investigator decision 
● Progression to MDS-EB2 or AML 
 
6.4 Replacement of individual subjects after withdrawal 
Drop-outs before three days after phlebotomy will be replaced. 
 
6.5 Follow-up of subjects withdrawn from treatment 
No follow-up is required as no substantial changes are initiated by the study. 
 
7. SAFETY REPORTING 
7.1 AEs, SAEs and SUSARs 
7.1.1 Adverse events (AEs) 
Adverse events are defined as any undesirable experience occurring to a subject 
during the study, whether or not considered related to the investigational product. All 
adverse events reported spontaneously by the subject or observed by the investigator 
or his staff will be recorded. 
7.1.2 Serious adverse events (SAEs) 
A serious adverse event is any untoward medical occurrence or effect that  
- 
results in death; 
- 
is life threatening (at the time of the event); 
- 
requires hospitalisation or prolongation of existing inpatients’ hospitalisation; 
- 
results in persistent or significant disability or incapacity; 
- 
is a congenital anomaly or birth defect; or 

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- 
any other important medical event that did not result in any of the outcomes listed 
above due to medical or surgical intervention but could have been based upon 
appropriate judgement by the investigator. 
An elective hospital admission will not be considered as a serious adverse event. 
 
The investigator will report all SAEs to the sponsor without undue delay after 
obtaining knowledge of the events, except for the following SAEs:   
- 
Elective hospitalisation to evaluate the treatment management plan for the 
patient’s disorder, or for procedures; 
- 
Elective hospitalisation for pre-existing conditions that, in the investigator’s 
opinion, have not been exacerbated by trial treatment; 
- 
Severe sepsis; 
- 
Disease progression; 
- 
Transient ischaemic attack, thromboembolic and ischaemic events (myocardial 
infarction, stroke, pulmonary embolus, DVT); 
- 
Any other serious event related to the underlying disease or medication used to 
treat the disease. 
7.2 Follow-up of adverse events 
All AEs will be followed until they have abated, or until a stable situation has been reached. 
Depending on the event, follow up may require additional tests or medical procedures as 
indicated, and/or referral to the general physician or a medical specialist. 
SAEs need to be reported till end of study within the Netherlands, as defined in the protocol  
7.3 Data Safety Monitoring  
A DSMB is not deemed necessary as this is a low-risk study.  
 
8. STATISTICAL ANALYSIS 
Data will be presented descriptively, as continuous variables, e.g. mean heart rate and activity 
per day per patient group. Data will be analyzed according to the per protocol analysis. Patients 
dropping out earlier than 3 days after phlebotomy will be replaced and excluded from analysis. 
The data from this study will be combined/compared to data from a parallel similar study: the 
FAINT-study, executed by Sanquin, in which 30 whole blood donors will be monitored in the 
same way. This comparison will grant us more insight on what the effect of a shift in Hb-mass 
is on various types of patients/donors, with different Hb start-off levels. 
 

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8.1 Primary study parameters 
- 
Data gathered by the Withings the clinically validated BPM connect 
- 
Heart rate 
 
For the primary endpoints linear mixed model with random intercept analysis will be used for 
correlating repeated measures. Residuals will be checked for normality. If they are not normally 
distributed, we will proceed with a generalized linear mixed model. Data will first visually be 
reviewed, if the blood donors and phlebotomy subjects appear to have a similar effect from the 
change in Hb mass, they will be analyzed in the same model. If, for example due to 
hyperviscosity issues, the effect appears different or even reversed in one of the two groups, 
they will be analyzed separately.  
Heart rate before phlebotomy/donation will be compared to the heart rate 1, 2, 3 and 6 days 
after the intervention.  
 
Statistical analysis will be conducted using SPSS (version 25.0, SPSS Inc., Chicago, USA). A 
p-value <0.05 (two-sided) will be considered statistically significant.   
 
8.2 Secondary study parameters  
- 
Data gathered by the Withings Steel HR: 
- 
Heart rate (compared to the clinically validated BPM connect) 
- 
Activity parameters: steps, exercise time, distance running and/or walking 
- 
Blood pressure as measured by the Withings BPM connect 
- 
Quality of life parameters (EQ5D) 
- 
Hb-level 
Secondary endpoints will also be analysed with a linear mixed model, provided that residuals 
are normally distributed. If not so, a generalized linear mixed model will be used.  
 
8.3 Other study parameters 
Other study parameters will be used for confounding and baseline characteristics. 
 
- 
Co-morbidity  
- 
Medication  
 
 
 
 
 
 
- 
Adverse reactions 
 
 
 
 
 
 
- 
Age, sex of the recipient 
 

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9. ETHICAL CONSIDERATIONS 
9.1 Regulation statement 
This study will be conducted according to the principle of the 10th version of the Declaration of 
Helsinki (Oct 2013) and in accordance with the GDPR.  
 
9.2 Recruitment and consent 
Recruitment of patients will be done by the local investigator. Treating physicians will be asked 
by the local investigator to notify the local investigator of potential subjects for the study. The 
patient will be provided with a patient information letter and will receive further explanation by 
the coordinating investigator. Informed consent will be asked after patient has had enough time 
to think and talk about it with relatives. This form is attached to the information letter. The 
contact information of the coordinating investigator and the independent  expert will be on the 
information letter for further questions. The form will be signed by the coordinating investigator 
and stored in the LUMC. 
9.3 Benefits and risks assessment 
Benefits  
There are no medical benefits for the participating subjects, besides contributing to 
knowledge regarding their disease.  
Risks  
We believe there are no relevant risks. There is, however, the burden of 1) filling out the 
EQ5D forms (2 minutes for 14 times; 28 minutes in total); 2) measuring the bloodpressure (2 
minutes, 16 times; 32 minutes in total) and wearing the smartwatch for two weeks. 
9.4 Incentives 
Participating subjects are not expected to travel more than usual, so travel expenses will not 
be compensated. 
 
10. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 
10.1 Handling and storage of data and documents 
Biosensor derived data will be transmitted from the device to a smartphone to the Withings 
data platform, which is in accordance with the GDPR:  
 
(https://www.withings.com/fr/en/legal/privacy-policy). 
The 
LUMC 
will 
generate 
an 
unidentifiable ‘Hart Long Centrum’ (HLC)-account (e-mail and password example: box-
3h8m@hlc.nl) per patient, which will be handed to the patient after inclusion to base the 
Withings account on. This way, Withings will not be able to identify the participating subjects. 

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Data can only be linked to the patient by the investigator and his research team. Secondary 
parameters will be stored in Castor (electronic data capture tool) and patient data will be coded 
so that data cannot be linked to the patient without the key. The key to link all patients to data 
will be kept on the departmental computer of the coordinating investigator (personal data I: in 
password secured files) in a separate file. Furthermore, handling and storage of personal data 
will comply to the Medical Treatment Agreement Act (MTAA) and the General Data Protection 
Regulation (GDPR). Coordination of the remote monitoring will be done in the LUMC. In order 
to send out the questionnaires, the patient’s e-mail address is required. Therefore, the LUMC 
will gather personal data in the form of contact details in order to be able to contact the included 
patients. Patients will give their consent for sharing contact details in the ICF. The ICF’s will be 
stored in the LUMC. All study documents will be stored for 20 years on the hospital computer 
of the coordinating investigator (departmental data I:) and will be deleted after 20 years. 
If a subject decides to withdraw from the study before the end of the study, the collected data 
up to that point will be used in the analysis. Before start of the study, data flow and storage will 
be checked by the data protection functionary. 
10.2 Monitoring and Quality Assurance  
Monitoring will be done according to the protocol of the LUMC.  
 
10.3 Amendments  
Amendments will only be submitted to the METC if the changes possibly make the research 
subject to the WMO 
 
10.4 Public disclosure and publication policy 
No arrangements have been made concerning public disclosure. All relevant results will be 
submitted for publication in peer reviewed journals. Publication will come about conform the 
‘CCMO-notitie Publicatiebeleid’. 
 
 

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11. REFERENCES 
1.  Penninx BWJ., Pahor M, Cesari M, et al. Anemia is associated with disability and 
decreased physical performance and muscle strength in the elderly. JAGS. 
2004;52(5):719-724. doi:10.1111/j. 1532-5415.2004.52208.x 
2.  Denny SD, Kuchibhatla MN, Cohen HJ. Impact of anemia on mortality, cognition, and 
function in community-dwelling elderly. Am J Med. 2006;119(4):327-334. 
doi:10.1016/j.amjmed.2005.08.027 
3.  Park S, Fenaux P, Greenberg P, et al. Efficacy and safety of darbepoetin alpha in patients 
with myelodysplastic syndromes: a systematic review and meta-analysis. Br J 
Haematol. Published online 2016. doi:10.1111/bjh.14116 
4.  Saunders PU, Garvican-Lewis LA, Schmidt WF, Gore CJ. Relationship between changes 
in haemoglobin mass and maximal oxygen uptake after hypoxic exposure. Br J Sports 
Med. 2013;47(SUPPL. 1). doi:10.1136/bjsports-2013-092841 
5.  Sgrò P, Sansone M, Sansone A, Romanelli F, Di Luigi L. Effects of erythropoietin abuse 
on exercise performance. Phys Sportsmed. 2018;46(1):105-115. 
doi:10.1080/00913847.2018.1402663 
6.  Solheim SA, Bejder J, Breenfeldt Andersen A, Mørkeberg J, Nordsborg NB. Autologous 
Blood Transfusion Enhances Exercise Performance—Strength of the Evidence and 
Physiological Mechanisms. Sport Med - Open. 2019;5(1):1-11. doi:10.1186/s40798-
019-0204-1 
7.  St. Lezin E, Karafin MS, Bruhn R, et al. Therapeutic impact of red blood cell transfusion 
on anemic outpatients: the RETRO study. Transfusion. 2019;59(6):1934-1943. 
doi:10.1111/trf.15249 
8.  Calbet JAL, Lundby C, Koskolou M, Boushel R. Importance of hemoglobin concentration 
to exercise: Acute manipulations. Respir Physiol Neurobiol. 2006;151(2-3):132-140. 
doi:10.1016/j.resp.2006.01.014 
9.  Gordon D, Marshall K, Connell A, Barnes RJ. Influence of blood donation on oxygen 
uptake kinetics during moderate and heavy intensity cycle exercise. Int J Sports Med. 
2010;31(5):298-303. doi:10.1055/s-0030-1248321 
10.  
Johnson DM, Roberts J, Gordon D. The acute effects of whole blood donation on 
cardiorespiratory and haematological factors in exercise: A systematic review. PLoS 
One. 2019;14(4):1-15. doi:10.1371/journal.pone.0215346