A DB Four-Arm, Parallel Group, Proof of Concept, Dose-Finding Adaptive Phase 2a/2b RCT to Investigate the Safety, Tolerability and Efficacy and Effect on QoL of Human Recombinant Alkaline Phosphatase in Patients With Sepsis-Associated AKI
Phase: PHASE2
Conditions: Acute Kidney Injury
Sponsor: AM-Pharma

CLINICAL STUDY PROTOCOL 
EUDRACT Number 2014-000761-40 
IND number: 117605 
A Randomized, Double-Blind, Placebo-Controlled, Four-Arm, 
Parallel-Group, Proof of Concept, and Dose-Finding Adaptive Phase 2a/2b 
Study to Investigate the Safety, Tolerability and Efficacy and Effect on 
Quality of Life of Human Recombinant Alkaline Phosphatase in the 
Treatment of Patients With Sepsis-Associated Acute Kidney Injury 
 
PROTOCOL NO. 
AP-recAP-AKI-02-01 
Sponsor: 
AM-Pharma B.V. 
Rumpsterweg 6 
3981 AK Bunnik 
The Netherlands 
Sponsor Contact: 
Rob ten Pas 
Director Global Clinical Research 
Tel: +31 (0) 302289224 
Fax: +31 (0) 302289220 
E-mail r.tenpas@am-pharma.com 
Medical Monitor: 
European Union: 
Hanna Orr, MD 
Associate Medical Director, Pharmacovigilance, 
PPD Office Warsaw (Home Based) 
49 Domaniewska Street, Trinity Park III; 1st floor  
02-672 Warsaw, Poland  
Phone: +48 781811328 
 
United States: 
William Crafford, MD, FACC 
Medical Director, Pharmacovigilance, 
PPD 
929 North Front Street 
Wilmington, NC 28401-3331 
Phone: 1-800-201-8725 
Version of Protocol:  
Protocol Version 3.0, including Amendment 2 
Date of Protocol Amendment:  
03 Feb 2016 

Previous Protocol Date(s) and 
Version(s): 
Protocol Version 2.0, including Amendment 1 
(08 Oct 2014) 
Protocol Version 1.0 (27 May 2014)  
CONFIDENTIAL 
All financial and non-financial support for this study will be provided by AM-Pharma B.V. 
The concepts and information contained in this document or generated during the study are 
considered proprietary and may not be disclosed in whole or in part without the expressed, 
written consent of AM-Pharma B.V. 
 
The study will be performed in accordance with the ethical principles that have their origin in 
the Declaration of Helsinki, the International Council for Harmonisation ICH E6(R1), US 
Code of Federal Regulations, and all other applicable regulations. 
 

AM-Pharma B.V. 
Recombinant alkaline phosphatase 
AP-recAP-AKI-02-01 
Protocol Version 3.0 
 
 
Protocol Approval – Principal/Coordinating Investigator 
Study Title 
A Randomized, Double-Blind, Placebo-Controlled, Four-Arm, 
Parallel-Group, Proof of Concept, and Dose-Finding Adaptive 
Phase 2a/2b Study to Investigate the Safety, Tolerability and Efficacy 
and Effect on Quality of Life of Human Recombinant Alkaline 
Phosphatase in the Treatment of Patients With Sepsis-Associated Acute 
Kidney Injury 
Protocol Number AP-recAP-AKI-02-01 
Protocol Date 
03 Feb 2016 
 
Protocol accepted and approved by: 
Principal/Coordinating Investigator 
Prof Peter Pickkers, MD PhD 
Department Intensive Care, Radboud University Medical Center, 
PO-box 9101, 
6500HB, Nijmegen, 
The Netherlands 
 
 
 
February 4th 2016 
Signature 
 
Date 
 
 

AM-Pharma B.V. 
Recombinant alkaline phosphatase 
AP-recAP-AKI-02-01 
Protocol Version 3.0 
 
Declaration of Investigator 
I have read and understood all sections of the protocol titled “A Randomized, Double-Blind, 
Placebo-Controlled, Four-Arm, Parallel-Group, Proof of Concept, and Dose-Finding 
Adaptive Phase 2a/2b Study to Investigate the Safety, Tolerability and Efficacy and Effect on 
Quality of Life of Human Recombinant Alkaline Phosphatase in the Treatment of Patients 
With Sepsis-Associated Acute Kidney Injury” and the accompanying investigator’s brochure, 
version 2.1, dated 09 Oct 2014. 
I agree to supervise all aspects of the protocol and to conduct the clinical investigation in 
accordance with the final protocol version 3.0, including amendment 2, dated 03 Feb 2016, 
the International Council for Harmonisation (ICH) harmonised tripartite guideline E6(R1): 
Good Clinical Practice and all applicable government regulations. I will not make changes to 
the protocol before consulting with AM-Pharma B.V. or implement protocol changes without 
independent ethics committee approval except to eliminate an immediate risk to patients. I 
agree to administer study drug only to patients under my personal supervision or the 
supervision of a sub-investigator. 
I will not supply the investigational drug to any person not authorized to receive it. 
Confidentiality will be protected. Patient identity will not be disclosed to third parties or 
appear in any study reports or publications. 
I will not disclose information regarding this clinical investigation or publish results of the 
investigation without authorization from AM-Pharma B.V. 
 
 
 
Signature of Investigator 
 
Date 
 
 
 
Printed Name of Investigator 
 
 

AM-Pharma B.V. 
Recombinant alkaline phosphatase 
AP-recAP-AKI-02-01 
Protocol Version 3.0 
 
Page 6 
Table of Contents 
Table of Contents ...................................................................................................................... 6 
List of Tables ........................................................................................................................... 14 
List of Figures ......................................................................................................................... 14 
Protocol Synopsis.................................................................................................................... 15 
List of Abbreviations............................................................................................................... 25 
1 Introduction ........................................................................................................................ 28 
2 Study Objectives ................................................................................................................ 31 
2.1 
Primary Objectives.................................................................................................31 
2.2 
Secondary Objectives.............................................................................................31 
2.3 
Other Objectives ....................................................................................................31 
3 Investigational Plan ............................................................................................................ 32 
3.1 
Study Design ..........................................................................................................32 
3.1.1 
Rationale of Study Design ........................................................................35 
3.1.2 
Dose Rationale ..........................................................................................35 
3.1.3 
Individual Benefit/Risk Considerations ....................................................37 
4 Patient Selection and Withdrawal Criteria ......................................................................... 37 
4.1 
Selection of Study Population ................................................................................37 
4.1.1 
Inclusion Criteria ......................................................................................38 
4.1.2 
Exclusion Criteria .....................................................................................39 
4.2 
Withdrawal of Patients From the Study .................................................................41 
4.2.1 
Reasons for Withdrawal/Discontinuation .................................................41 
4.2.2 
Handling of Withdrawals ..........................................................................42 
4.2.3 
Replacements ............................................................................................43 
5 Study Drugs ........................................................................................................................ 43 
5.1 
Method of Assigning Patients to Treatment Groups ..............................................43 
5.2 
Treatments Administered .......................................................................................43 
5.3 
Identity of Investigational Product.........................................................................44 
5.4 
Management of Clinical Supplies ..........................................................................46 
5.4.1 
Study Drug Packaging and Storage ..........................................................46 

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Protocol Version 3.0 
 
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5.4.2 
Test Article Accountability .......................................................................46 
5.5 
Management of Medication Errors or Overdose ...................................................47 
5.5.1 
Medication Errors .....................................................................................47 
5.5.2 
Treatment of Overdose .............................................................................47 
5.6 
Blinding..................................................................................................................47 
5.6.1 
Breaking the Blind ....................................................................................48 
5.7 
Concomitant Therapy .............................................................................................48 
5.7.1 
Concomitant Medications to be Avoided ..................................................49 
6 Days, Assessments, and Procedures ................................................................................... 49 
6.1 
Days 
49 
6.1.1 
Pre-screening, Screening and Baseline .....................................................49 
6.1.2 
Day 1 to Day 3: Treatment Days ..............................................................51 
6.1.3 
Day 4 to Day 28: Assessments and Procedures ........................................51 
6.1.4 
Days 60 and 90: Follow-up Assessments and Procedures ........................51 
6.2 
Study Assessments .................................................................................................52 
6.2.1 
Screening Assessments .............................................................................52 
6.2.2 
Baseline Assessments ...............................................................................53 
6.2.3 
Efficacy Assessments ................................................................................54 
6.2.4 
Safety Assessments ...................................................................................56 
6.2.5 
Exploratory Assessments ..........................................................................57 
6.3 
Study Procedures ...................................................................................................57 
6.3.1 
Demographics and Medical History .........................................................57 
6.3.2 
Site of Infection and Pathogen ..................................................................58 
6.3.3 
Physical Examination ...............................................................................58 
6.3.4 
Vital Signs .................................................................................................58 
6.3.5 
Weight .......................................................................................................59 
6.3.6 
12-Lead Electrocardiogram ......................................................................59 
6.3.7 
Laboratory Tests Performed by the Local Laboratory ..............................59 
6.3.8 
Laboratory Tests Performed by Central Laboratory .................................60 
6.3.8.1 
Endogenous Creatinine and Blood Urea Nitrogen Clearance 61 
6.3.8.2 
Alkaline Phosphatase Activity ............................................... 62 
6.3.8.3 
Pharmacokinetic Assessments ............................................... 62 
6.3.8.4 
Immunogenicity Assessments ................................................ 63 
6.3.8.5 
Biomarker Assessments ......................................................... 63 

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AP-recAP-AKI-02-01 
Protocol Version 3.0 
 
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6.3.8.6 
Pharmacodynamic Assessments ............................................ 64 
6.3.8.7 
Glomerular Filtration Rate ..................................................... 64 
6.3.9 
Renal Replacement Therapy .....................................................................64 
6.3.10 Lung Function Assessments .....................................................................66 
6.3.11 Scoring Systems........................................................................................66 
6.3.11.1 
Acute Physiology and Chronic Health Evaluation Score ...... 66 
6.3.11.2 
Simplified Acute Physiology Score 2 .................................... 67 
6.3.11.3 
Sequential Organ Failure Assessment Score ......................... 67 
6.3.11.4 
Quality of Life ....................................................................... 67 
6.3.12 Concomitant Medication ..........................................................................67 
6.3.13 Other Collected Data ................................................................................68 
6.3.14 Adverse Events .........................................................................................68 
6.3.14.1 
Definitions of Adverse Events ............................................... 68 
6.3.14.2 
Eliciting and Documenting Adverse Events .......................... 69 
6.3.14.3 
Reporting Adverse Events ..................................................... 70 
6.3.14.4 
Assessment of Severity .......................................................... 70 
6.3.14.5 
Assessment of Causality ........................................................ 71 
6.3.14.6 
Follow-up of Patients Reporting Adverse Events .................. 72 
6.4 
Pregnancy ...............................................................................................................72 
6.5 
Laboratory Analyses ..............................................................................................73 
7 Statistical and Analytical Plan ............................................................................................ 73 
7.1 
Primary Endpoint ...................................................................................................73 
7.2 
Key Secondary Endpoint .......................................................................................74 
7.3 
Other Secondary Endpoints ...................................................................................74 
7.3.1 
Renal .........................................................................................................74 
7.3.2 
Other Organs .............................................................................................76 
7.3.3 
Biomarkers ................................................................................................77 
7.3.4 
Other Endpoints ........................................................................................77 
7.4 
Sample Size Calculations .......................................................................................78 
7.5 
Analysis Sets ..........................................................................................................79 
7.6 
Description of Subgroups to Be Analyzed .............................................................80 
7.7 
Statistical Analyses Methodology ..........................................................................81 
7.7.1 
Analysis of Primary Efficacy Endpoint ....................................................82 

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Protocol Version 3.0 
 
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7.7.2 
Analyses of Secondary Efficacy Endpoints ..............................................83 
7.7.3 
Safety Analyses .........................................................................................84 
7.7.4 
Pharmacokinetic Analyses ........................................................................85 
7.7.5 
Other Analyses ..........................................................................................85 
7.7.6 
Interim Analyses .......................................................................................85 
7.8 
Data Quality Assurance..........................................................................................86 
7.8.1 
Data Management .....................................................................................87 
8 Ethics .................................................................................................................................. 87 
8.1 
Independent Ethics Committee or Institutional Review Board .............................87 
8.2 
Ethical Conduct of the Study .................................................................................88 
8.3 
Patient Information and Consent ...........................................................................88 
9 Investigator’s Obligations .................................................................................................. 89 
9.1 
Confidentiality .......................................................................................................89 
9.2 
Financial Disclosure and Obligations ....................................................................89 
9.3 
Investigator Documentation ...................................................................................90 
9.4 
Study Conduct ........................................................................................................90 
9.5 
Adherence to Protocol............................................................................................90 
9.6 
Adverse Events and Study Report Requirements ..................................................90 
9.7 
Investigator’s Final Report ....................................................................................91 
9.8 
Records Retention ..................................................................................................91 
9.9 
Publications ............................................................................................................91 
10 Study Management ............................................................................................................. 91 
10.1 Monitoring .............................................................................................................93 
10.1.1 External Data Monitoring Committee ......................................................93 
10.1.2 Monitoring of the Study ............................................................................94 
10.1.3 Inspection of Records ...............................................................................94 
10.2 Management of Protocol Amendments and Deviations.........................................95 
10.2.1 Modification of the Protocol .....................................................................95 
10.2.2 Protocol Deviations ..................................................................................95 
10.3 Study Termination ..................................................................................................96 
10.4 Final Report ...........................................................................................................96 

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Protocol Version 3.0 
 
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11 Quality Control and Good Clinical Practice Audits ........................................................... 96 
11.1 Quality Control ......................................................................................................96 
11.2 Good Clinical Practice Audits ................................................................................97 
12 Reference List .................................................................................................................... 98 
13 Appendices ....................................................................................................................... 103 
13.1 Appendix 1: Schedule of Assessments ................................................................104 
13.2 Appendix 2: Flowchart of Assessments ...............................................................109 
13.3 Appendix 3: Fluid-Corrected Serum Creatinine Assessment .............................. 114 
13.4 Appendix 4: Weight Ranges and Pre-calculated Corresponding Volumes .......... 115 
13.5 Appendix 5: Iohexol and Exogenous Creatinine Clearance Protocol (Including 
Pharmacodynamics) for Selected Sites Only ....................................................... 116 
13.5.1 Introduction ............................................................................................. 116 
13.5.2 Iohexol Dosing ........................................................................................ 117 
13.5.3 Iohexol Sampling .................................................................................... 117 
13.5.4 Pharmacodynamic Assessments ............................................................. 118 
13.5.5 Statistical Data Analyses ......................................................................... 118 
13.5.5.1 
Iohexol and Creatinine Clearance .........................................118 
13.5.5.2 
Pharmacodynamics ...............................................................119 
13.5.6 References ............................................................................................... 119 
13.5.7 Schedule of Assessments for Iohexol and Exogenous Creatinine 
Clearance (Including Pharmacodynamics) .............................................120 
13.5.8 Flowchart of Assessments for Iohexol and Exogenous Creatinine 
Clearance (Including Pharmacodynamics) .............................................122 
14 Protocol Amendments ...................................................................................................... 127 
14.1 Amendment 1 .......................................................................................................127 
14.1.1 Change Number 1 ...................................................................................127 
14.1.1.1 
Reason: ................................................................................ 127 
14.1.1.2 
Protocol Section: .................................................................. 127 
14.1.2 Change Number 2 ...................................................................................127 
14.1.2.1 
Reason: ................................................................................ 127 
14.1.2.2 
Protocol Section: .................................................................. 127 
14.1.2.3 
Protocol Section: .................................................................. 128 
14.1.3 Change Number 3 ...................................................................................128 

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14.1.3.1 
Reason: ................................................................................ 128 
14.1.3.2 
Protocol Section: .................................................................. 128 
14.1.3.3 
Protocol Section: .................................................................. 129 
14.1.3.4 
Protocol Section: .................................................................. 129 
14.1.3.5 
Protocol Section: .................................................................. 129 
14.1.3.6 
Protocol Section: .................................................................. 130 
14.1.3.7 
Protocol Section: .................................................................. 130 
14.1.3.8 
Protocol Section: .................................................................. 131 
14.1.3.9 
Protocol Section: .................................................................. 131 
14.1.3.10 Protocol Section: .................................................................. 131 
14.1.3.11 Protocol Section: .................................................................. 132 
14.1.4 Change Number 4 ...................................................................................132 
14.1.4.1 
Reason: ................................................................................ 132 
14.1.4.2 
Protocol Section: .................................................................. 133 
14.1.4.3 
Protocol Section: .................................................................. 133 
14.1.4.4 
Protocol Section: .................................................................. 133 
14.1.4.5 
Protocol Section: .................................................................. 134 
14.1.4.6 
Protocol Section: .................................................................. 134 
14.1.5 Change Number 5 ...................................................................................135 
14.1.5.1 
Reason: ................................................................................ 135 
14.1.5.2 
Protocol Section: .................................................................. 135 
14.1.6 Change Number 6 ...................................................................................136 
14.1.6.1 
Reason: ................................................................................ 136 
14.1.6.2 
Protocol Section: .................................................................. 136 
14.1.6.3 
Protocol Section: .................................................................. 137 
14.1.6.4 
Protocol Section: .................................................................. 137 
14.1.6.5 
Protocol Section: .................................................................. 137 
14.1.6.6 
Protocol Section: .................................................................. 138 
14.1.6.7 
Protocol Section: .................................................................. 138 
14.1.6.8 
Protocol Section: .................................................................. 139 
14.1.6.9 
Protocol Section: .................................................................. 139 
14.1.6.10 Protocol Section: .................................................................. 140 
14.1.6.11 Protocol Section: .................................................................. 140 
14.1.7 Change Number 7 ...................................................................................142 
14.1.7.1 
Reason: ................................................................................ 142 

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Protocol Version 3.0 
 
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14.1.7.2 
Protocol Section: .................................................................. 142 
14.1.7.3 
Protocol Section: .................................................................. 143 
14.1.7.4 
Protocol Section: .................................................................. 143 
14.1.8 Change Number 8 ...................................................................................144 
14.1.8.1 
Reason: ................................................................................ 144 
14.1.8.2 
Protocol Section: .................................................................. 144 
14.1.9 Change Number 9 ...................................................................................145 
14.1.9.1 
Reason: ................................................................................ 146 
14.1.9.2 
Protocol Section: .................................................................. 146 
14.1.10 Change Number 10 .................................................................................146 
14.1.10.1 Reason: ................................................................................ 146 
14.1.10.2 Protocol Section: .................................................................. 147 
14.1.11 Change Number 11 .................................................................................147 
14.1.11.1 Reason: ................................................................................ 147 
14.1.11.2 Protocol Section: .................................................................. 147 
14.1.11.3 Protocol Section: .................................................................. 148 
14.1.12 Change Number 12 .................................................................................148 
14.1.12.1 Reason: ................................................................................ 148 
14.1.12.2 Protocol Section: .................................................................. 148 
14.1.13 Change Number 13 .................................................................................149 
14.1.13.1 Reason: ................................................................................ 149 
14.1.13.2 Protocol Section: .................................................................. 149 
14.1.14 Change Number 14 .................................................................................150 
14.1.14.1 Reason: ................................................................................ 150 
14.1.14.2 Protocol Section: .................................................................. 150 
14.1.14.3 Protocol Section: .................................................................. 150 
14.1.15 Change Number 15 .................................................................................151 
14.1.15.1 Reason: ................................................................................ 151 
14.1.15.2 Protocol Section: .................................................................. 151 
14.1.16 Change Number 16 .................................................................................151 
14.1.16.1 Reason: ................................................................................ 151 
14.1.16.2 Protocol Section: .................................................................. 152 
14.2 Amendment 2 .......................................................................................................152 
14.2.1 Change Number 1 ...................................................................................152 
14.2.1.1 
Reason: ................................................................................ 152 

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14.2.1.2 
Protocol Section: .................................................................. 152 
14.2.2 Change Number 2 ...................................................................................153 
14.2.2.1 
Reason: ................................................................................ 153 
14.2.2.2 
Protocol Section: .................................................................. 153 
14.2.3 Change Number 3 ...................................................................................155 
14.2.3.1 
Reason: ................................................................................ 155 
14.2.3.2 
Protocol Section: .................................................................. 155 
14.2.4 Change Number 4 ...................................................................................156 
14.2.4.1 
Reason: ................................................................................ 156 
14.2.4.2 
Protocol Section: .................................................................. 156 
14.2.5 Change Number 5 ...................................................................................157 
14.2.5.1 
Reason: ................................................................................ 157 
14.2.5.2 
Protocol Section: .................................................................. 157 
14.2.6 Change Number 6 ...................................................................................157 
14.2.6.1 
Reason: ................................................................................ 157 
14.2.6.2 
Protocol Section: .................................................................. 157 
14.2.7 Change Number 7 ...................................................................................158 
14.2.7.1 
Reason: ................................................................................ 158 
14.2.7.2 
Protocol Section: .................................................................. 158 
14.2.8 Change Number 8 ...................................................................................159 
14.2.8.1 
Reason: ................................................................................ 159 
14.2.8.2 
Protocol Section: .................................................................. 159 
14.2.9 Change Number 9 ...................................................................................159 
14.2.9.1 
Reason: ................................................................................ 159 
14.2.9.2 
Protocol Section: .................................................................. 160 
14.2.10 Change Number 10 .................................................................................160 
14.2.10.1 Reason: ................................................................................ 160 
14.2.10.2 Protocol Section: .................................................................. 161 
14.2.11 Change Number 11 .................................................................................161 
14.2.11.1 Reason .................................................................................. 161 
14.2.11.2 Protocol Section: .................................................................. 161 

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List of Tables 
Table 3–1 
Proposed Dose Groups for AP-recAP-AKI-02-01 Protocol ........................... 36 
Table 10–1 
Study Administrative Table ............................................................................. 92 
Table 13-1 
Schedule of Assessments .............................................................................. 104 
Table 13-2 
Weight Ranges and Pre-calculated Corresponding Volumes .........................115 
Table 13-3 
Schedule of Assessments for Iohexol and Exogenous Creatinine Clearance 120 
Table 13-4 
Schedule of Assessments for Pharmacodynamics ........................................ 121 
List of Figures 
Figure 3–1 
Study Design ................................................................................................... 34 
Figure 13-1 
Flowchart of Assessments ............................................................................. 109 
Figure 13-2 
Flowchart of Assessments for Iohexol and Exogenous Creatinine Clearance 
(Including Pharmacodynamics) .................................................................... 122 

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Protocol Version 3.0 
 
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Protocol Synopsis 
Protocol Number: 
AP-recAP-AKI-02-01 
Title: 
A Randomized, Double-Blind, Placebo-Controlled, Four-Arm, 
Parallel-Group, Proof of Concept, and Dose-Finding Adaptive 
Phase 2a/2b Study to Investigate the Safety, Tolerability and 
Efficacy and Effect on Quality of Life of Human Recombinant 
Alkaline Phosphatase in the Treatment of Patients With 
Sepsis-Associated Acute Kidney Injury 
Sponsor: 
Rob ten Pas 
Director Global Clinical Research 
Tel: +31 (0) 302289224 
Fax: +31 (0) 302289220 
E-mail r.tenpas@am-pharma.com 
Study Phase: 
2a/2b 
Study Sites: 
Approximately 100 sites will participate in the study; 
approximately 75 in the European Union and approximately 25 
in the United States and Canada. Recruitment will continue 
during the interim analysis. 
Indication: 
Sepsis-associated acute kidney injury (SA-AKI) 
Rationale: 
As there are no guidelines for the development of drugs for the 
indication SA-AKI, the proposed design was determined to be 
optimal by a group of leading global experts in acute kidney 
injury (AKI) and sepsis, and subsequently was discussed (and 
agreed) with European and United States regulatory agencies. 
The study has been set up with an adaptive study design 
including 2 parts, with dose selection based on an interim 
analysis after the 120th patient of Part 1 has completed the Day 7 
visit. The 3 active doses in Part 1 are selected based on a 
combination of information from previous clinical studies 
conducted with bovine intestinal alkaline phosphatase (BiAP), 
and pre-clinical animal models and pharmacokinetic (PK) 
modeling and simulation in a Phase 1 healthy volunteer study 
with recombinant human AP (recAP). Assuming comparable 
safety profiles, the optimal dose will be selected at the interim 
analysis by an independent data monitoring committee (DMC). 
The primary endpoint, area under the time-corrected endogenous 
creatinine clearance curve, was chosen because as a continuous 
variable it is sensitive for detecting relatively small treatment 
effect differences of recAP versus placebo, as well as 
determination of effect size differences between the different 

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dosages. Incidence of dialysis, considered to be a relevant 
clinical endpoint for Phase 3 pivotal studies, was chosen as the 
key secondary endpoint. In the first 120 patients from Part 1 
only, PK samples will be taken to assess the pharmacological 
properties of recAP in patients, in addition to the information 
previously derived from the healthy volunteers. 
Currently there is no treatment available for SA-AKI; hence, 
recAP is considered as add-on therapy and with that the use of a 
placebo arm is fully justified. 
Following patients up to a period of 90 days allows for assessing 
potential disease-modifying characteristics of recAP in kidney 
function (occurrence or worsening of chronic kidney disease 
[CKD]). 
Objectives: 
Primary objectives 
 To investigate the effect of recAP on renal function and 
related clinical parameters in patients with SA-AKI. 
 To determine the therapeutic dose(s) of recAP to support the 
pivotal Phase 3 program. 
Secondary objectives 
 To investigate the safety and tolerability of recAP in patients 
with SA-AKI. 
 To investigate the pharmacokinetics (PK) of recAP in a 
subset of patients with SA-AKI (in the first 120 patients 
from Part 1 only). 
 To investigate the immunogenic potential of recAP in 
patients with SA-AKI.  
 To investigate the effect on quality of life (using the 
EuroQol, EQ-5D). 
Other objectives 
To determine whether specific patient groups that benefit most 
from recAP treatment and whether patient groups that are non-
responders can be identified. The identification of such groups 
will be based on: 
 Baseline characteristics, including: 
o Kidney function markers (e.g., urine and serum 
creatinine, BUN/urea clearance, sodium, proteinuria, 
fractional excretion of sodium and urea, and urine 
output) 
o Tubular injury biomarkers (e.g., kidney injury 
molecule-1 [KIM-1], interleukin 18 [IL-18], 

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Protocol Version 3.0 
 
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alpha-glutathione s-transferase [GST-alpha]) 
o Biomarkers for systemic inflammation (e.g., IL-6, 
C-reactive protein [CRP], lipopolysaccharide-binding 
protein [LBP]) 
o Glomerular filtration rate (eGFR by chronic kidney 
disease epidemiology collaboration [CKD-EPI]) 
o APACHE II score (<25, ≥25) 
 Timing from first diagnosis of SA-AKI to start of recAP 
treatment, e.g., in time intervals (0 to < 6 hours, 6 to 
< 12 hours, 12 to < 18 hours, 18 to < 24 hours) 
 Baseline Acute Kidney Injury Network (AKIN) stage (stage 
1, stage 2, stage 3) 
Additional parameters may also be considered (e.g., urine output 
[over or under 200 mL/day], diabetes mellitus [yes or no], 
hypertension [yes or no], age [< 55 years old, ≥ 55 years old and 
< 70 years old, or ≥ 70 years old], sex (male or female), risk 
scores [high or low]). 
Patient Population: 
Adult (18 to 85 years, inclusive) patients admitted to the 
intensive care unit (ICU) or intermediate care unit for whom a 
diagnosis of sepsis (according to criteria defined by the 
American College of Chest Physicians/Society of Critical Care 
Medicine) can be made, and who also show signs of early AKI 
according to the AKIN criteria. 
Patients with life support limitations, already on dialysis (renal 
replacement therapy [RRT]) or a decision has been made to 
initiate RRT within 24 hours after planned start of study drug 
administration, with known prior history of CKD with a 
documented eGFR of < 60 mL/min or a known history of 
persistent creatinine level equal or greater than 150 µmol/L, or 
with other causes of AKI present, will be excluded. 
Study Design: 
This is a randomized, double-blind, placebo-controlled, 4-arm, 
parallel-group, proof-of-concept, and dose-finding adaptive 
Phase 2a/2b study. 
A minimum of 290 patients with SA-AKI will be enrolled in the 
study. The study involves 2 parts (Part 1, Part 2) with an interim 
analysis between the parts, with continued recruitment during 
this interim analysis. Of the 290 planned patients, at least 
120 patients will enroll in Part 1 and 170 patients will enroll in 
Part 2 with an estimated 50 patients during the interim analysis.  
Patients enrolled during Part 1 and during the interim analysis 
will be randomly assigned to receive, by 1-hour intravenous (IV) 

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infusion, either placebo (Part 1; n1 = 30) or one of 3 different 
doses of recAP (Part 1; n1 = 30 in each dosing arm; i.e., 
0.4 mg/kg [250 U/kg], or 0.8 mg/kg [500 U/kg], or 1.6 mg/kg 
[1000 U/kg]) using a 1:1:1:1 allocation ratio. Patients will 
receive study drug by 1-hour IV infusion once daily for 3 days 
(Days 1, 2, and 3). The interim analysis on the primary endpoint 
will be performed on all data collected after the 120th patient of 
Part 1 has completed the Day 7 visit of the study to select the 
dose to be administered in Part 2. The dose chosen will be the 
optimal dose of recAP on the primary endpoint in Part 1, 
provided there are no safety issues with that dose as judged by 
the DMC. In Part 2, patients will be randomly assigned to 
receive, by 1-hour IV infusion, either placebo (n2 = 85) or the 
dose of recAP (n2 = 85) selected during the interim analysis. 
Patients recruited during the interim analysis period to the dose 
selected in Part 2 will form part of the Part 2 populations, but 
those recruited to the doses that are not selected will be included 
in the Part 1 population. 
Each part involves the following schedule of events: potential 
patients who have been admitted to the ICU or intermediate care 
unit will undergo a pre-screening to assess the presence of SA-
AKI, will provide informed consent, and will undergo screening 
assessments to determine eligibility. As soon as possible when 
all inclusion and none of the exclusion criteria are met, and after 
confirmation of continuing (i.e., not resolving) AKI by a fluid-
corrected serum creatinine assessment or urine output, eligible 
patients will be randomly assigned to a treatment group 
(baseline), undergo baseline determinations, and start treatment 
with study drug (Day 1). Treatment must be administered within 
24 hours, at the latest, after SA-AKI is first diagnosed and 
within 96 hours from first diagnosis of sepsis.  
Due to potential unblinding, it is not allowed to locally measure 
alkaline phosphatase (AP) activity in the blood up to Day 14 
(inclusive) irrespective of whether the patient is in the ICU or 
intermediate care unit or in the ward.  

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Estimated Study 
Duration: 
Duration of the study for a patient is defined from the date that 
signed written informed consent is provided until the last follow-
up visit on Day 90. 
Assessments will be performed during a total of 12 visits, at the 
following intervals: daily from Day 1 to Day 7 ± 1 day (7 visits); 
weekly on Day 14 ± 2 days, Day 21 ± 3 days, and 
Day 28 ± 3 days (3 visits); and follow-up assessments will be 
completed on Day 60 ± 5 days and Day 90 ± 10 days (2 visits). 
Efficacy Assessments: 
The following assessments will be considered as efficacy 
measurements:  
 Urine volume, urinary creatinine, and the average of two 
serum creatinine measurements will be used for calculation 
of the time-corrected endogenous creatinine clearance at all 
visits from baseline to Day 7. Calculations will be performed 
by the central laboratory. The measurements from Day 1 to 
Day 7, inclusive, will be used to calculate the primary 
endpoint. Only if reliable urine collection is possible, urine 
will be collected on Days 14, 21, and 28 for time-corrected 
endogenous creatinine clearance calculation (i.e., patient is 
in the ICU or intermediate care unit or hospital). If reliable 
urine collection is not possible, one serum creatinine sample 
still needs to be taken for calculating eGFR. 
 Urine volume collection in a 6 ± 1 hour collection period at 
baseline and at all visits from Day 1 to Day 28, but only 
required if reliable urine collection is possible (i.e., patient is 
in the ICU or intermediate care unit or hospital) 
 Blood urea nitrogen (BUN) clearance at all visits from 
baseline to Day 7 
 Urinary urea at baseline and at all visits from Day 1 to 
Day 28, only if reliable urine collection is possible (i.e., 
patient is in the ICU or intermediate care unit or hospital)  
 Fractional excretion of sodium at all visits from baseline to 
Day 7 
 Fractional excretion of urea at all visits from baseline to 
Day 7 
 Proteinuria at baseline and at all visits from Day 1 to Day 90 
 Tubular injury biomarkers, KIM-1, IL-18, and GST-alpha, in 
urine at baseline and at all visits from Day 1 to Day 28 
 Serum creatinine at baseline and at all visits from Day 1 to 
Day 90 

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 Serum BUN at baseline and at all visits from Day 1 to 
Day 28 
 Systemic inflammatory serum biomarkers, e.g., IL-6, CRP, 
LBP, at baseline and at all visits from Day 1 to Day 28 
 RRT incidence, considered as the key secondary endpoint, 
during the study period Day 1 to Day 28 
 RRT duration, during the study period Day 1 to Day 28 
 Incidence of dialysis dependency on Day 60 and Day 90 
 Sequential Organ Failure Assessment score results at 
baseline, at all visits from Day 1 to Day 28 (when patient is 
in the ICU or intermediate care unit ), and on the day of ICU 
or intermediate care unit discharge if discharged on a non-
visit day. Note that platelets, bilirubin, creatinine, and urine 
output are required to obtain a SOFA score. 
 Quality of life, EQ-5D questionnaire at baseline, at ICU or 
intermediate care unit discharge, and Day 90 
 Recording start and stop date, name, and mean daily dose of 
vasopressor and inotropic therapy for determination of 
shock-free days, at baseline and at all visits from Day 1 to 
Day 28, only required when patient is in the ICU or 
intermediate care unit  
 Length of hospital and ICU or intermediate care unit stay by 
recording actual admission dates and both planned and 
actual discharge dates from the ICU or intermediate care unit 
and hospital (planned meaning when decision is taken to 
discharge the patient, not necessarily being the same as the 
actual discharge date, e.g., because of lack of beds on the 
regular ward) 
Safety Assessments: 
The following assessments will be considered safety 
measurements: 
 Vital signs, including blood pressure, heart rate, oxygen 
saturation, respiratory rate, and body temperature at baseline 
and at all visits from Day 1 to Day 28. During the 3 dosing 
days (Day 1 to Day 3), repeated vital sign measurements will 
be performed. 
 Physical examination at baseline and at all visits from Day 1 
to Day 28 
 12-lead ECG at baseline and at visits on Days 3 and 14 
 Local laboratory at baseline and at visits on Days 1, 3, 5, 7, 
14, 21, and 28: 

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o Hematology 
o Clinical chemistry, including liver function parameters 
(aspartate transaminase, alanine aminotransferase, 
gamma-glutamyl transpeptidase lactate dehydrogenase, 
and bilirubin; excluding AP) 
 Serology (IgG, IgE and total immunoglobulin) at baseline 
and at visits on Days 14 and 28 
 Anti-drug antibodies at baseline and at visits on Days 14, 28, 
60, and 90. Samples taken on Days 60 and 90 will only be 
analyzed in case of a positive result on Day 28 
 Concomitant medication at screening, baseline, and all visits 
from Day 1 to Day 28 
 AEs during the duration of the study 
 Mortality (monitored continuously throughout the study) 
Exploratory 
Assessments: 
The following assessments will be considered as exploratory 
measurements: 
 PK analyses performed at all visits from Day 1 to Day 7 
(inclusive) in the first 120 patients from Part 1 only 
 Lung function. The following must be recorded during the 
study: 
o Ventilation modality (e.g., non-rebreathing mask, non-
invasive mechanical ventilation, invasive mechanical 
ventilation) and start and stop dates 
o Non-mechanical ventilation: non-rebreathing mask, or 
nasal oxygen delivery (liters of oxygen/min, estimated 
daily average) 
o Mechanical ventilation (non-invasive and invasive): 
 Arterial partial oxygen pressure (PaO2) (estimated 
daily average) 
 Fraction of inspired oxygen (FiO2) and positive 
end-expiratory pressure (PEEP) (estimated daily 
average) 
 Tidal volume (estimated daily average) for invasive 
mechanical ventilation only) 
 To enable calculation of the fraction PaO2/FiO2: 
PaO2 and FiO2 must be captured at the same time 
point. Only one simultaneous measurement will be 
used. In case of multiple measurements of this 
fraction the worst value must be used. 

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Study Drug, Dosage, 
and Route of 
Administration: 
Study drug will be administered by 1-hour IV infusion as soon 
as possible on Day 1, and on Days 2 and 3 at 24 ± 1 hour after 
the previous drug administration, by trained staff in the ICU or 
intermediate care unit. Patients randomly assigned to receive 
recAP in Part 1 or during interim analysis will receive one of the 
following 3 doses of recAP: 0.4 mg/kg (250 U/kg), 0.8 mg/kg 
(500 U/kg), or 1.6 mg/kg (1000 U/kg). Patients will receive 
study drug by 1-hour IV infusion once daily for 3 days (Days 1, 
2, and 3). At the start of each drug administration, the exact 
volume of recAP or placebo to be administered to each patient 
will be calculated on the basis of the patient’s weight. Patients 
weighing between 95 to 115 kg will receive the same dose as 
that for patients weighing 100 kg. A medication preparation 
instruction sheet including a table with weight ranges and pre-
calculated corresponding volumes will be provided. The 
maximum weight is limited to 115 kg (253 lb). The volume of 
the matching placebo medication will be identical to the volume 
the patient would receive if randomly assigned to recAP. 

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Sample Size: 
A sample size of n1 = 30 patients per treatment group in Part 1 
with an additional n2 = 85 patients recruited to the optimal recAP 
dose and placebo treatment groups in Part 2 (for a total sample 
size of n = 290 patients) is planned. Custom programmed 
simulations were performed using SAS® software Version 9.2 
(SAS Institute, Inc, Cary, North Carolina) to determine power 
and type I error rate of the chosen sample size and design under 
a number of different dose response scenarios. Each scenario 
assumed a standard deviation of 49 mL/min for the primary 
endpoint (area under the time-corrected endogenous creatinine 
clearance curve from Day 1 to Day 7 [AUC1-7]) with an assumed 
response of 60 mL/min for the placebo group, and between 
60 mL/min (no treatment effect) and 79 mL/min (strong 
treatment effect) for the recAP dose groups. 
Fifty-thousand simulations were performed to show that the 
1-sided type I error rate is 2.4% (and hence is well controlled at 
the 1-sided 2.5% significance level). The power was defined as 
the probability of rejecting the null hypothesis (of no difference 
between treatment groups) when 1 or more recAP dose groups 
have an effective treatment effect, defined as a response of 
69.5 mL/min. This was investigated across 7 scenarios with 
10 000 simulations performed for each. In the most realistic 
scenarios (with strong treatment effects, i.e., responses of 
79 mL/min for the medium and high recAP dose groups and a 
varying response of between 60 mL/min and 79 mL/min for the 
low-dose group) the chosen design achieved power of between 
79% and 86%. This dropped to 66% to 67% for other scenarios 
where only the high recAP dose group had a strong treatment 
effect. 
Statistical Methods: 
Statistical analyses will be performed using SAS software 
Version 9.2 or later. Continuous variables will be summarized 
using descriptive statistics. Categorical variables will be 
summarized using frequency counts and percentages. All data 
collected across the 4 treatment groups throughout the study will 
be listed in data listings. 
All statistical tests will be 2-sided and performed using a 5% 
significance level, leading to 95% (2-sided) confidence intervals 
(CIs). As the primary efficacy endpoint is analyzed at the interim 
analysis and at the end of the study, multiplicity will be 
addressed by using a combination test to combine the results. A 
hierarchical method will be employed to address any multiplicity 
arising from the analysis of the key secondary endpoint. In other 

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words, the formal analysis of this endpoint will be performed 
only if a statistically significant result is obtained from the 
combination test analysis of the primary endpoint. All analyses 
performed on the other secondary endpoints are for exploratory 
purposes only; therefore, no further multiplicity adjustment is 
required. 
The primary efficacy endpoint, area under the time-corrected 
endogenous creatinine clearance curve from Day 1 to Day 7 
(AUC1-7), will be summarized using descriptive statistics and 
analyzed using analysis of variance with treatment and site as 
explanatory variables. The analysis will be performed separately 
for Parts 1 and 2: for Part 1, AUC1-7 will be compared between 
the 3 recAP doses and placebo. This analysis will be considered 
in conjunction with the safety data to determine the optimal 
recAP dose for use in Part 2. For Part 2, the optimal recAP dose 
will be compared with placebo. Confirmatory testing of the 
single hypothesis comparing optimal dose with placebo will be 
based on a closed-testing procedure. This hypothesis will be 
rejected at level α if it and all intersection hypotheses involving 
it are all rejected at local level α. The testing strategy used to 
combine results from Parts 1 and 2 will be a combination test 
based on the inverse normal method. The difference in least 
squares means between the treatment groups will also be 
presented along with the associated 95% CI. 
Analyses of the secondary efficacy endpoints will be conducted 
at the conclusion of Part 2.  
The key secondary endpoint, the incidence of RRT from Day 1 
to Day 28, inclusive, will be summarized by treatment group 
using counts and percentages. Should a statistically significant 
result be obtained from the combination test analysis of the 
primary endpoint, the optimal recAP dose will be formally 
compared with placebo using a logistic regression model with 
treatment group and site as explanatory variables. Otherwise the 
results will be reported as exploratory analyses only. The odds 
ratio and associated 95% CI from this comparison will also be 
presented. 
The safety summaries will include all 4 treatment groups, 
comprising all patients in the safety set. 
Date of Protocol: 
03 Feb 2016 

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List of Abbreviations 
Abbreviation 
Definition 
ADP 
adenosine diphosphate 
AE 
adverse event 
AKI 
acute kidney injury 
AKIN 
Acute Kidney Injury Network 
ALT 
alanine aminotransferase 
AMP 
adenosine monophosphate 
ANOVA 
analysis of variance 
AP 
alkaline phosphatase 
APACHE 
Acute Physiology and Chronic Health Evaluation II 
AST 
aspartate aminotransferase 
ATP 
adenosine triphosphate 
AUC0-inf 
area under the concentration-time curve from zero up to an infinite time 
AUC1-7 
area under the time-corrected endogenous creatinine clearance curve 
from Day 1 to Day 7 
BiAP 
bovine intestinal alkaline phosphatase 
BUN 
blood urea nitrogen 
cAMP 
cyclic adenosine monophosphate 
CFR 
Code of Federal Regulations 
CI 
confidence interval 
ClIohexol 
iohexol clearance 
CKD 
chronic kidney disease 
CKD-EPI 
Chronic Kidney Disease Epidemiology Collaboration 
Cmax 
observed maximum plasma or serum concentration after administration 
Cmin 
observed minimum plasma or serum concentration after administration 
CPAP 
continuous positive airway pressure 
CRP 
C-reactive protein 
DMC 
data monitoring committee 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
eGFR 
estimated glomerular filtration rate 
EQ-5D 
EuroQol-5D 

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Abbreviation 
Definition 
ERPF 
effective renal plasma flow  
FDA 
Food and Drug Administration 
FiO2 
fraction of inspired oxygen 
GFR 
glomerular filtration rate 
GGT 
gamma-glutamyl transpeptidase 
GST-alpha 
alpha-glutathione s-transferase 
hCG 
human chorionic gonadotropin 
ICF 
informed consent form 
ICH 
The International Council for Harmonisation 
ICU 
intensive care unit 
IEC 
independent ethics committee 
IgE 
immunoglobulin E 
IgG 
immunoglobulin G 
IL-6 
interleukin 6 
IL-18 
interleukin 18 
IRB 
institutional review board 
ITT 
intent to treat 
IV 
Intravenous 
IVRS 
interactive voice response system 
KDIGO 
Kidney Disease: Improving Global Outcomes 
KIM-1 
kidney injury molecule-1 
LBP 
lipopolysaccharide-binding protein 
LDH 
lactate dehydrogenase 
LOCF 
last observation carried forward 
LPS 
lipopolysaccharide 
MDRD 
Modification of Diet in Renal Disease 
MedDRA 
Medical Dictionary for Regulatory Activities 
NSAID 
non-steroidal anti-inflammatory drug 
PD 
pharmacodynamic(s) 
PEEP 
positive end expiratory pressure 
P/F ratio 
fraction PaO2/FiO2 (Carrico index) 
PK 
pharmacokinetic(s) 

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Abbreviation 
Definition 
PP 
per protocol 
recAP 
recombinant human alkaline phosphatase 
RRT 
renal replacement therapy 
SA-AKI 
sepsis-associated acute kidney injury 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SAPS-2 
Simplified Acute Physiology Score 2 
SIRS 
systemic inflammatory response syndrome 
SOFA 
Sequential Organ Failure Assessment 
SPM 
study procedures manual 
TEAE 
treatment-emergent adverse event 
TLR4 
toll-like receptor 4 
 

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1 Introduction 
Sepsis is a major cause of multiple organ dysfunction and death in the intensive care unit 
(ICU). Despite modern anti-microbial therapy and intensive care facilities, the mortality rate 
of sepsis remains high (Martin et al 2003). It is estimated that in the United States alone, 
sepsis occurs in 750 000 patients per year with a mortality rate of approximately 30% to 50% 
(CDC 1990; Rangel-Frausto et al 1995; Angus et al 2000; Annane et al 2000). In addition, 
sepsis is the most common cause of non-cardiac death in the ICU (Parrillo et al 1990). Sepsis 
is a systemic inflammatory cascade that occurs in the human body in response to an infection 
with bacteria, or other pathogens (Rackow 1986; Bone et al 1997). Patients with sepsis 
present with clinical manifestations of systemic inflammation and suspicion or evidence of 
infection. 
Sepsis-associated acute kidney injury (SA-AKI) is a serious condition. Sepsis-associated 
acute kidney injury results in a mortality rate of up to 70% while patients surviving an 
episode of acute kidney injury (AKI) are at risk of developing chronic kidney disease (CKD) 
(Oppert et al 2008; Chawla et al 2011, Vaara et al 2012). Acute kidney injury is thought to be 
a multi-factorial disease with inflammatory, direct nephrotoxic, and ischemic insults acting 
simultaneously with other pathogenic responses to rapidly cause functional failure of the 
kidney (Bonventre and Yang 2011; Wen et al 2011; Gomez et al 2014). In sepsis, the initial 
host response to an infection, mostly caused by bacteria, becomes amplified and then 
deregulated, bringing the body into an inflammatory state (Cohen 2002). There are no 
pharmacological interventions approved for the treatment of SA-AKI. Currently, renal 
replacement therapy (RRT) is the only supportive treatment option available for AKI 
(Vincent et al 2006; Oppert et al 2008; Bagshaw et al 2009). 
Alkaline phosphatase (AP) is an endogenous enzyme present in many cells and organs (e.g., 
intestines, placenta, liver, bone, kidney, and granulocytes) that exerts detoxifying effects 
through dephosphorylation of endotoxins (Bentala et al 2002; Koyama et al 2002) and other 
pro-inflammatory compounds including extracellular adenosine triphosphate (ATP) (Picher et 
al 2003). Local AP concentrations reflect the host defense against endotoxin in the kidney 
(Kapojos et al 2003), and during ischemia enzyme levels are markedly depleted, associated 
with the development of AKI (Khundmiri et al 1997). Apart from local effects in the kidney, 
AP may attenuate the innate immune response, as dephosphorylation of endotoxin abolishes 
its biological activity and acts as a toll-like receptor 4 (TLR4) antagonist (Wy et al 2000). In 

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animal models of sepsis, AP administration attenuates the inflammatory response and reduces 
mortality (Beumer et al 2003; Su et al 2006). There is increasing evidence that the protein 
plays a significant role in host defense and innate immunity, particularly against 
inflammatory reactions due to lipopolysaccharide (LPS) release (Verweij et al 2004; Su et al 
2006).  
Lipopolysaccharides (also named endotoxins) are constituents of the cell wall of 
gram-negative bacteria, which can also be present in the circulation during gram-positive 
infections (Marshall et al 2004), and are released when these bacteria disintegrate. It is a 
group of negatively charged molecules, of which the Lipid A moiety binds through 2, for this 
purpose essential, phosphate groups to its receptor, the CD14-TLR4 complex. These 
receptors are present on the surface of leukocytes (macrophages, white blood cells) and 
endothelial cells, and once activated they secrete a number of inflammatory cytokines. These 
in turn can cause a devastating and life-threatening derailment of the human innate immune 
system.  
Alkaline phosphatase is thought to exert a dual mode of action. First of all, it binds and 
subsequently dephosphorylates LPS (Kiffer-Moreira et al 2014), thereby eliminating the root 
cause of the systemic inflammatory response syndrome (SIRS). Secondly, the enzymatic 
reaction product, dephosphorylated LPS, is a non-toxic substance for mammals, and acts as a 
partial antagonist on the LPS receptor complex. Unlike other potential treatments, AP has 
been shown to act at the front end of the inflammatory cascade. By doing so, it may eliminate 
the root cause of the SIRS, and prevent the progression into sepsis and septic shock. Also, in 
ongoing sepsis, it cuts out the peaks of inflammatory responses induced by new LPS, which 
enters the systemic circulation after a septic insult. In addition, AP acts in the 
dephosphorylation of extracellular ATP via adenosine diphosphate (ADP) and adenosine 
monophosphate (AMP) into adenosine (Kiffer-Moreira et al 2014), with ATP having 
pro-inflammatory effects, whilst adenosine exhibits anti-inflammatory and tissue-protective 
effects (Day et al 2006). 
Two clinical studies previously performed with purified bovine intestinal AP (BiAP) 
generated clinical and biomarker data supporting the use of AP as a therapeutic intervention 
to improve the outcome of AKI associated with sepsis (Heemskerk et al 2009; 
Pickkers et al 2012). In the latter APREN-01-01 study, a prospective, randomized clinical 
study, BiAP significantly improved kidney function (determined by a composite endpoint of 

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creatinine clearance, requirement for RRT, and duration of RRT) and significantly reduced 
the length of ICU stay. In addition, the duration of mechanical ventilation tended to be 
reduced, although not significantly. Moreover, a range of markers of systemic inflammation, 
renal function, and renal damage in blood and urine demonstrated significant improvement, 
suggesting that a systemic anti-inflammatory effect induced by the treatment resulted in fast 
recovery and prevention of further kidney damage. In these relatively small studies (n = 36, 
each) no significant effects on mortality could be observed. 
Previous studies with BiAP in non-patient volunteers and in patients with sepsis and 
end-organ failure have established the tolerability and potential efficacy of BiAP. Following 
these encouraging positive results, AM-Pharma B.V. has developed a recombinant human 
chimeric form of AP, from parts of the intestinal and the placental isoforms (details are 
provided in the investigator’s brochure [AM-Pharma B.V. 2014]). 
Recombinant human AP is encoded by a human intestinal AP sequence, wherein the 
sequence encoding the crown domain has been substituted with the corresponding human 
placental AP sequence. Recombinant human AP is produced in Chinese hamster ovary cells 
using state-of-the-art mammalian cell culture technology. The investigational product is a 
concentrate for solution for infusion-containing recAP as active ingredient. AM-Pharma B.V. 
has developed recAP as a medicinal product to be used via intravenous (IV) infusion for the 
treatment of SA-AKI. In line with pre-clinical and clinical studies using purified BiAP, 
pre-clinical studies with recAP indicated that it asserts potent anti-inflammatory activity 
preserving function and histological integrity of the affected kidneys. In rodent and porcine 
models of AKI induced by ischemia-reperfusion injury or systemic endotoxemia, a 
single-dose administration of recAP consistently inhibited markers of inflammation and 
reduced kidney damage and functional impairment as determined by serum creatinine, blood 
urea nitrogen (BUN), creatinine clearance, and histopathological examination 
(AM-Pharma B.V. 2014). Its therapeutic activity is thought to be exerted through 
dephosphorylation and detoxification of pro-inflammatory substrates such as LPS, ATP and 
ADP. Adenosine triphosphate and ADP are highly potent triggers of inflammation released in 
damaged kidney tissue. In vitro, recAP inhibits immunological activation and chemotaxis of 
freshly isolated human leukocytes as well as platelet activation and aggregation induced by 
ATP and ADP. Therapeutic application of recAP is predicted to have potent 
anti-inflammatory and tissue-protective activity in patients suffering from AKI. 

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2 Study Objectives 
2.1 Primary Objectives 
The primary objectives of the study are as follows: 
 To investigate the effect of recAP on renal function and related clinical parameters in 
patients with SA-AKI. 
 To determine the therapeutic dose(s) of recAP to support the pivotal Phase 3 program. 
2.2 Secondary Objectives 
The secondary objectives of the study are as follows: 
 To investigate the safety and tolerability of recAP in patients with SA-AKI. 
 To investigate the pharmacokinetics (PK) of recAP in a subset of patients with SA-AKI 
(in the first 120 patients from Part 1 only). 
 To investigate the immunogenic potential of recAP in patients with SA-AKI.  
 To investigate the effect on quality of life (using the EuroQol, EQ-5D). 
2.3 Other Objectives 
To determine whether specific patient groups that benefit most from recAP treatment and 
whether patient groups that are non-responders can be identified. The identification of such 
groups will be based on: 
 Baseline characteristics, including: 
o Kidney function markers (e.g., urine and serum creatinine, BUN/urea clearance, 
sodium, proteinuria, fractional excretion of sodium and urea, and urine output]) 
o Tubular injury biomarkers (e.g., kidney injury molecule-1 [KIM-1], interleukin 18 
[IL-18], alpha-glutathione s-transferase [GST-alpha]) 
o Biomarkers for systemic inflammation (e.g., IL-6, C-reactive protein [CRP], 
lipopolysaccharide-binding protein [LBP]) 
o Glomerular filtration rate (eGFR by chronic kidney disease epidemiology 
collaboration [CKD-EPI]) 
o APACHE II score (<25, ≥25) 

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 Timing from first diagnosis of SA-AKI to start of recAP treatment, e.g., in time intervals 
(0 to < 6 hours, 6 to < 12 hours, 12 to < 18 hours, 18 to 24 hours). 
 Baseline AKIN stage (stage 1, stage 2, stage 3) 
Additional parameters may also be considered (e.g., urine output [over or under 
200 mL/day], diabetes mellitus [yes or no], hypertension [yes or no], age [< 55 years old, 
≥ 55 years old and < 70 years old, or ≥ 70 years old], sex (male or female), risk scores [high 
or low]). 
3 Investigational Plan 
3.1 Study Design 
This is a randomized, double-blind, placebo-controlled, 4-arm, parallel-group, 
proof-of-concept, and dose-finding adaptive Phase 2a/2b study. 
Approximately 100 sites will participate in the study; approximately 75 in the European 
Union and approximately 25 in the United States and Canada. Participating sites will be 
required to adhere to the Surviving Sepsis Campaign 2012 (Delinger et al 2013) and 
KDIGO® (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for AKI 
recommendations (KDIGO Acute Kidney Working Group 2012).  
A minimum of 290 patients with SA-AKI will be enrolled in the study. The study involves 
2 parts (Part 1, Part 2) with an interim analysis between the parts, with continued recruitment 
during this interim analysis. Of the 290 planned patients, at least 120 patients will enroll in 
Part 1 and 170 patients will enroll in Part 2 with an estimated 50 patients during the interim 
analysis. Patients enrolled during Part 1 and interim analysis will be randomly assigned to 
receive, by 1-hour IV infusion, either placebo (Part 1; n1 = 30) or one of 3 different doses of 
recAP (Part 1; n1 = 30 in each dosing arm; i.e., 0.4 mg/kg [250 U/kg], or 0.8 mg/kg 
[500 U/kg], or 1.6 mg/kg [1000 U/kg]) using a 1:1:1:1 allocation ratio. Patients will receive 
study drug by 1-hour IV infusion once daily for 3 days (Days 1, 2, and 3). The interim 
analysis on the primary endpoint will be performed on all the data collected after the 120th 
patient of Part 1 has completed the Day 7 visit of the study to select the dose to be 
administered in Part 2. The dose chosen will be the optimal dose of recAP on the primary 
endpoint in Part 1, provided there are no safety issues with that dose as judged by the data 
monitoring committee (DMC). In Part 2, patients will be randomly assigned to receive, by 1-

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hour IV infusion, either placebo (n2 = 85) or the dose of recAP (n2 = 85) selected during the 
interim analysis. Patients recruited during the interim analysis period to the dose selected in 
Part 2 will form part of the Part 2 populations, but those recruited to the doses that are not 
selected will be included in the Part 1 population. 
Each part involves the following schedule of events: potential patients who have been 
admitted to the ICU or intermediate care unit will undergo a pre-screening to assess the 
presence of SA-AKI, will provide informed consent, and will undergo screening assessments 
to determine eligibility. As soon as possible when all inclusion and none of the exclusion 
criteria are met (see Section 4.1), and after confirmation of continuing (i.e., not resolving) 
AKI by a fluid-corrected serum creatinine assessment (see Section 13.3) or urine output, 
eligible patients will be randomly assigned to a treatment group (baseline), undergo baseline 
determinations, and start treatment with study drug (Day 1). Treatment must be administered 
within 24 hours, at the latest, after SA-AKI is first diagnosed and within 96 hours from first 
diagnosis of sepsis.  
Assessments will be performed during a total of 12 visits, at the following intervals: daily 
from Day 1 to Day 7 ± 1 day (7 visits); weekly on Day 14 ± 2 days, Day 21 ± 3 days, and 
Day 28 ± 3 days (3 visits); and follow-up assessments will be completed on Day 60 ± 5 days 
and Day 90 ± 10 days (2 visits). The Schedule of Assessments is presented in Section 13.1 
(Table 13-1) and the Flowchart of Assessments is presented in Section 13.2 (Figure 13-1). 
Due to potential unblinding, it is not allowed to locally measure AP activity in the blood up 
to Day 14 (inclusive), irrespective of whether the patient is in the ICU or intermediate care 
unit or in the ward. 

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Figure 3–1 
Study Design  
 
 
Abbreviations: ICF = informed consent form; IV = intravenous; recAP = recombinant human alkaline 
phosphatase; RRT = renal replacement therapy; SA-AKI = sepsis-associated acute kidney injury.

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3.1.1 Rationale of Study Design  
As there are no guidelines for the development of drugs for the indication SA-AKI, the 
proposed design was determined to be optimal by a group of leading global experts in AKI 
and sepsis, and subsequently was discussed (and agreed) with European and US regulatory 
agencies. 
The dosing schedule is described in the dosing rationale section. To determine the optimal 
dose the study has been set up with an adaptive study design including 2 parts, with dose 
selection based on an interim analysis after the 120th patient in Part 1 has completed the 
Day 7 visit. The 3 active doses in Part 1 are selected based on a combination of information 
from previous clinical studies conducted with BiAP, and pre-clinical animal models and PK 
modeling and simulation in a Phase 1 healthy volunteer study with recAP. Assuming 
comparable safety profiles, the optimal dose will be selected at the interim analysis by an 
independent DMC. The primary endpoint, area under the time-corrected endogenous 
creatinine clearance curve, was chosen because as a continuous variable it is sensitive for 
detecting relatively small treatment effect differences of recAP versus placebo, as well as 
determination of effect size differences between the different dosages. Incidence of dialysis, 
considered to be a relevant clinical endpoint for Phase 3 pivotal studies, was chosen as the 
key secondary endpoint. In the first 120 patients from Part 1 only, PK samples will be taken 
to assess the pharmacological properties of recAP in patients, in addition to the information 
previously derived from the healthy volunteers. 
Currently there is no treatment available for SA-AKI; hence, recAP is considered as add-on 
therapy and with that the use of a placebo arm is fully justified. 
Following patients up to a period of 90 days allows for assessing potential disease-modifying 
characteristics of recAP in kidney function (occurrence or worsening of CKD).  
3.1.2 Dose Rationale 
No dose-limiting toxicity was observed in pre-clinical and clinical studies with recAP up to 
daily doses of 16 mg/kg (10 000 U/kg) and 32 mg/kg (20 000 U/kg) maintained for 14 days 
in Göttingen mini-pigs, and in healthy volunteers for a single dose up to 3.2 mg/kg 
(2000 U/kg) and for multiple doses up to 3 daily doses of 1.6 mg/kg (1000 U/kg). Therefore, 
the dose rationale is primarily based on: 1) observed Phase 1 recAP PK parameters; 2) trough 

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levels (293 U/L, corresponding to 0.171 mg/L recAP) obtained in the APREN-01-01 study; 
and 3) exposure maintained during the APREN-01-01 study and associated with clinical 
activity. The 3 dose level schedules proposed for the first part of this Phase 2 study, in 
addition to the placebo group, are shown in Table 3–1. 
Table 3–1 
Proposed Dose Groups for AP-recAP-AKI-02-01 Protocol 
Dose group 
AUC0-inf 
(h•U/L) 
Fold 
(over BiAP) 
Cmin 
(U/L) 
Fold 
(over BiAP) 
ttrough 
(h) 
250 U/kg or 
0.40 mg/kg 
qd ×3 
45 762 
(26 225 - 75 202) 
2.29 
Cmin1: 120 (74 - 187) 
Cmin2: 183 (113 - 287) 
0.41 
0.62 
ttrough1: 7.2 
ttrough2: 35.0 
ttrough3: 63.2 
500 U/kg or 
0.80 mg/kg 
qd ×3 
90 901 
(50 782 - 156 914) 
4.55 
Cmin1: 241 (140 - 391) 
Cmin2: 369 (213 - 599) 
0.82 
1.26 
ttrough1: 18.7 
ttrough2: NR 
ttrough3: 92.1 
1000 U/kg or 
1.60 mg/kg 
qd ×3 
184 347 
(102 688 - 301 544) 
9.22 
Cmin1: 486 (288 - 742) 
Cmin2: 746 (443 - 
1136) 
1.66 
2.54 
ttrough1: NR 
ttrough2: NR 
ttrough3: 144 
BiAP 
(APREN-01-01) 
67.5 U/kg (10 
min) + 132.5 
U/kg/24 h for 48 h 
20 000 
(estimated) 
NA 
293 ± 257 
(‘trough’) 
NA 
NA 
Abbreviations: BiAP = bovine intestinal alkaline phosphatase; Cmin = observed minimum plasma or serum concentration 
after administration; h = hour; min = minute; NA = not available; NR = not recorded; qd = every day (quaque die). 
Cmin is determined just before re-infusion (Cmin1 at t = 24 h; Cmin2 at t = 48 h). 
Trough is set at 293 U/L (based on APREN-01-01 study). 
Ttrough reflects the time to reach trough (ttrough1 after first infusion, ttrough2, etc). 
 
Using PK simulation experiments, these schedules achieve the area under the concentration-
time curve from zero up to an infinite time (AUC0-inf) and observed minimum plasma or 
serum concentration after administration (Cmin) levels that are similar to or exceed the 
presumed minimal requirements based on BiAP studies APSEP-02-01 and APREN-01-01. 
Furthermore, these dose groups are likely to achieve significantly different exposures when 
comparing 3 groups of 30 patients (as informed by the observed PK variability in Phase 1 
patients). Analyzing PK simulations, compared to the APREN-01-01 study results the recAP 
low-dose group is expected to achieve sufficient exposure with Cmin dropping below target 
trough before re-infusion, whereas the mid-dose and high-dose groups exceed target 
exposure and Cmin. If clinical activity is observed to be different in Phase 2 at interim 

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analysis, the proposed set up of dose groups is likely to enable a clear decision on optimal 
recAP dose for continuation into the second part of the study. 
3.1.3 Individual Benefit/Risk Considerations 
Benefits for patients with sepsis and AKI are anticipated based on pharmacodynamic (PD) 
data and data from 2 Phase 2 studies described in the investigator’s brochure. In the APSEP 
02-01 study, BiAP was associated with a non-significant survival benefit versus placebo and 
clinically important benefits on renal function parameters of serum creatinine, inflammatory 
and kidney damage biomarkers and dialysis requirements. In the APREN01-01 study, BiAP 
significantly improved kidney function (determined by a composite endpoint of creatinine 
clearance, requirement for RRT and duration of RRT) and significantly reduced the length of 
ICU stay. There was a non-significant trend toward a reduction in the requirement for 
mechanical ventilation and a significant improvement in biomarkers of systemic 
inflammation, of renal function, and of renal damage in blood and urine, suggesting that a 
systemic anti-inflammatory effect induced by the treatment resulted in fast recovery and 
prevention of further kidney damage. 
No safety concerns were identified in either of these Phase 2 clinical studies with BiAP or in 
the Phase 1 study in 51 healthy volunteers with recAP. 
4 Patient Selection and Withdrawal Criteria 
4.1 Selection of Study Population 
A minimum of 290 patients will be enrolled (Part 1: at least 120 patients; 
Part 2: 170 patients) at approximately 100 sites (75 sites in the European Union and 25 sites 
in the United States and Canada). Patients will be enrolled and randomly assigned to study 
drug only if all of the inclusion criteria and none of the exclusion criteria are met. 
Recruitment will continue and additional patients may be recruited during the interim 
analysis (approximately 50 patients). 
Deviations from the inclusion and exclusion criteria are not allowed because they can 
potentially jeopardize the scientific integrity of the study, regulatory acceptability, and, most 
importantly, patient safety. Therefore, strict adherence to the criteria as specified in the 
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4.1.1 Inclusion Criteria 
Each patient must meet all of the following criteria to be enrolled in this study: 
1. Has informed consent form (ICF) signed according to local rules and approved 
regulations. 
2. Is aged 18 to 85 years, inclusive. 
3. Is admitted to the ICU or intermediate care unit. 
4. Has diagnosis of sepsis (<96 hours prior to first study drug administration or < 72 hours 
prior to AKI diagnosis), according to criteria defined by the American College of Chest 
Physicians/Society of Critical Care Medicine (Bone 1992]), based on: 
a. Has a proven or strongly suspected bacterial infection and 
b. Have at least 2 of the following 4 SIRS criteria within a timeframe of 72 hours at time 
of AKI diagnosis. Note: it is not required that symptoms are present simultaneously at 
study randomization: 
i. Has a core temperature > 38°C or < 36°C.  
ii. Has a heart rate > 90 beats/minute (unless the patient has a medical condition 
known to increase heart rate or is receiving treatment to prevent tachycardia).  
iii. Has a respiratory rate > 20 breaths/minute, PaCO2 < 32 mm Hg or the use of 
mechanical ventilation for an acute respiratory process.  
iv. Has a white cell count > 12 000/mm3 or < 4000/mm3 or a differential count 
showing > 10% immature neutrophils (band cells).  
5. Has first diagnosis of AKI, defined as any of the following: 
AKI Stage 1 or greater, according to the following Acute Kidney Injury Network (AKIN) 
criteria (Note: adjusted in regards to time-window):  
a. 
Increase (absolute) in serum creatinine > 26.2 µmol/L (0.30 mg/dL) compared with 
a serum creatinine value within the previous 48 hours, or presumed to have 
occurred in the previous 48 hours when compared to a reference* creatinine value  

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b. Increase (relative) in serum creatinine to > 150% (> 1.5–fold) compared with a 
serum creatinine value in the previous 48 hours or presumed to have occurred in 
the previous 48 hours when compared to a reference* creatinine value.  
*The reference creatinine value is a serum creatinine value in the following order 
of preference: 
1. 
Lowest value within 3 months of the hospital admission. If not available: 
2. 
At hospital admission. If not available: 
3. 
At ICU or intermediate care unit admission. If not available: 
4. 
Lowest value between 3 and 12 months prior to hospital admission 
c. 
Urinary output < 0.5 mL/kg/h for > 6 hours following adequate fluid resuscitation 
when applicable, in the absence of underlying primary renal disease.  
6. When the diagnosis of AKI is made according to one of the AKIN serum creatinine 
criteria (absolute or relative increase, see inclusion criteria 5a and 5b), continuing AKI 
needs to be confirmed by a confirmative serum creatinine measure (that is corrected for 
fluid administrations), defined as no decrease in serum creatinine ≥ 26.2 µmol/L 
(≥0.30 mg/dL). The result must be available prior to randomization, within 24 hours after 
the primary AKI diagnosis so that administration of the first study treatment can be 
started within 24 hours after AKI diagnosis. 
7. When the AKI diagnosis is made according to the AKIN urine output criteria (urinary 
output < 0.5 mL/kg/h for > 6 hours, see inclusion criterion 5c), the oliguria or anuria 
should still meet the AKIN urine output criteria prior to randomization and study drug 
administration; administration of study treatment must be started within 24 hours after 
first AKI diagnosis. 
4.1.2 Exclusion Criteria 
Patients meeting any of the following criteria will be excluded from the study: 
1. Woman of childbearing potential with a positive pregnancy test (blood or urine), 
pregnant, or breastfeeding. 
2. Weighs more than 115 kg (253 lb). 
3. Has life support limitations (i.e., do not intubate, do not dialyze, do not resuscitate). 

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4. Is known to be human immunodeficiency virus positive. 
5. Has urosepsis. 
6. Is already on dialysis (RRT) or a decision has been made to initiate RRT within 24 hours 
after planned start of study drug administration. 
7. Is receiving immunosuppressant treatment or is on chronic high doses (high-dose therapy 
exceeding 2 weeks of treatment) of steroids equivalent to prednisone/prednisolone 
0.5 mg/kg/day, including solid organ transplant patients. Patients with septic shock 
treated with hydrocortisone (e.g., 3 × 100 mg) can be included. 
8. Is expected to have rapidly fatal outcome (within 24 hours). 
9. Has known, confirmed fungal sepsis. 
10. Has advanced chronic liver disease, confirmed by a Child-Pugh score of 10 to 15 
(Class C). 
11. Has acute pancreatitis with no established source of infection.  
12. Has participated in another investigational study within 30 days prior to enrollment into 
the study. 
13. Is not expected to survive for 28 days due to medical conditions other than SA-AKI, e.g., 
end-stage cancer, end-stage cardiac disease, cardiac arrest requiring cardiopulmonary 
resuscitation or with pulseless electrical activity or asystole within the past 30 days, 
end-stage lung disease, and end-stage liver disease. 
14. Has known prior history of CKD with a documented sustained estimated GFR 
(eGFR) < 60 mL/min by a commonly used formula such as Modification of Diet in Renal 
Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), a 
measured GFR < 60 mL/min, or a known history of persistent creatinine level equal or 
greater than 150 µmol/L (1.70 mg/dL) prior to entry for reasons other than the current 
sepsis condition. 
15. Has diagnosis of malaria or other parasite infections. 
16. Has burns on > 20% of body surface. 
17. Has had AKI diagnosis according to the AKI inclusion criteria for a period longer than 
24 hours prior to study drug administration. 
18. Is anticipated to be treated with non-continuous RRT from Day 1 to Day 7. 

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19. During Day 1 to Day 7 continuous RRT is anticipated to be started or stopped not 
according to per protocol criteria (Section 6.3.9). 
20. The AKI is most likely attributable to other causes than sepsis, such as nephrotoxic drugs 
(NSAIDs, contrast, aminoglycosides) and renal perfusion-related (acute abdominal aortic 
aneurysm, dissection, renal artery stenosis). 
21. Improvement in serum creatinine of at least 0.30 mg/dL or (26.2 µmol/L) prior to 
administration of the study drug. 
22. Patients who use nephrotoxic medication e.g., NSAIDs, angiotensin-converting enzyme 
inhibitors, gentamycin, tobramycin) and who fulfill the SA-AKI inclusion criteria at 
screening are not eligible if the use of this nephrotoxic medication is to continue when 
alternative, medically appropriate, non-nephrotoxic medication is available . (Note: this is 
according to KDIGO Clinical Practice Guideline for AKI recommendations [KDIGO 
Acute Kidney Working Group 2012]) to avoid nephrotoxic medication, where possible). 
23. Has a history of known IV drug abuse. 
24. Is an employee or family member of the investigator or study site personnel. 
25. Has active hematological malignancy. 
4.2 Withdrawal of Patients From the Study 
The duration of the study for a patient is defined from the date that signed written informed 
consent is provided until the last follow-up visit on Day 90.  
4.2.1 Reasons for Withdrawal/Discontinuation 
Patients may withdraw from the study at any time and for any reason without prejudice to 
their future medical care by the investigator or at the study site. Investigators should attempt 
to determine the cause of withdrawal and, if agreed by the patient, to let the patient return for 
the Day 90 visit (last safety follow-up visit). The extent of a patient’s withdrawal from the 
study (i.e., withdrawal from further study treatment, withdrawal from active participation in 
the study, withdrawal from any further contact) should be documented in the eCRF. Efforts 
should be made to follow-up the randomized and withdrawn patients as much as possible, 
i.e., to the extent that the patients agree to. 

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Treatment with study drug will be stopped for any of the following reasons: 
1. Any clinical adverse event (AE), laboratory abnormality, or intercurrent illness which, in 
the opinion of the investigator, indicates that continued treatment with study drug is not 
in the best interest of the patient. 
2. The patient withdraws consent or the investigator or sponsor decide to discontinue the 
patient’s participation in the study. 
3. AM-Pharma B.V. terminates the study 
Additionally, treatment with study drug may be stopped in case of protocol non-compliance 
or violations. In this case, the investigator will contact the Medical Monitor to discuss 
risk/benefit balance of continued treatment with study drug. 
In case study drug administration is discontinued prematurely the patient will preferably 
continue follow-up in the study as per protocol for safety and to allow for intent-to-treat 
(ITT) analysis. If study drug administration is interrupted for any reason, re-starting of study 
drug should be discussed with the Medical Monitor. 
The reason for and date of study drug discontinuation and/or the reason for and date of 
withdrawal from the study must be recorded in the electronic case report form (eCRF). If 
study drug is discontinued because of an AE or a clinically significant abnormal laboratory 
test result, evaluations will continue until the event has resolved or stabilized or until a 
determination of a cause unrelated to the study drug or study procedure is made. The specific 
event or laboratory finding(s) must be documented. 
4.2.2 Handling of Withdrawals 
When a patient withdraws from the study, the investigator will record the reason(s) for 
withdrawal on the relevant page of the eCRF. All patients who withdraw from the study 
prematurely will preferably undergo end-of-study (Day 28) assessments immediately upon 
discontinuation. Investigators should attempt to determine the cause of withdrawal and, if 
agreed by the patient, to let the patient return for the Day 90 visit (last safety only follow-up 
visit). 
It is highly desirable to obtain follow-up safety data on any patient withdrawn because of an 
AE or serious adverse event (SAE). In every case, efforts must be made to undertake 

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protocol-specified, safety, follow-up procedures (Section 6.3.14). All data from withdrawals 
will be included in the final ITT analyses. 
Patients who fail to return for final assessments in general will be contacted by the site in an 
attempt to have them comply with the protocol; attempts to contact patients will be recorded 
in the eCRF. Three documented attempts to follow up of which at least one is a registered 
letter are considered a reasonable effort to obtain information before subject is considered 
lost to follow-up. 
4.2.3 Replacements 
As the sample size determination is based on the number of patients required for the ITT 
analysis, patients who are randomly assigned and subsequently withdraw prior to completion 
of the study will not be replaced. 
5 Study Drugs 
5.1 Method of Assigning Patients to Treatment Groups 
Patients will be randomly assigned to receive either placebo or one of 3 doses of recAP using 
a 1:1:1:1 allocation ratio in Part 1. The randomization schedule will be stratified by site. 
Once it has been decided which is the optimal dose of recAP on the primary endpoint to be 
administered in Part 2, the codes for the treatment groups corresponding to the 2 dropped 
doses will be discontinued, and treatment allocation will continue using the codes for the 
remaining treatments on the same schedule. 
An interactive voice response system (IVRS) will be used to administer the randomization 
schedule. An independent PPD statistician will generate a permuted block randomization 
schedule using SAS® software Version 9.2 or later (SAS Institute, Inc, Cary, North Carolina) 
for IVRS, which will link sequential patient randomization numbers to treatment codes. Each 
patient will be assigned a randomization number which will be separate from the patient 
identification number. Once a randomization number has been allocated to a patient, it may 
not be assigned to another patient. 
5.2 Treatments Administered 
Study drug will be administered by 1-hour IV infusion as soon as possible on Day 1 after 
confirmation of continuing AKI, and on Days 2 and 3, 24 ± 1 hour after previous drug 

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administration, by trained staff in the ICU or intermediate care unit. A total of 50 mL (see 
Section 5.3) will be infused at a constant rate of 50 mL/hour, followed by a flushing of 
infusion lines with minimal 4 mL saline. The preferred route for study drug administration 
will be through a central line; if this is not possible, a peripheral line will be acceptable. 
Study drug will be administered separately from any concomitant drugs using a dedicated 
lumen of the catheter. 
Vital signs will be monitored during infusion on all treatment days (see Section 6.3.4). 
Patients randomly assigned to receive recAP in Part 1 and during the interim analysis will 
receive one of the following 3 doses of recAP: 0.4 mg/kg (250 U/kg), 0.8 mg/kg (500 U/kg), 
or 1.6 mg/kg (1000 U/kg). Patients will receive study drug by 1-hour IV infusion once daily 
for 3 days (Days 1, 2, and 3). The exact volume of recAP or placebo prior to dilution will be 
determined according to the patient’s weight. Patients weighing between 95 to 115 kg will 
receive the same dose as that for patients weighing 100 kg. A detailed medication preparation 
instruction sheet will be provided. A table with weight ranges and pre-calculated 
corresponding volumes is provided in Section 13.4. The maximum weight is limited to 
115 kg (253 lb).  
Treatment with recAP will not be repeated in the same patient beyond the scope of the 
protocol. All patients should be monitored closely for signs of adverse reactions. Due to the 
IV route of administration, local irritation and hematoma at the infusion site may occur 
(when administered through a peripheral line). No specific measures are required when 
extravasation occurs. 
5.3 Identity of Investigational Product 
Alkaline phosphatases are homodimeric enzymes responsible for dephosphorylation of 
monoesters of phosphoric acid by hydrolysis. Recombinant human AP is a full-length human 
chimeric AP derived by recombinant technology and produced in Chinese hamster ovary 
cells. Recombinant human AP has a projected mass of approximately 105 kDa based on the 
amino acid sequence derived from the DNA sequence and approximately 130 kDa as a fully 
glycosylated molecule. 
Recombinant human AP is supplied as an IV solution for infusion with an activity of 
5000 U/mL (units of AP activity) and a content of 40 mg per vial at 8.0 mg/mL (protein 

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concentration) in an aqueous buffer containing 20 mM citrate, 250 mM sorbitol, 
2 mM MgCl2, 50 µM ZnCl2, and with a pH of 7.0. 
Matching placebo for use in controlled studies consists of an IV solution for infusion 
containing an aqueous buffer containing 20 mM citrate, 250 mM sorbitol, 2 mM MgCl2, 
50 µM ZnCl2, and with a pH of 7.0. 
Recombinant human AP is supplied as a clear, colorless, pyrogen-free solution in 10-mL 
type 1 glass vials with a Teflon-coated bromobutyl rubber stopper and “Flip-Tear Up” 
overcap. Each vial contains 5 mL of recAP solution. Matching placebo is supplied as a clear, 
colorless, pyrogen-free solution in 10-mL type 1 glass vials with a Teflon-coated bromobutyl 
rubber stopper and “Flip-Tear Up” overcap. Each vial contains 5 mL of placebo solution. 
Patient doses will be prepared from 4 vials in a combination of recAP drug product and 
placebo. All content of all 4 vials will be used to fill an IV dosing syringe (50 mL). 
According to Table 13-2, part of the medication volume might be discarded in order to obtain 
an appropriate volume corresponding to the body weight of the patient, followed by addition 
of physiological saline solution to a total volume of 50 mL. 
Detailed instructions are provided in the study drug preparation manual. 
All study drug is to be stored in a lockable storage facility under appropriate and monitored 
pharmacy conditions. Alkaline phosphatase vials are to be stored at 2°C to 8°C and protected 
from light and moisture until preparation for use. 
Study drug needs to be prepared within 3 hours before dosing. Prior to use, the medication 
will be prepared according to the pharmacy manual; reconstituted medication can be stored at 
2 to 8°C for up to 3 hours and/or a maximum of 1 hour at room temperature. If applicable, 
the study drug will be re-labelled (as per current regulations) by the hospital pharmacy. 
Additional details will be provided in the study drug preparation manual. 
The hospital/study pharmacist is responsible for receipt of the study drug from PPD and for 
transfer to the ICU or intermediate care unit.  

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5.4 Management of Clinical Supplies 
5.4.1 Study Drug Packaging and Storage 
Recombinant human AP active 8 mg/mL and matching placebo will be prepared in 
randomized treatment packs comprising 3 daily doses, each of 4 vials (in any combination of 
recAP drug product and placebo) and shipped by PPD to the clinical site. Each pack will 
contain a (randomized) dosage for 1 patient and will contain a sufficient quantity for 
dispensing during the 3-day double-blind treatment period. 
The labeling of recAP and matching placebo will be in accordance with applicable local 
requirements in the countries where this study is conducted. 
Recombinant human AP must be stored in a secure area protected from light and kept at a 
controlled temperature of 2°C to 8°C. 
Full details of study drug packaging, storage, and shipment will be provided in the pharmacy 
manual. 
5.4.2 Test Article Accountability 
The investigator has the responsibility to maintain accurate records of receipt of all test 
articles, including dates of receipt. In addition, accurate records will be kept regarding when 
and how much test article is dispensed and used by each patient in the study. Reasons for 
deviating from the expected dispensing regimen as instructed must also be recorded. At the 
completion of the study, to satisfy regulatory requirements regarding drug accountability, all 
study drugs will be reconciled and retained or destroyed according to applicable regulations. 
The drugs supplied for this study are only intended for use by patients in this study. A drug 
accountability record must be maintained by the persons responsible for preparing and 
administering the study drug at the ICU or intermediate care unit. The drug accountability 
record will be provided and will be collected by the monitor at the end of the study. The 
monitor will also arrange for the secure disposal of unused and returned medication at the 
end of the study. 

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5.5 Management of Medication Errors or Overdose 
5.5.1 Medication Errors 
Since the study drug will be prepared, double-checked, and administered by trained hospital 
staff, and since the dose levels under study have not caused any SAEs in healthy volunteers, 
the risks for potential hazardous or life-threatening events due to medication errors is 
considered to be minimal. Hospital staff will prepare the study drug by adjusting downward 
the maximum volume of 20 mL based on body weight according to the table provided in the 
medication preparation instruction sheet (see Section 5.2). Study site staff will have checks in 
place to verify the preparation of the medication solution. Discarded volume will be collected 
in a vial for review of medication administration by the monitor during a regular monitoring 
visit. 
No specific treatment is available for medication errors and it is unknown whether or not 
specific symptoms will occur. If a medication error occurs, as a general rule supportive care 
and treatment of symptoms should be provided. 
5.5.2 Treatment of Overdose 
In healthy volunteers the maximum administered single dose that did not result in any SAEs 
was 3.2 mg/kg (2000 U/kg). The maximum multiple dose that was administered to healthy 
volunteers was 1.6 mg/kg (1000 U/kg) per day for 3 days without any SAEs. As an example 
of a possible dose error (e.g., administration of the highest study dose [i.e., 1.6 mg/kg 
{1000 U/kg} which is the dose for a 100-kg person] to a 50-kg person), 1-day administration 
of study drug still would not exceed the tested maximum dose in healthy volunteers.  
No specific treatment is available for overdose and it is unknown whether or not specific 
symptoms will occur. If an overdose occurs, as a general rule supportive care and treatment 
of symptoms should be provided. 
5.6 Blinding 
All persons involved in the study (including but not limited to the patient, site staff, 
AM-Pharma B.V. team members, and PPD team members) will be blinded to treatment 
assignment. The randomization schedule will be held by an independent PPD team at a 
different regional location and will not be revealed until all patients have completed the study 

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and the database has been finalized for the end of the study, except for the unblinded interim 
analysis (see Section 7.7.6). 
The determination of AP activity, often part of the routine clinical chemistry panel, could lead 
to unblinding and to erroneous interpretation of liver function, as the recAP administered will 
increase the AP activity, exceeding many times the reference range AP levels. For that reason, 
AP activity levels from samples taken during the first 14 days of the study are not allowed to 
be reported to the study team members or to any other study staff member involved in the 
conduct of the study. After Day 14, considering the terminal half-life of recAP, AP activity 
levels are expected to have returned to normal levels. Therefore, results of AP activity in 
samples that are taken after Day 14 may be reported. 
5.6.1 Breaking the Blind 
A patient’s treatment assignment will not be broken until the end of the study unless 
knowledge of the treatment assignment the patient received is necessary to guide medical 
treatment of the patient. In the event that the blind needs to be broken because of a medical 
emergency, the investigator may unblind an individual patient’s treatment allocation. The 
investigator should contact the Medical Monitor to discuss the medical emergency and the 
reason for revealing the actual treatment received by that patient unless immediate 
unblinding is necessary to ensure the patient’s safety. The treatment assignment will be 
unblinded through IVRS. Reasons for treatment unblinding must be clearly explained and 
justified in the eCRF. The date on which the code was broken together with the identity of 
the person responsible must also be documented. 
5.7 Concomitant Therapy 
Concomitant medication use, including the drug name (brand or generic), dose, and dates of 
administration, will be recorded in the eCRF beginning on baseline to Day 28. Changes in 
dosage of any concomitant medication will be recorded in the eCRF, except for IV 
medications that undergo frequent adjustments during the same day or over time, such as 
insulin, vasopressors, inotropics, diuretics, sedatives, metoprolol, and potassium. In these 
cases, only estimated mean daily dose or mean daily dose as calculated by the system used 
will be recorded. Concomitant medications will include all prescription drugs, including 
vitamins and minerals, herbal products, and over-the-counter medications. Only brand names 

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of nutritional products are to be recorded, while the single constituents of nutritional products 
need not be recorded. 
Administered resuscitation fluids should only be recorded as total daily volume in the 
concomitant medication section in the eCRF. Blood products should be recorded separately. 
5.7.1 Concomitant Medications to be Avoided 
A list of nephrotoxic concomitant medications that should be avoided, if possible, is provided 
in the study procedures manual (SPM). Based on findings that emerge during study conduct, 
the SPM will be updated as appropriate to include any additional concomitant medications 
that should be avoided, if possible. 
After randomization until the resolution of the current AKI episode, the administration of 
nephrotoxic drugs such as contrast agents, NSAIDs, angiotensin-converting enzyme 
inhibitors, gentamycin, or tobramycin should be avoided where possible, as recommended in 
the KDIGO Clinical Practice Guideline for AKI recommendations (KDIGO Acute Kidney 
Working Group 2012). 
6 Days, Assessments, and Procedures 
The Schedule of Assessments is presented in Section 13.1 (Table 13-1) and the Flowchart of 
Assessments is presented in Section 13.2 (Figure 13-1). 
Visits Day 1 through Day 7 are calculated on a 24-hour clock starting from the start of the 
first study drug administration. One visit day might cover 2 calendar days. After the Day 7 
visit, visit days are similar to calendar days. Counting is to start on the calendar day of the 
first study drug administration. 
6.1 Days  
6.1.1 Pre-screening, Screening and Baseline  
Fully informed consent will be obtained before any study-specific procedures are performed. 
Country-specific regulations regarding the collection of informed consent and personal data 
will be followed at each site. It is anticipated by the very nature of the study that many 
patients who will be eligible for this protocol due to their severe underlying condition will 
not be able to provide informed consent themselves for various reasons including sedation or 

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unconscious state. In a situation where a patient is unable to provide consent, the patient’s 
legally authorized representative may provide written consent, as approved by the 
institutional-specific guidelines. Informed consent may be obtained from an independent 
consulting physician or obtained on the basis of emergency study protocol by the investigator 
in countries where regulation and institution guidelines permit and where regulatory 
authorities and/or institutional review board (IRB)/independent ethics committee (IEC) have 
approved the procedure for the study. This form of consent can only be used when the patient 
and legally authorized representative are unable to provide consent. In cases where the initial 
informed consent is obtained from a legal representative, an independent consulting 
physician, or by investigator, the patient must also give written informed consent as soon as 
they are able. 
Pre-identified patients (or their legal representative, or independent physician, or other 
according to local regulatory requirements) who meet all of the inclusion criteria and none of 
the exclusion criteria that can be assessed in a non-invasive manner will be asked if they are 
willing to participate in the study by the attending physician. If they agree, patients (or their 
legal representative, or independent physician, or other according to local regulatory 
requirements) will be informed verbally about the study schedule and potential risks. They 
will also receive written information on the study. They will be given adequate time to read 
the information and sufficient opportunity to ask any questions. A patient should not enter the 
study if he/she (or his/her legal representative) has not understood the written and verbal 
information provided and/or if there is no signed and dated ICF. Patients (or their legally 
authorized representative) will have the opportunity to have any questions answered before 
signing the ICF. The person obtaining consent must address all questions raised by the patient 
or their legally authorized representative. The person obtaining consent will also sign and 
date the ICF. A copy of the written information and the signed ICF will be provided to the 
participant (or his/her legal representative), whereas the original version will be retained by 
the investigator. It is the responsibility of the investigator to ensure that the patient meets the 
study enrollment criteria. 
After informed consent has been obtained, each participant will be assigned a unique patient 
study identification number, consisting of 6 digits, 3 digits reflecting the site number 
followed by 3 digits reflecting the patient number. An IVRS supplies a patient number at 
screening and retains a unique randomization number for all patients. Once the screening 
assessments are performed (including assessment of all inclusion and exclusion criteria), data 

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have been reviewed by an investigator, and the patient is considered to be eligible (including 
the confirmatory fluid-corrected serum creatinine [see Section 13.3]), the investigator will 
contact the IVRS to randomly assign the patient a treatment number through IVRS. Reasons 
for screen failure of patients with an allocated patient number will be recorded in the IVRS 
system. The assessments performed before randomization during screening, and after 
randomization at baseline and on Day 1 are listed in the Schedule of Assessments presented 
in Section 13.1 (Table 13-1) and the Flowchart of Assessments is presented in Section 13.2 
(Figure 13-1). 
6.1.2 Day 1 to Day 3: Treatment Days 
Study drug will be administered on Day 1, as soon as possible when criteria are met, 
immediately after confirmation of continuing (i.e., not resolving) AKI either by a 
fluid-corrected serum creatinine assessment (see Section 13.3) or by assessment of 
continuation of decreased urine output. Treatment must be administered as soon as possible 
and within 24 hours, at the latest, after first meeting the criteria of SA-AKI.  
Study drug will also be administered on Days 2 and 3 at 24 ± 1 hour after the previous 
administration. Exact administration clock times will be recorded. 
The assessments performed from Day 1 to Day 3 are listed in Sections 6.2.3 to 6.2.5 and in 
the Schedule of Assessments presented in Section 13.1 (Table 13-1) and the Flowchart of 
Assessments is presented in Section 13.2 (Figure 13-1). 
6.1.3 Day 4 to Day 28: Assessments and Procedures 
Assessments and procedures to be performed from Day 4 to Day 28 are listed in 
Sections 6.2.3 to 6.2.5 and in the Schedule of Assessments presented in Section 13.1 
(Table 13-1) and the Flowchart of Assessments is presented in Section 13.2 (Figure 13-1). 
Day 28 is considered end of study. 
6.1.4 Days 60 and 90: Follow-up Assessments and Procedures 
Assessments and procedures to be performed at follow-up are listed in Sections 6.2.3 to 6.2.5 
and in the Schedule of Assessments presented in Section 13.1 (Table 13-1) and the Flowchart 
of Assessments is presented in Section 13.2 (Figure 13-1). 

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6.2 Study Assessments 
6.2.1 Screening Assessments 
Patients with AKI and a suspected or proven bacterial-induced sepsis might be considered to 
be enrolled in the study. 
The following assessments and procedures will be performed during screening: 
 AKI diagnosis and record site of infection and pathogen, if known 
 Inclusion and exclusion criteria 
 Signature of the ICF by the patient, or his/her legal representative, or independent 
physician, or other according to local regulatory requirements 
 In case of liver disease, Child-Pugh score to exclude chronic liver disease (score of 10 to 
15 [Class C]) 
 Pregnancy test (urine or blood) performed by local laboratory 
 Collection of recent microbial test results, if available 
 Collection of demographics and medical history 
 Collection of recent hematology and clinical chemistry results, if available 
 Verification that no concomitant medications that should be avoided are taken 
 Shortly prior to randomization and study drug administration, a confirmatory 
fluid-corrected serum creatinine sample or confirmatory assessment of continuation of 
decreased urine output (see Section 13.3) 
 When the diagnosis of AKI is made according to one of the AKIN serum creatinine 
criteria (absolute or relative increase, see inclusion criteria 5a and 5b), patients will be 
eligible for the study and can be randomly assigned when the fluid-corrected 
confirmatory serum creatinine sample, confirms the continuation of AKI according to the 
AKIN criteria for serum creatinine defined as no decrease in serum creatinine 
≥ 26.2 µmol/L (≥ 0.3 mg/dL). When the AKI diagnosis is made according to the AKIN 
urine output criteria (urinary output < 0.5 mL/kg/h for > 6 hours, see inclusion criterion 
5c), the oliguria or anuria should still meet the minimum AKIN urine output criterion 
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6.2.2 Baseline Assessments 
The following assessments will be performed at baseline after randomization (i.e., at study 
inclusion, not necessarily at ICU or intermediate care unit admission date): 
 Vital signs (temperature, heart rate, respiratory rate, oxygen saturation, and blood 
pressure) 
 Physical examination 
 12-lead electrocardiogram (ECG) 
 Acute Physiology And Chronic Health Evaluation II (APACHE II) score 
 Simplified Acute Physiology Score 2 (SAPS-2) score 
 Sequential Organ Failure Assessment (SOFA) score 
 Quality of life questionnaire (EQ-5D) 
 Urine collection during 6 ± 1 hour period with registration of exact time of collection and 
determination of urine volume (only required when possible within the 24-hour time 
window from first AKI diagnosis to treatment) 
 Local laboratory assessments  
o Hematology 
o Clinical chemistry, excluding AP activity 
o Note: Platelets, bilirubin, creatinine, and urine output are required to obtain a SOFA 
score. 
 Central laboratory  
o Tubular injury biomarkers (e.g., KIM-1, IL-18, GST-alpha) in urine 
o Biomarkers for systemic inflammation (e.g., IL-6, CRP, LBP) in plasma/serum 
o Kidney function markers (e.g., urine and serum creatinine, BUN/urea clearance, 
sodium, proteinuria, fractional excretion of sodium and urea, and urine output) 
o Serology (immunoglobulin G [IgG], IgE, and total immunoglobulin) in 
plasma/serum 
o Anti-drug antibodies in plasma/serum 

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o AP activity (pre-dose) in plasma/serum 
 For patients who are ventilated:  
o Non-mechanical ventilation: non-rebreathing mask, or nasal oxygen delivery (liters 
of oxygen/min, estimated daily average) 
o Mechanical ventilation (non-invasive and invasive): 
 Arterial partial oxygen pressure (PaO2) (estimated daily average) 
 Fraction of inspired oxygen (FiO2) and positive end-expiratory pressure 
(PEEP) (estimated daily average) 
 Tidal volume (estimated daily average) for invasive mechanical ventilation 
only, and  
 To enable calculation of P/F ratio: PaO2 and FiO2 must be captured at the 
same time point. Only one simultaneous measurement will be used. In case of 
multiple measurements of this fraction the worst value must be used. 
 Concomitant medication 
 Recording start and stop date, name, and mean daily dose of vasopressor and inotropic 
therapy for determination of shock-free days 
 Time from first diagnosis of SA-AKI to start of recAP treatment 
All screening and baseline assessments have to be performed within 24 hours from the first 
diagnosis of SA-AKI to first infusion of study drug. 
6.2.3 Efficacy Assessments 
The following assessments will be considered as efficacy measurements. 
 Urine volume, urinary creatinine, and the average of two serum creatinine measurements 
will be used for the calculation of time-corrected endogenous creatinine clearance at all 
visits from baseline to Day 7, and will be calculated by the central laboratory. The 
measurements from Day 1 to Day 7, inclusive, will be used to calculate the primary 
endpoint. Only if reliable urine collection is possible, urine will be collected on Days 14, 
21, and 28 for time-corrected endogenous creatinine clearance calculation (i.e., patient is 
in the ICU or intermediate care unit or hospital). If reliable urine collection is not 
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 Urine volume collection in a 6 ± 1 hour collection period at baseline and at all visits from 
Day 1 to Day 28, but only required if reliable urine collection is possible (i.e., patient is 
in the ICU or intermediate care unit or hospital) 
 BUN clearance at all visits from Day 1 to Day 7.  
 Urinary urea at baseline and at all visits from Day 1 to Day 28, only if reliable urine 
collection is possible (i.e., patient is in the ICU or intermediate care unit or hospital)  
 Fractional excretion of sodium at all visits from baseline to Day 7 
 Fractional excretion of urea at all visits from baseline to Day 7 
 Proteinuria at baseline and at all visits from Day 1 to Day 90 
 Tubular injury biomarkers, KIM-1, IL-18 and GST-alpha, in urine at baseline and at all 
visits from Day 1 to Day 28 
 Serum creatinine at baseline and at all visits from Day 1 to Day 90 
 Serum BUN at baseline and at all visits from Day 1 to Day 28. 
 Systemic inflammatory serum biomarkers, e.g., IL-6, CRP, LBP, at baseline and at all 
visits from Day 1 to Day 28 
 RRT incidence, considered as the key secondary endpoint, during the study period Day 1 
to Day 28 
 RRT duration, during the study period Day 1 to Day 28 
 Incidence of dialysis dependency on Day 60 and Day 90 
 SOFA score results at baseline, at all visits from Day 1 to Day 28 (when patient is in the 
ICU or intermediate care unit), and on the day of ICU or intermediate care unit discharge 
if discharged on a non-visit day. Note that platelets, bilirubin, creatinine and urine output 
are required to obtain a SOFA score. 
 Quality of life, EQ-5D questionnaire at baseline, at ICU or intermediate care unit 
discharge, and Day 90 
 Recording start and stop date, name, and mean daily dose of vasopressor and inotropic 
therapy for determination of shock-free days, at baseline and at all visits from Day 1 to 
Day 28, only required when patient is in the ICU or intermediate care unit  

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 Length of hospital and ICU or intermediate care unit stay by recording actual admission 
dates and both planned and actual discharge dates from the ICU or intermediate care unit 
and hospital (planned meaning when decision is taken to discharge the patient, not 
necessarily being the same as the actual discharge date, e.g., because of lack of beds on 
the regular ward) 
6.2.4 Safety Assessments 
The following assessments will be considered safety measurements: 
 Vital signs, including blood pressure, heart rate, oxygen saturation, respiratory rate, and 
body temperature at baseline and at all visits from Day 1 to Day 28. During the 3 dosing 
days (Day 1 to Day 3), repeated vital sign measurements will be performed (see 
Section 6.3.4). 
 Physical examination at baseline and at all visits from Day 1 to Day 28 
 12-lead ECG at baseline and at visits on Days 3 and 14 
 Local laboratory at baseline and at visits on Days 1, 3, 5, 7, 14, 21, and 28: 
o Hematology 
o Clinical chemistry, including liver function parameters (aspartate aminotransferase 
[AST], alanine aminotransferase [ALT], gamma-glutamyl transpeptidase [GGT] 
lactate dehydrogenase [LDH], and bilirubin; excluding AP) 
 Serology (IgG, IgE and total immunoglobulin) at baseline and at visits on Days 14 and 28 
 Anti-drug antibodies at baseline and at visits on Days 14, 28, 60, and 90. Samples taken 
on Days 60 and 90 will only be analyzed in case of a positive result on Day 28 
 Concomitant medication at screening, baseline, and all visits from Day 1 to Day 28 
 AEs during the duration of the study (see Section 6.3.14) 
 Mortality (monitored continuously throughout the study) 

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6.2.5 Exploratory Assessments 
The following assessments will be considered as exploratory measurements: 
 PK analyses performed at all visits from Day 1 to Day 7 (inclusive) in the first 
120 patients from Part 1 only 
 Lung function. The following must be recorded during the study: 
o Ventilation modality (e.g., non-rebreathing mask, non-invasive mechanical 
ventilation, invasive mechanical ventilation) and start and stop dates 
o Non-mechanical ventilation: non-rebreathing mask, or nasal oxygen delivery (liters 
of oxygen/min, estimated daily average) 
o Mechanical ventilation (non-invasive and invasive): 
 Arterial PaO2 (estimated daily average) 
 FiO2 and PEEP (estimated daily average) 
 Tidal volume (estimated daily average) for invasive mechanical ventilation 
only 
 To enable calculation of P/F ratio: PaO2 and FiO2 must be captured at the 
same time point. Only one simultaneous measurement will be used. In case of 
multiple measurements of this fraction the worst value must be used. 
6.3 Study Procedures 
The investigator or designee will determine and document in a timely manner if abnormal 
outcomes (e.g., abnormalities on physical examination, vital signs, or laboratory parameters) 
are clinically significant. Details of AE reporting are provided in Section 6.3.14.3. 
6.3.1 Demographics and Medical History 
Demographics and medical history should be recorded at baseline (see Section 13.1 
[Table 13-1] and Section 13.2 [Figure 13-1]). Height will be collected at baseline for 
calculation of body mass index (BMI; body weight (kg) / [height (m)]2). 
Medical history should be recorded with special emphasis for pre-existent renal disease and 
the use of immunosuppressant medication, steroids, and nephrotoxic drugs. The medical 

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history must be documented in the patient’s chart and also recorded on the appropriate page 
of the eCRF. 
6.3.2 Site of Infection and Pathogen 
The location and identification of the pathogen causing the septic condition of the patient will 
be recorded at screening, if available (see Section 13.1 [Table 13-1] and Section 13.2 
[Figure 13-1]). 
6.3.3 Physical Examination 
A complete physical examination will be performed at baseline and at all subsequent visits up 
to the Day 28 visit (see Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). Results 
obtained with hand-held echography equipment may be included. 
The physical examination should be performed by a physician or another study team member 
with appropriate training to perform the examination. 
6.3.4 Vital Signs 
Vital signs, including temperature, heart rate, oxygen saturation, respiratory rate and blood 
pressure, will be measured at baseline, and at all subsequent visits from Day 1 to Day 28 (see 
Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). Vital signs in ambulant patients 
will be measured with the patient in a sitting position and after 5 minutes rest. Blood pressure 
will be monitored non-invasively. In patients who already have an arterial line placed as part 
of standard of care, readings from invasive blood pressure monitoring are to be recorded. 
On visit days when study drug is administered (Days 1, 2 and 3), vital signs (excluding 
temperature) will be measured and recorded as follows: 
 Immediately before the administration of the study drug 
 Within 5 minutes of the start of the study drug infusion 
 30 minutes after the start of the study drug infusion  
 Immediately after the completion of the administration of the study drug, which includes 
post-dose saline flushing 
 30 and 60 minutes after completion of study drug administration 

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Additionally, on Day 1 only, vital signs will be measured and recorded as follows:  
 2 hours, 3 hours, 4 hours, and 5 hours after completion of study drug administration 
At all other visits, the vital signs can be assessed at any moment during the day. The time at 
which vital signs have been measured will be recorded in the eCRF. 
6.3.5 Weight 
For determination of study drug dosage, body weight (in kg or lb) will be estimated or 
measured. The hospital admission weight (in kg or lb) will be used for study drug preparation 
and for calculation of fluid-corrected serum creatinine.  
6.3.6 12-Lead Electrocardiogram 
A 12-lead ECG will be performed at baseline, Day 3, and Day 14 (see Section 13.1 
[Table 13-1] and Section 13.2 [Figure 13-1]).  
A 12-lead ECG with at least a 30-second rhythm strip will be recorded after the patient has 
rested supine or semi-recumbent for at least 5 minutes. The recording should be printed, 
signed, and dated by the investigator (or designee) and retained as source documentation. The 
ECG print should include the date and time of the assessment and the patient’s study number. 
The interpretation of the investigator or designee will be recorded in the source documents. 
6.3.7 Laboratory Tests Performed by the Local Laboratory 
Blood samples will be collected for local laboratory measurements at baseline, and at visits 
on Days 1, 3, 5, 7, 14, 21, and 28 (see Section 13.1 [Table 13-1] and Section 13.2 
[Figure 13-1]). Approximately 178 to 208 mL (35 to 42 teaspoons) of blood will be collected 
per patient in total during the study, including tests performed in the local and in the central 
laboratories. 
To decide when to stop RRT (see Section 6.3.9), local urine creatinine, urine volume, and 
serum creatinine samples will be taken and the creatinine clearance calculated. This will be 
based on local laboratory results.  
The following laboratory tests should be performed at the visits indicated above, unless 
otherwise indicated: 

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Clinical chemistry: CRP, ALT, AST, GGT, urea, LDH, creatinine, bilirubin, creatine 
phosphokinase, total protein, albumin, glucose, sodium, potassium, chloride, bicarbonate, 
and lactate. 
Note: AP is not allowed to be measured locally until Day 14 (see Section 6.3.8.2). 
Hematology: hemoglobin, hematocrit, leukocytes, differential leukocytes, erythrocytes, 
thrombocytes, activated partial thromboplastin time. 
Pregnancy test: only at baseline. Blood human chorionic gonadotropin (hCG) or urine hCG 
(dipstick). See Section 6.4 for additional details. 
When the diagnosis of AKI was made according to one of the AKIN serum creatinine criteria 
(absolute or relative increase, see inclusion criteria 5a and 5b), the confirmative 
fluid-corrected serum creatinine sample with results available prior to randomization and 
prior to study drug administration is to confirm continuation of AKI.  
Note that platelets, bilirubin, creatinine, and urine output are required to obtain a SOFA 
score. 
6.3.8 Laboratory Tests Performed by Central Laboratory 
Blood and urine samples for laboratory tests at baseline and at visits from Day 1 to Day 90 as 
shown in Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1] will be collected and 
forwarded to the central laboratory for analysis. Samples will be processed, stored (if 
necessary), and shipped according to the instructions provided in the central laboratory 
manual. 
Serum and urine samples for creatinine, urea, proteinuria, AP activity (baseline), sodium, 
tubular injury biomarkers, purines, systemic markers for inflammation, PK, serology, and 
anti-drug antibodies will be collected and shipped to the central laboratory.  
For selected sites only, detailed instructions for iohexol and related measurements are 
provided in Section 13.5 (Appendix 5). 

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6.3.8.1 Endogenous Creatinine and Blood Urea Nitrogen Clearance 
The efficacy of the treatment will be investigated by calculating the time-corrected 
endogenous creatinine clearance. Blood urea nitrogen clearance will also be measured. To 
calculate the time-corrected endogenous creatinine clearance, timed urine (including 
measurement of volume) and blood samples need to be collected.  
Urine and serum creatinine samples will be collected at all visits from baseline to Day 7 and 
shipped to the central laboratory. Two serum creatinine samples, one right before the start 
and one after the stop of the 6 ± 1 hour urine collections have to be collected. Urine volume, 
urinary creatinine, and the average of two serum creatinine measurements will be used for 
the calculation of time corrected endogenous creatinine clearance at all visits from baseline 
to Day 7, and will be calculated by the central laboratory. The measurements from Day 1 to 
Day 7, inclusive, will be used to calculate endogenous creatinine clearance, the primary 
endpoint. Only if reliable urine collection is possible, urine will be collected on Days 14, 21, 
and 28 for time-corrected endogenous creatinine clearance (i.e., patient is in the ICU or 
intermediate care unit or hospital). If reliable urine collection is not possible, one serum 
creatinine sample still needs to be taken for calculating eGFR (see Section 13.1 [Table 13-1] 
and Section 13.2 [Figure 13-1]). 
Urine must be collected daily for a period of 6 ± 1 hour at baseline and from Day 1 to 
Day 7.The collection period will take a minimum of 5 hours, and a maximum of 7 hours. The 
exact duration of urine collection period and of volume collected will be recorded in the 
eCRF. The volume should be corrected to account for the volume of samples previously 
taken from the total urine initially collected. 
Endogenous creatinine and BUN clearance will be calculated as follows: 
clearance = (urine volume × concentration in urine) / concentration in serum 
Note: when patients during the study leave the ICU or intermediate care unit, but are still in 
the hospital, attempts should be made to continue with the 6-hour urine collection. If the 
patient is discharged from the ICU or intermediate care unit, the Foley catheter might be 
removed. In this case, a patient might urinate spontaneously and all efforts should be 
undertaken to start collecting urine produced from this time point onward. Approximately 6 
hours later (exact duration needs to be recorded) the patient might urinate again and this 

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urine will be used for analysis, a blood sample will be drawn at this time too. The urine 
volume produced over the last approximately 6 hours will be entered in the eCRF. When 
patients are discharged from the hospital, 6-hour urine collection at home is not considered 
feasible or reliable and, thus, will not be performed. 
6.3.8.2 Alkaline Phosphatase Activity 
Alkaline phosphatase activity will only be measured at baseline (pre-dose). Alkaline 
phosphatase activity results from blood samples taken during the first 14 days of the study 
are not to be reported to the study team members or to any other study staff member involved 
in the conduct of the study as it could lead to unblinding and to erroneous interpretation of 
liver function, as the recAP administered will increase the AP activity (see Section 5.6). 
6.3.8.3 Pharmacokinetic Assessments 
Pharmacokinetic assessments will be performed during Part 1 only. 
The following PK samples will be taken from Day 1 to Day 7 (inclusive) in the first 
120 patients from Part 1 only and exact sampling clock times will be recorded: 
 Day 1: One pre-dose sample and one post-dose sample near peak (approximately 
2.5 ± 1.0 hour after dosing). 
 Day 2: One sample near trough (1.5 ± 1 hour before the second dose) and one sample 
near peak (approximately 2.5 ± 1.0 hour after Day 2 dosing).* 
 Day 3: One sample near trough (1.5 ± 1 hour before the third dose) and one sample near 
peak (approximately 2.5 ± 1.0 hour after Day 3 dosing).* 
 Day 4: One PK sample, random time. 
 Day 5: One PK sample, random time. 
 Day 6: One PK sample, random time. 
 Day 7: One PK sample, random time. 

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6.3.8.4 Immunogenicity Assessments 
The following immunogenicity assessments will be performed: 
 IgG, IgE, and total immunoglobulin 
 Anti-drug antibodies 
Blood samples for IgG, IgE, and total immunoglobulin assessment will be taken at baseline 
and on Days 14 and 28 (see Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]).  
Blood samples for anti-drug antibodies assessment will be taken at baseline and on Days 14, 
28, 60, and 90 (see Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). Samples taken 
on Days 60 and 90 will only be analyzed in case of a positive result on Day 28; however, as 
the results for Day 28 will not be available before Day 60, blood samples for anti-drug 
antibodies will be taken from all patients on Days 60 and 90. In case the results are negative 
on Day 14 and Day 28, samples taken on Days 60 and 90 will not be analyzed. 
Assays for the determination of levels of circulating recAP (Section 6.3.8.3) and anti-drug 
antibodies were previously qualified in normal human serum samples according to validation 
procedures and acceptance of the Food and Drug Administration (FDA) Guidance for 
Industry, EMA guidelines and ICH guidelines for use in Phase 1 clinical trial (DHHS 2001, 
DeSilva et al 2003; EMA 2006; Neyer et al 2006; Shankar et al 2006; Viswanathan et al 
2007; EMA 2007; EMA 2009; EMA 2011; ICH 2011). Additional qualification studies for 
both assays have been successfully completed in serum from sepsis patients under study plan 
AMF2013EL-14213-A for the determination of levels of circulating recAP and study plan 
AMF2013EL-14213-C for the determination of anti-drug antibodies, to support the use of the 
assays in the Phase 2 clinical study (AP-recAP-AKI-02-01). 
6.3.8.5 Biomarker Assessments 
Kidney function markers (e.g., urine and serum creatinine, BUN/urea clearance, sodium, 
proteinuria, fractional excretion of sodium and urea, and urine output), tubular injury 
biomarkers (e.g., KIM-1, IL-18, GST-alpha), and biomarkers for systemic inflammation (e.g., 
IL-6, CRP, LBP) will be measured during the duration of the study. Blood and urine samples 
will be collected at baseline, and at all visits from Day 1 to Day 28 (see Section 13.1 
[Table 13-1] and Section 13.2 [Figure 13-1]). 

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Blood samples will be collected for the systemic inflammatory biomarkers: e.g., Il-6, CRP, 
and LBP. 
Urine samples will be collected for the renal damage biomarkers: KIM-1, IL-18 and 
GST-alpha. 
Any blood and urine samples not used for the biomarker assessments described will be stored 
by the central laboratory for a maximum of 1 year after the finalization of the study report to 
be possibly analyzed in an exploratory manner, in case new biomarkers are developed during 
the conduct of the study. 
6.3.8.6 Pharmacodynamic Assessments 
For a limited number of sites only, a urine sample for PD assessment will be taken from the 
6 ± 1 hour urine collection see Section 13.5 (Appendix 5).  
6.3.8.7 Glomerular Filtration Rate 
A limited number of sites only will simultaneously determine GFR with iohexol 
administration and blood sampling (considered the golden standard) to globally compare and 
assess correlation of GFR and calculated endogenous creatinine clearance. In addition, at 
these sites samples from the effluent from patients on RRT will be taken to assess exogenous 
(machine) creatinine clearance. Detailed instructions to these sites for iohexol and exogenous 
creatinine clearance are provided in Section 13.5. 
6.3.9 Renal Replacement Therapy 
From Day 1 to Day 7 only continuous modalities of RRT are allowed. From Day 8 onward, 
intermittent/non-continuous modalities such as intermittent hemodialysis are allowed. 
Initiation of RRT: Initiation of RRT should be based on the criteria described by Bellomo 
et al (2012). 
Meeting at least one criterion of the below makes the patient eligible for initiation of RRT: 
1. Anuria (negligible urine output for 6 hours) 
2. Severe oliguria (urine output < 200 mL over 12 hours) 
3. Hyperkalemia (potassium concentrations > 6.5 mmol/L) 
4. Severe metabolic acidosis (pH < 7.2 despite normal or low partial pressure of carbon 
dioxide in arterial blood) 

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5. Volume overload (especially pulmonary edema unresponsive to diuretics) 
6. Pronounced azotemia (urea concentrations > 30 mmol/L or creatinine concentrations 
> 300 µmol/L) 
7. Clinical complications of uremia (e.g., encephalopathy, pericarditis, neuropathy) 
Timing of Stopping RRT: Termination of dialysis is based on criteria as used in the VA/NIH 
Acute Renal Failure Trial Network Study (VA/NIH Acute Renal Failure Trial Network, 
2008). If (on continuous renal replacement therapy or between intermittent hemodialysis 
sessions) diuresis > 30 mL/hour and there are no other indications for RRT, then endogenous 
creatinine clearance should be calculated using a 6-hour urine collection period. If 
endogenous creatinine clearance ≥ 20 mL/min, RRT should be discontinued. If endogenous 
creatinine clearance ≤ 12 mL/min, RRT should be continued. If endogenous creatinine 
clearance > 12 mL/min and < 20 mL/min, continuation or termination will be the decision of 
the treating physician. Exact criterion or criteria, corresponding values (e.g., sodium, 
potassium, or pH) and deviations (e.g., RRT not started when indicated or RRT started when 
not indicated) need to be meticulously recorded in the eCRF. 
However, although the criteria for starting and stopping mentioned above are strongly 
preferred within the protocol setting, based on clinical judgment investigators may deviate 
from these criteria. For example, several individual criteria might just not meet the required 
threshold, but together could provide a valid clinical reason to start RRT. It is also possible 
that an investigator decides not to initiate RRT based on clinical judgment, although starting 
criteria might be met. When RRT is initiated despite not meeting criteria, or when RRT is not 
initiated despite meeting criteria, this should be recorded and a reason for the clinical 
decision should be provided in the eCRF. Similarly, deviations from the protocol-defined 
stopping criteria, should be recorded in the CRF, together with the reason for the deviation. A 
worksheet will be provided as source to record decisions on initiation and termination RRT 
and deviations. 
The following data will be collected in the eCRF: 
 Requirement for RRT (over study period): RRT initiated (yes or no) 
 Duration of RRT: Exact initiation and termination dates, times of dialysis, and reasons to 
initiate and terminate RRT. Temporary stopping of RRT need not be recorded (e.g., for 
filter failures or procedures requiring transportation such as computed tomography scan 
or others) 
 Incidence of dialysis dependency at Day 60 and Day 90. 

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6.3.10 Lung Function Assessments 
Method of ventilation, e.g., non-rebreathing mask, non-invasive mechanical ventilation, 
invasive mechanical ventilation, will be recorded in the eCRF.  
Details on mechanical ventilation will be measured to assess the patient’s dependency on 
mechanical ventilation. 
If the patient requires mechanical ventilation (invasive or non-invasive), the start and stop 
day and time will be recorded in the eCRF in order to calculate the number of days in which 
mechanical ventilation is needed. If modes of mechanical ventilation are changed (e.g. 
invasive mechanical ventilation is replaced with non-invasive continuous positive airway 
pressure (CPAP), a new eCRF page needs to be completed for new mode of mechanical 
ventilation. 
During mechanical ventilation, arterial PaO2, FiO2, and PEEP, and during invasive 
mechanical ventilation only tidal volume will be captured as estimated daily averages at 
baseline and at all visits from Day 1 to Day 28 (see Section 13.1 [Table 13-1] and 
Section 13.2 [Figure 13-1]).  
The fraction PaO2 /FiO2 will be measured to assess the degree of severity of lung function 
damage. Fraction PaO2/FiO2 will be calculated based on values which must be captured at 
the same time point. Only one simultaneous measurement will be used (i.e., do not use daily 
average). In case of multiple measurements of this fraction the worst value must be used. 
6.3.11 Scoring Systems 
6.3.11.1 
Acute Physiology and Chronic Health Evaluation Score 
The APACHE II score is a severity-of-disease classification system, used in ICU or 
intermediate care unit settings. The score from 0 to 71 is computed on 12 physiological 
measurements. The higher the score the more severe the disease and higher the risk of death. 
The APACHE II score will be assessed at baseline (i.e., not necessarily at ICU or 
intermediate care unit admission) and recorded in the eCRF. 

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6.3.11.2 
Simplified Acute Physiology Score 2 
The SAPS-2 score is another severity-to-disease classification system, based upon 
17 variables, including 12 physiological parameters. 
The SAPS-2 score will be assessed at baseline and recorded in the eCRF. 
6.3.11.3 
Sequential Organ Failure Assessment Score 
The SOFA score provides a tool to quantify the severity of the patient’s illness, based on the 
degree of organ dysfunction. The SOFA score is used to follow the condition of the patients 
in terms of organ failure over time.  
The SOFA score will be assessed at baseline, and at all planned visits from Day 1 to Day 28 
(as long as the patient is in the ICU or intermediate care unit ) and at discharge from ICU or 
intermediate care unit (see Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). Results 
will be recorded in the eCRF. Note that platelets, bilirubin, creatinine, and urine output are 
required to obtain a SOFA score. 
6.3.11.4 
Quality of Life 
The EQ-5D questionnaires will be performed at baseline, at discharge from ICU or 
intermediate care unit, and at Day 90 (see Section 13.1 [Table 13-1] and Section 13.2 
[Figure 13-1]). 
The EQ-5D covers 5 dimensions of general well-being. The questionnaire consists of 1 page 
with 5 questions and 1 page with an analog scale. The questionnaire should be completed by 
the patient. If the patient is not able to complete the questionnaire himself or herself (e.g., at 
baseline), it can be completed by a relative. 
6.3.12 Concomitant Medication 
Concomitant medication will be checked at each visit and recorded in the eCRF. 
Concomitant medication will be recorded at screening (verification that no concomitant 
medications that should be avoided are taken), and from baseline up to Day 28, inclusive (see 
Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). 

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For continuously intravenously administered medication (e.g., insulin, vasopressors, 
inotropics, diuretics, sedatives, metoprolol, and potassium), only the name, estimated mean 
daily dose or mean daily dose as calculated by the system will be recorded, and stop and start 
dates should be recorded in the eCRF for those patients who are in the ICU or intermediate 
care unit (see Section 5.7). 
6.3.13 Other Collected Data 
The following data will also be collected during the study: 
Number of shock-free days: measured with dates and times of treatment with inotropic 
agents or vasopressors – day and hour 
Length of ICU or intermediate care unit stay: the admission date and planned and actual 
discharge date of the patient will be recorded. 
Length of hospital stay: the admission date and planned and actual discharge date of the 
patient will be recorded. Reason for hospitalization will also be recorded. 
6.3.14 Adverse Events 
The investigator is responsible for reporting all treatment-emergent AEs (TEAEs) that are 
observed or reported during the study, regardless of their relationship to study drug or their 
clinical significance.  
6.3.14.1 
Definitions of Adverse Events 
An AE is defined as any untoward medical occurrence (e.g., symptom, sign, diagnosis or 
diagnostic test finding) in a patient enrolled into a clinical study regardless of its causal 
relationship to study drug.  
A TEAE is defined as any event not present before exposure to study drug or any event 
already present that worsens in either intensity or frequency after exposure to study drug. 
An SAE is defined as any event that results in death, is immediately life threatening, requires 
inpatient hospitalization or prolongation of existing hospitalization, results in persistent or 
significant disability/incapacity, or is a congenital anomaly/birth defect. Important medical 
events that may not result in death, be life threatening, or require hospitalization may be 

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considered SAEs when, based upon appropriate medical judgment, they may jeopardize the 
patient or may require medical or surgical intervention to prevent one of the outcomes listed 
in this definition. Medical and scientific judgment should be exercised in deciding whether 
expedited reporting is appropriate in other situations, such as important medical events that 
may not be immediately life threatening or result in death or hospitalization but may 
jeopardize the patient or may require intervention to prevent one of the other outcomes listed 
in the aforementioned definition. These should also be considered serious. A death occurring 
during the study or which comes to the attention of the investigator until Day 28 visit, 
whether considered treatment related or not, must be reported as an SAE. In the event of an 
SAE the investigator may immediately stop treatment (during the treatment phase, i.e., the 
first 3 days of the study) if it is considered in the best interest of the patient. In case study 
drug is discontinued early, the patient will continue follow-up in the study as per protocol. If 
interrupted for any reason, re-starting of study drug should be discussed with the Medical 
Monitor (see Section 4.2.1). 
Any medical condition that is present at the time that the patient is screened but does not 
deteriorate should not be reported as an AE. However, if the medical condition deteriorates at 
any time during the study, it should be recorded as an AE. 
6.3.14.2 
Eliciting and Documenting Adverse Events 
Adverse events will be collected and assessed from the time the patient signs the ICF until 
Day 28 visit for all AEs (including SAEs) regardless of its relationship to study drug. Any AE 
that occurs during or after the first dose of study drug is considered treatment emergent. 
At every study visit, patients will be asked a standard non-leading question to elicit any 
medically related changes in their well-being. At follow-up visits, they will also be asked if 
they have been admitted to the hospital, had any accidents, used any new medications, or 
changed concomitant medication regimens. 
When patients have left the hospital they will be instructed to contact the investigator at any 
time if any symptoms develop. 
Adverse events and SAEs that occur after Day 28 visit, will be reported to PPD or sponsor, 
only if the investigator considers them possibly, probably, or definitely related to study drug. 

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In addition to patient accounts, AEs will be identified through physical examination, review 
of laboratory values, diagnostic test findings (Section 6.5) and monitoring in the ICU/ 
healthcare facility and (if relevant) report from carers.. 
6.3.14.3 
Reporting Adverse Events 
All AEs reported or observed after the patient signs the ICF until Day 28 visit will be 
recorded on the AE page of the eCRF. Information to be collected includes event term, time 
of onset, investigator-specified assessment of severity and relationship to study drug, date of 
resolution of the event, seriousness, any required treatment or evaluations, and outcome. 
Adverse events resulting from concurrent illnesses, reactions to concurrent illnesses, 
reactions to concurrent medications, or progression of disease states must also be reported. 
All AEs will be followed to adequate resolution. The Medical Dictionary for Regulatory 
Activities (MedDRA) will be used to code all AEs. 
Any AE that meets SAE criteria (see Section 6.3.14.1) must be reported to the PPD 
Pharmacovigilance Department immediately (i.e., within 24 hours) after the time site staff 
first learn about the event. The following contact information is to be used for SAE reporting: 
 
PPD Pharmacovigilance Department 
 
SAE Hotline United States:  
1-888-483-7729 
 
SAE Fax line United States:  
1-888-529-3580 
 
SAE Hotline European Union: 
+44 (0) 1223374240 
 
SAE Fax line European Union: 
+44 (0) 1223374102 
6.3.14.4 
Assessment of Severity 
The severity of an AE refers to the extent to which an AE affects the patient’s daily activities. 
The severity of the AE will be rated as mild, moderate, or severe using the following criteria: 
Mild: 
These events require minimal or no treatment and do not interfere with the 
patient’s daily activities. 
Moderate: 
These events are sufficiently discomforting to interfere with normal activities. 
Severe: 
These events interrupt a patient’s usual daily activity and may require systemic 
drug therapy or other treatment. Severe events are usually incapacitating. 

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When changes in the severity of an AE occur more frequently than once a day, the maximum 
severity for the event should be noted for that day. Any change in severity of signs and 
symptoms over a number of days will be captured by recording a new AE, with the amended 
severity grade and the date (and time, if known) of the change. Changes in the severity of an 
AE should be documented to allow an assessment of the duration of the event at each level of 
intensity to be performed.  
6.3.14.5 
Assessment of Causality 
The assessment of the relationship of an AE to the administration of study drug (unrelated, 
possible, probable, definite) is a clinical decision based on all available information at the 
time of completion of the eCRF. As per the International Council for Harmonisation 
harmonised tripartite guideline E6(R1): Good Clinical Practice (ICH E6[R1]) guidelines, 
factors to be considered include the following:  
 Temporal sequence from drug administration: the event must occur after the study drug is 
given. The length of time from exposure to medication to event should be evaluated in 
the clinical context of the event. 
 Recovery on discontinuation (dechallenge) and recurrence on reintroduction 
(rechallenge). 
 Underlying, concomitant, intercurrent diseases: each report should be evaluated in the 
context of the natural history and course of the disease being treated and any other 
disease the patient may have had prior to, or developed during the course of the study. 
 Concomitant medication or treatment: the other drugs the patient is taking or the 
treatment the patient is receiving at the time of the event should be examined to 
determine whether any of them may be recognized to cause the event in question. 
 The pharmacology and PK of the study drug: absorption, distribution, metabolism, and 
excretion of the study drug or other medications the patient is receiving coupled with the 
PD responses should be considered when evaluating an event. 
The investigator’s assessment of an AE’s relationship to study drug is part of the 
documentation process. If there is any doubt as to whether a clinical observation is an AE or 
whether it is related to study drug, the event should be reported.  

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The relationship or association of the study drug in causing or contributing to the AE will be 
characterized using the following classification and criteria: 
Unrelated: 
This relationship suggests that there is no association between the study drug 
and the reported event. 
Possible: 
This relationship suggests that treatment with the study drug caused or 
contributed to the AE; i.e., the event follows a reasonable temporal sequence 
from the time of drug administration or follows a known response pattern to the 
study drug, but could also have been produced by other factors. 
Probable: 
This relationship suggests that a reasonable temporal sequence of the event 
with drug administration exists and, based upon the known pharmacological 
action of the drug, known or previously reported adverse reactions to the drug 
or class of drugs, or judgment based on the investigator’s clinical experience, 
the association of the event with the study drug seems likely. The event 
disappears or decreases on cessation or reduction of the dose of study drug. 
Definite: 
This relationship suggests that a definite causal relationship exists between drug 
administration and the AE, and other conditions (concurrent illness, 
progression/expression of disease state, or concurrent medication reaction) do 
not appear to explain the event. The event reappears or worsens if the study 
drug is re-administered. 
6.3.14.6 
Follow-up of Patients Reporting Adverse Events 
All AEs must be reported in detail on the appropriate page of the eCRF and followed to 
satisfactory resolution, until the investigator deems the event to be chronic or not clinically 
significant, until the patient is considered to be stable or subject is lost to follow-up. 
6.4 Pregnancy 
The effect of recAP on pregnancies or infants is not known, as the safety of this drug during 
pregnancy has not been tested previously in either human or in animal studies. Because AP is 
present in the human placenta it is theoretically possible that anti-placental antibodies are 
developed after receiving study drug. Such antibodies could interfere with the ability to have 
a successful pregnancy. While development of anti-drug antibodies has not been seen to date 
in human studies, the safety experience with this drug is limited to only 37 subjects who 
received study drug and no data are available regarding effect of the drug on human 
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Therefore, female patients who are pregnant or lactating/breastfeeding at time of screening or 
who intend to become pregnant within 28 days of enrolling into the study will be excluded 
from the study (see Section 4.1.2). If a pregnancy occurs while a patient is participating in 
the study, it is not regarded as an AE unless there is a suspicion that an investigational 
product may have interfered with the effectiveness of a contraceptive medication. Any 
pregnancy that occurs during study participation must be reported using a clinical study 
pregnancy form. To ensure patient safety, each pregnancy must be reported to AM-Pharma 
B.V. within 2 weeks of learning of its occurrence. The pregnancy must be followed-up to 
determine outcome (including spontaneous miscarriage, elective termination, normal birth, or 
congenital abnormality) and status of mother and child, even if the patient was discontinued 
from the study. Pregnancy complications and elective terminations for medical reasons 
should not be reported as an AE or SAE. Spontaneous miscarriages must be reported as 
SAEs. 
Any SAE occurring in association with a pregnancy, brought to the investigator’s attention 
after the patient has completed the study, and considered by the investigator as possibly 
related to the study drug, must be promptly reported to AM-Pharma B.V. 
6.5 Laboratory Analyses 
Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or other 
safety assessments (e.g., ECGs, vital sign measurements), including those that worsen from 
baseline, felt to be clinically significant in the medical and scientific judgment of the 
investigator, are to be recorded as (S)AEs. 
7 Statistical and Analytical Plan 
7.1 Primary Endpoint 
The primary endpoint will be calculated from time-corrected endogenous creatinine 
clearance measurements on Day 1 (first measurement after treatment) to Day 7, inclusive. 
Time-corrected endogenous creatinine clearance is assessed on each day during a 6 ± 1 hour 
period and calculated in mL/min as the mean creatinine clearance over the period, which is 
expected to be representative of the full 24 hours for that day. The primary endpoint is the 
area under the time-corrected endogenous creatinine clearance curve from Day 1 to Day 7 
(AUC1-7), calculated as the average of the time-corrected endogenous creatinine clearance 

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values over the 7 days. Specifically, denoting 
 as the mean time-corrected endogenous 
creatinine clearance on Day , AUC1-7 is defined as: 
 
Any missing 
 values will be handled by linear interpolation where possible, otherwise they 
will be imputed by last observation carried forward (LOCF). When there are no preceding 
post-baseline measurements to use, the baseline measurement (i.e., prior to treatment) will be 
carried forward. 
7.2 Key Secondary Endpoint 
The key secondary endpoint is RRT incidence during the period Day 1 (after first treatment) 
to Day 28, inclusive. Should a patient die or withdraw from the study during this period 
without recording RRT incidence, he or she will be counted as having not required RRT. The 
analysis of this endpoint will be repeated excluding patients who died or withdrew from the 
study prior to completion of this period. 
7.3 Other Secondary Endpoints 
7.3.1 Renal 
 Renal endpoints include the following: 
 Volume of urine (daily from Day 1 to Day 7, inclusive, and on subsequent visit days if 
reliable urine collection is possible) 
 Serum creatinine and BUN (daily from Day 1 to Day 7, inclusive, and on subsequent visit 
days if reliable urine collection is possible) 
 BUN clearance (daily from Day 1 to Day 7, inclusive, and on subsequent visit days if 
reliable urine collection is possible)  
 Peak value of serum creatinine and BUN (during the period Day 1 to Day 7, inclusive) 
 RRT-free days (during the period Day 1 to Day 28 excluding patients who died or 
withdrew from the study prior to the end of this period), i.e., 28 days minus the number 
of days a patient is on RRT during this period. An RRT-free day is defined as a day on 

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which a patient did not receive any form of RRT. Conversely, a day on RRT is defined as 
a day on which a patient received any form of RRT for any period of time on that day. 
For intermittent RRT, the following additional rules apply: 
a. Following conclusion of intermittent RRT, if the patient then has a period of 
six or more days before next initiation of any form of RRT, all (six or more) 
days in this intervening period are counted as RRT-free 
b. Following conclusion of intermittent RRT, if the patient then has a period of 
five or less days before next initiation of any form of RRT, all (five or less) 
days in this intervening period are counted as on RRT 
 Total number of days on RRT (during the period Day 1 to Day 28, inclusive). A day on 
RRT is defined as a day on which a patient did receive any form of RRT for any period of 
time on that day. 
 Reasons for initiation of RRT (during the period Day 1 to Day 28, inclusive) 
 Kidney function at Day 28 as assessed by measured creatinine clearance if available, 
otherwise as assessed by eGFR (estimated by the CKD-EPI formula based on serum 
creatinine). Patients who die prior to Day 28 will be excluded from this endpoint, with 
any other missing assessments (including early withdrawals) imputed using LOCF. 
 Kidney function at Day 60 and Day 90 as assessed by eGFR (estimated by the CKD-EPI 
formula based on serum creatinine). Patients who die prior to Day 60 or Day 90, 
respectively, will be excluded from this endpoint, with any other missing assessments 
(including early withdrawals) imputed using LOCF. 
 Sustained loss of kidney function at Day 60 and Day 90, defined by eGFR < 60 mL/min 
(with eGFR estimated by the CKD-EPI formula based on serum creatinine). Patients who 
die prior to Day 60 or Day 90, respectively, will be excluded from this endpoint, with any 
other missing assessments (including early withdrawals) at Day 60 or Day 90 imputed 
using LOCF. 
 Incidence of dialysis dependency at Day 60 and Day 90. Patients who die or withdraw 
from the study prior to Day 60 or Day 90, respectively, without recording incidence of 
dialysis dependency will be counted as not having required dialysis dependency. 

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7.3.2 Other Organs 
Endpoints for organs other than renal function include the following: 
 Liver enzymes (AST, ALT, GGT, LDH, bilirubin but excluding AP). 
 Lung function as assessed by arterial PaO2, FiO2, P/F ratio, PEEP, and tidal volume in 
mechanically ventilated patients. 
 Ventilator-free days (from Day 1 to Day 28, inclusive), i.e., 28 days minus the number of 
days a patient is on ventilator during this period. Should a patient die or withdraw prior to 
Day 28, the days remaining in this period will be counted as per the status of the patient 
at time of death or withdrawal. 
 Time from start of first administration of study drug to being off-ventilator (from Day 1 
to Day 28, inclusive) for those patients who are on ventilator at the start of this period. 
Patients who remain on ventilator will be censored at the earliest of Day 28 or withdrawal 
from the study for any reason. 
 Shock-free days (during the period Day 1 to Day 28, inclusive), i.e., 28 days minus the 
number of days a patient is on inotropic or vasopressor therapy during this period. Should 
a patient die or withdraw prior to Day 28, the days remaining in this period will be 
counted as per the status of the patient at time of death or withdrawal. A patient is 
considered to be shock free if he or she is not on vasopressors or inotropic agents 
(including but not limited to noradrenaline, adrenaline, dobutamine, dopamine, 
vasopressin, and enoximone). 
 Time from start of first administration of treatment to being shock free (from Day 1 to 
Day 28, inclusive) for those patients who are not shock free at the start of this period. 
Patients who do not become shock free will be censored at the earliest of Day 28 or 
withdrawal from the study for any reason. 
 SOFA scores during ICU or intermediate care unit stay. 
 Number of dysfunctional organs as assessed by SOFA scores. 
 Deaths during the 90-day study period (by recording date). 

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7.3.3 Biomarkers 
Biomarker endpoints include the following: 
 Kidney function markers (e.g., urine and serum creatinine, BUN/urea clearance, sodium, 
proteinuria, fractional excretion of sodium, urea, and urine output).  
 Tubular injury biomarkers (e.g., KIM-1, IL 18, GST-alpha).  
 Biomarkers for systemic inflammation (e.g., IL-6, CRP, LBP).  
 Pharmacokinetics of recAP in all 3 active treatment groups in the first 120 patients from 
Part 1 only 
 In addition to recAP PK concentration measurements, baseline (pre-dose) AP will be 
measured by activity (central laboratory) 
7.3.4 Other Endpoints 
Additional endpoints include the following: 
 Composite endpoints – patients that meet, or do not meet, at least one of the following 
criteria: 
a. Received RRT or died (prior to Day 28 [inclusive]) 
b. eGFR < 60 mL/min (at Day 60, estimated by a commonly used formula such as 
MDRD or CKD-EPI), or requiring chronic RRT, or died (prior to Day 60) 
c. eGFR < 60 mL/min (at Day 90, estimated by the CKD-EPI formula based on serum 
creatinine), or requiring chronic RRT, hospitalized for a new episode of AKI (at 
Day 90), or died (prior to Day 90) 
 Serology as assessed by IgG, IgE, and total immunoglobulin  
 Safety parameters including (S)AEs, laboratory assessments (clinical chemistry, 
hematology, and urinalysis parameters not considered in the efficacy analysis), vital 
signs, and ECG data 
 Quality of life, assessed by the EQ-5D questionnaire at baseline, ICU or intermediate 
care unit discharge, and Day 90 
 Time from start of first administration of treatment to discharge from ICU or intermediate 
care unit (during the period Day 1 to Day 28, inclusive, for patients in ICU or 

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intermediate care unit at the start of this period) where discharge is defined as the time 
when the decision was made to transfer the patient (as opposed to the time of actual 
transfer) 
 Total time in ICU or intermediate care unit from the start of first administration of study 
drug (during the period Day 1 to Day 90, inclusive) using the times when the decision is 
made to admit or discharge the patient as appropriate 
 Time from start of first administration of treatment to discharge from hospital (during the 
period Day 1 to Day 90, inclusive) where discharge is defined as the time when the 
decision was made to transfer the patient (as opposed to the time of actual transfer) 
 Total time in hospital from the start of first administration of study drug (during the 
period Day 1 to Day 90, inclusive) using the times when the decision is made to admit or 
discharge the patient as appropriate 
7.4 Sample Size Calculations 
A sample size of n1 = 30 patients per treatment group in Part 1 with an additional 
n2 = 85 patients recruited to the optimal recAP dose and placebo treatment groups in Part 2 
(for a total sample size of n = 290 patients) is planned. Recruitment will continue during the 
interim analysis so the total number of patients may exceed 290 patients. Patients recruited 
during this period to the dose selected in Part 2 will form part of the Part 2 populations, but 
those recruited to the doses that are not selected will be included in the Part 1 population. 
Custom programmed simulations were performed using SAS software Version 9.2 to 
determine power and type I error rate of the chosen sample size and design under a number 
of different dose response scenarios. Each scenario assumed a standard deviation of 
49 mL/min for the primary endpoint (AUC1-7) with an assumed response of 60 mL/min for 
the placebo group, and between 60 mL/min (no treatment effect) and 79 mL/min (strong 
treatment effect) for the recAP dose groups. 
Fifty-thousand simulations were performed to show that the 1-sided type I error rate is 2.4% 
(and hence is well controlled at the 1-sided 2.5% significance level). The power was defined 
as the probability of rejecting the null hypothesis (of no difference between treatment groups) 
when 1 or more recAP dose groups have an effective treatment effect, defined as a response 
of 69.5 mL/min. This was investigated across 7 scenarios with 10 000 simulations performed 
for each. In the most realistic scenarios (with strong treatment effects, i.e., responses of 

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79 mL/min for the medium and high recAP dose groups and a varying response of between 
60 mL/min and 79 mL/min for the low-dose group) the chosen design achieved power of 
between 79% and 86%. This dropped to 66% to 67% for other scenarios where only the high 
recAP dose group had a strong treatment effect. 
7.5 Analysis Sets 
The following analysis sets will be used in the statistical analyses: 
 All enrolled set: all patients enrolled in the study. Patients will be analyzed according 
to the treatment they were randomly assigned to, with a “Not randomly assigned” 
treatment group included if required. 
 ITT combined set: all patients who were randomly assigned to a study drug. This is 
the primary analysis set for the efficacy analyses, and patients will be analyzed 
according to the treatment to which they were randomly assigned. 
 ITT Part 1 set: all patients who were randomly assigned to a study drug prior to the 
conclusion of Part 1 of the study. This analysis set will be used to compare patients 
enrolled during the different parts of the study. Patients will be analyzed according to 
the treatment they were randomly assigned to. 
 ITT Part 1 interim set:  all patients who were randomly assigned to a study drug 
prior to the conclusion of Part 1 of the study and were included in the interim 
analysis. Patients will be analyzed according to the treatment they were randomly 
assigned to. 
 ITT Part 2 set: all patients who were randomly assigned to a study drug after the 
conclusion of Part 1 of the study. This analysis set will be used to compare patients 
enrolled during the different parts of the study. Patients will be analyzed according to 
the treatment they were randomly assigned to. 
 Per-protocol (PP) Day 1-7 combined set: all patients who were randomly assigned 
to a study drug, had no significant protocol deviations (e.g., wrong drug volume 
received, administration of prohibited concomitant medication, patient did not meet 
all inclusion criteria or met 1 or more exclusion criteria) and had complete data for 
the primary endpoint. The primary endpoint will be analyzed for the PP Day 1-7 

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combined set, with patients analyzed according to the treatment they received. See 
Section 10.2.2 and the Significant Protocol Deviation Rules document for further 
information on the handling of protocol deviations for this study. 
 Per-protocol (PP) Day 1-7 Part 2 set: all patients who were randomly assigned to a 
study drug after the conclusion of Part 1 of the study, had no significant protocol 
deviations (e.g., wrong drug volume received, administration of prohibited 
concomitant medication, patient did not meet all inclusion criteria or met 1 or more 
exclusion criteria) and had complete data for the primary endpoint. The primary 
endpoint will be analyzed for the PP Day 1-7 Part 2 set, with patients analyzed 
according to the treatment they received. See Section 10.2.2 and the Significant 
Protocol Deviation Rules document for further information on the handling of 
protocol deviations for this study. 
 PP Day 1-28 set: all patients who were randomly assigned to a study drug, had no 
significant protocol deviations (e.g., wrong drug volume received, administration of 
prohibited concomitant medication, patient did not meet all inclusion criteria or met 1 
or more exclusion criteria) and had complete data for the key secondary endpoint. 
The key secondary endpoint will be analyzed for the PP Day 1-28 set, with patients 
analyzed according to the treatment they received. See Section 10.2.2 and the 
Significant Protocol Deviation Rules document for further information on the 
handling of protocol deviations for this study. 
 Safety set: all patients who were randomly assigned and received a dose of study 
drug. All safety analyses will be based on the safety set, with patients analyzed 
according to the treatment they received. 
 PK set: all patients who were randomly assigned and received at least one treatment 
during Part 1 of the study. The PK analyses will be based on this set, with patients 
analyzed according to the treatment they received. 
7.6 Description of Subgroups to Be Analyzed 
To determine whether patient groups that benefit most from recAP treatment and whether 
patient groups that are non-responders can be identified, additional analyses will be 
performed on a selection of endpoints (AUC1-7; RRT incidence from Day 1 to Day 28, 

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inclusive; peak value of serum creatinine from Day 1 to Day 7, inclusive; RRT-free days 
from Day 1 to Day 28, inclusive; time to discharge from ICU or intermediate care unit from 
Day 1 to Day 28, inclusive; deaths during the 90-day study period) for subgroups based on 
the following parameters: 
 Baseline characteristics, including: 
o Kidney function markers (e.g., urine and serum creatinine, BUN/urea clearance, 
sodium, proteinuria, fractional excretion of sodium and urea, and urine output) 
o Tubular injury biomarkers (e.g., KIM-1, IL-18, GST-alpha) 
o Biomarkers for systemic inflammation (e.g., IL-6, CRP, LBP) 
o Glomerular filtration rate (eGFR by chronic kidney disease epidemiology 
collaboration [CKD-EPI]) 
o APACHE II score (<25, ≥25) 
 Timing from first diagnosis of SA-AKI to start of recAP treatment, e.g., in time intervals 
(0 to < 6 hours, 6 to < 12 hours, 12 to < 18 hours, 18 to < 24 hours). 
 Baseline AKIN stage (stage 1, stage 2, stage 3) 
Additional parameters may also be considered (e.g., urine output [over or under 
200 mL/day], diabetes mellitus [yes or no], hypertension [yes or no], age [< 55 years old, 
≥ 55 years old and < 70 years old, or ≥ 70 years old], sex (male or female), risk scores [high 
or low]). 
Further details of these subgroups, including cut-off points and relevant outputs to be 
produced will be provided in the SAP. 
7.7 Statistical Analyses Methodology 
Statistical analyses will be performed using SAS software Version 9.2 or later. Continuous 
variables will be summarized using descriptive statistics, including but not limited to the 
mean, the standard deviation, median, minimum value, and maximum value. Categorical 
variables will be summarized using frequency counts and percentages. All data collected 
across the 4 treatment groups throughout the study will be listed in data listings. 

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All statistical tests will be 2-sided and performed using a 5% significance level, leading to 
95% (2-sided) CIs. As the primary efficacy endpoint is analyzed at the interim analysis and at 
the end of the study, multiplicity will be addressed by using a combination test to combine 
the results (see Section 7.7.1). A hierarchical method will be employed to address any 
multiplicity arising from the analysis of the key secondary endpoint. In other words, the 
formal analysis of this endpoint will be performed only if a statistically significant result is 
obtained from the combination test analysis of the primary endpoint. All analyses performed 
on the other secondary endpoints are for exploratory purposes only; therefore, no further 
multiplicity adjustment is required. 
The combined analysis of patients from Parts 1 and 2 rests on the assumption that patients 
recruited in each part of the study will belong to the same overall patient population. To 
check this assumption, data related to the baseline characteristics (for all 4 treatment groups) 
will be repeated for Part 1 and Part 2. If any notable differences are observed, then the 
combined analysis of Parts 1 and 2 will need to be interpreted with caution and further 
exploratory analysis will need to be conducted to investigate the possible causes. 
The assumption of a consistent treatment effect across Parts 1 and 2 will be investigated by 
repeating the primary and key secondary efficacy analyses (for the optimal recAP dose and 
placebo treatment groups) for Part 1 and Part 2. Again, any notable differences will lead to 
the combined analysis of Parts 1 and 2 being interpreted with caution and further exploratory 
analyses conducted to investigate the possible causes.  
Further details of the statistical analyses, methods, and data conventions will be described in 
the SAP. 
7.7.1 Analysis of Primary Efficacy Endpoint 
The primary efficacy endpoint is the area under the time-corrected endogenous creatinine 
clearance curve from Day 1 to Day 7, i.e., AUC1-7. 
Area under the time-corrected endogenous creatinine clearance curve from Day 1 to Day 7 
will be summarized using descriptive statistics and analyzed using an analysis of variance 
(ANOVA) with treatment and site as explanatory variables. The analysis will be performed 
separately for Parts 1 and 2: for Part 1, AUC1-7 will be compared between the 3 recAP doses 
and placebo. This analysis will be considered in conjunction with the safety data to determine 

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the optimal recAP dose for use in Part2. For Part 2, the optimal recAP dose will be compared 
with placebo. Confirmatory testing of the single hypothesis comparing optimal dose with 
placebo will be based on a closed-testing procedure. This hypothesis will be rejected at level 
α if it and all intersection hypotheses involving it are all rejected at local level α. The testing 
strategy used to combine results from Parts 1 and 2 will be a combination test based on the 
inverse normal method, with the test statistic of the combination test calculated as (Bauer and 
Köhne 1994): 
 
where 
 and 
 are the sample sizes per group in Parts 1 and 2, respectively, 
, 
Φ refers to the standard normal distribution, and 
 and 
 are the p-values from Parts 1 and 
2, respectively. For the single hypothesis, 
 is the unadjusted p-value to compare optimal 
dose with placebo in Part 1. For the intersection hypotheses, 
 is the Dunnett-adjusted p-
value in Part 1, and 
 is the unadjusted p-value to compare optimal dose with placebo in 
Part 2 for all hypotheses.  
The difference in least squares means between the treatment groups will also be presented 
along with the associated 95% CI. 
The underlying assumptions for ANOVA (normality and homogeneity of variance of the 
studentized residuals) will be investigated for Part 1 by examining a normal probability plot 
of the residuals and a plot of the fitted values against the residuals. Should there be a strong 
indication that these assumptions are not satisfied, a corresponding non-parametric analysis 
will be conducted to calculate the p-values for Parts 1 and 2 (i.e., using ANOVA with the 
rank-transformed values of AUC1-7 as the outcome variable and treatment and site as 
explanatory variables). 
In addition to the above, the summarization using descriptive statistics will be repeated for all 
4 treatment groups for the patients randomly assigned prior to Part 2. 
7.7.2 Analyses of Secondary Efficacy Endpoints 
Analyses of the secondary efficacy endpoints will be conducted at the conclusion of Part 2.  

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The key secondary endpoint is the incidence of RRT from Day 1 to Day 28, inclusive with 
patients who die or withdraw from the study during this period without recording RRT 
incidence being counted as having not required RRT. This endpoint will be summarized by 
treatment group using counts and percentages. Should a statistically significant result be 
obtained from the combination test analysis of the primary endpoint, the optimal recAP dose 
will be formally compared with placebo using a logistic regression model with treatment 
group and site as explanatory variables. Otherwise the results will be reported as exploratory 
analyses only. The odds ratio and associated 95% confidence interval from this comparison 
will also be presented. 
The above summarization and analysis will also be repeated, excluding those patients who 
die or withdraw from the study from Day 1 to Day 28, inclusive. Should statistically 
significant results not be obtained from both the primary endpoint and the key secondary 
endpoint, the results from the logistic regression model for this comparison will be reported 
as exploratory analyses only. 
Descriptive statistics will be used for all other continuous secondary efficacy endpoints, 
summarizing absolute values and/or change from baseline as required across all four 
treatment groups in tables and/or figures as appropriate. Categorical secondary efficacy 
endpoints will be summarized for the treatment groups by counts and percentages, and shift 
tables as appropriate. Selected endpoints will be analyzed by appropriate methods; these 
analyses will be exploratory only and defined in more detail in the SAP. 
7.7.3 Safety Analyses 
The safety summaries will include all 4 treatment groups, comprising all patients in the 
safety set. 
Treatment-emergent adverse events will be tabulated by treatment group. The number and 
percentage of patients with at least 1 TEAE will be presented along with a breakdown by 
system organ class and preferred term, with each patient being counted once at each 
summarization level. This summary will be repeated for treatment-related TEAEs, TEAEs 
that lead to study drug discontinuation, by relationship to study drug, by intensity, and for 
treatment-emergent SAEs. 

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Laboratory test results (for hematology, clinical chemistry, and urinalysis parameters not 
considered in the efficacy analyses), vital signs data, and ECG data will be presented in 
tables summarizing absolute values and change from baseline by treatment group, with shift 
tables included as appropriate. Other safety data will be listed only. 
7.7.4 Pharmacokinetic Analyses 
A population PK analysis of plasma concentration-time data will be performed using non-
linear mixed-effects modeling. Data from this study may be combined with data from an 
additional study in healthy adult volunteers and included in an integrated PK analysis.  The 
structural model will contain clearance and volume of distribution as fixed-effect 
parameters.  The intersubject variability in the parameter estimates and the random residual 
error in the data will be estimated with an appropriate error model. Available patient 
characteristics will be tested as potential covariates affecting PK parameters. Details of the 
analysis will be given in a population PK analysis plan and the results of the population PK 
analysis will be presented in a separate report. 
7.7.5 Other Analyses 
Information from any additional, baseline, or screening assessments (e.g., disposition of 
patients, demographics, previous medical history, site of infection and pathogen, APACHE II 
score, SAPS-2, AP levels) will be listed and, where appropriate, presented by means of 
descriptive statistics for continuous variables, or frequency counts and percentages for 
categorical variables. 
7.7.6 Interim Analyses 
An unblinded interim analysis will be conducted on the Part 1 data to determine the optimal 
recAP dose for Part 2. This analysis will compare the 4 treatment groups from Part 1 on the 
primary efficacy endpoint, and a selection of the safety data. Further details on the data 
required will be specified in the DMC charter and the interim analysis plan. The interim 
analysis will be conducted on all data collected up to the first 7 days of laboratory data of the 
120th patient from Part 1.  
To maintain the blind, the interim analysis will be conducted and delivered by an unblinded 
PPD Biostatistics team located at a different site to the blinded PPD biostatistics personnel 
involved in the study. The results will be reviewed by an independent DMC, who will make 

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the dose selection decision. The type 1 error rate will be controlled by combining the results 
for the primary efficacy endpoint from the interim analysis (Part 1) and the final analysis 
(Part 2) using the inverse normal method described in Section 7.7.1. A futility analysis will 
also be conducted at the interim analysis. If none of the 3 recAP doses in Part 1 show 
evidence of efficacy (i.e., all 3 groups have 1-sided, unadjusted p-value greater than 0.8), 
then the study will be terminated. 
7.8 Data Quality Assurance 
The sites will maintain source documentation and enter patient data into the eCRF as 
accurately as possible and will rapidly respond to any reported discrepancies. Electronic 
CRFs are accessed through Medidata Rave® (Medidata Solutions Inc, New York, New York). 
This electronic data capture system is validated and compliant with US Title 21 Code of 
Federal Regulations (CFR) Part 11. Each person involved with the study will have an 
individual user name and password that allows for record traceability. Thus, the system, and 
subsequently any investigative reviews, can identify coordinators, investigators, and 
individuals who have entered or modified records, as well as the time and date of any 
modifications. A quality review of the data will be performed by the site with additional 
reviews by the clinical monitor through source data verification.  
Each eCRF is presented as an electronic copy, allowing data entry by study site staff, who 
can add and edit data, identify, and resolve discrepancies, and view records. This system 
provides immediate direct data transfer to the database, as well as immediate detection of 
discrepancies, enabling site coordinators to resolve and manage discrepancies in a timely 
manner.  
Paper copies of the eCRFs and other database reports may be printed by the investigator. This 
system provides study site staff, monitors, and reviewers with access to hard copy audits, 
discrepancy reviews, and investigator comment information.  
After all data reviews and query resolutions are complete, the statistical analysis plan 
approved and signed, and any summary/analysis populations approved, the database will be 
locked. 

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7.8.1 Data Management 
As part of the responsibilities assumed by participating in the study, the investigator agrees to 
maintain adequate case histories for the patients treated as part of the research under this 
protocol. The investigator agrees to maintain accurate eCRFs and source documentation as 
part of the case histories. These source documents may include diary cards, laboratory 
reports, etc. 
All eCRF information is to be completed. If an item is not available or is not applicable, this 
fact should be indicated. Blank spaces should not be present unless otherwise directed.  
Investigative site staff will enter patient data into the electronic data capture system Medidata 
Rave. The analysis data sets will be a combination of these data and data from other sources 
(e.g., laboratory data). 
Clinical data management will be performed in accordance with applicable PPD standards 
and data cleaning procedures to ensure the integrity of the data, e.g., removing errors and 
inconsistencies in the data. Adverse events and concomitant medication terms will be coded 
using MedDRA, an internal validated medication dictionary, and concomitant medications 
will be coded using WHO Drug Dictionary. 
After database lock, each study site will receive a CD-ROM containing all of their site 
specific eCRF data as entered into Medidata Rave for the study, including full discrepancy 
and audit history. Additionally, a CD-ROM copy of all of the study site’s data from the study 
will be created and sent to the sponsor for storage. PPD will maintain a duplicate CD-ROM 
copy for their records. In all cases, patient initials will not be collected or transmitted to the 
sponsor. 
8 Ethics 
8.1 Independent Ethics Committee or Institutional Review Board 
Federal regulations and the ICH E6(R1) guidelines require that approval be obtained from an 
IRB/ IEC before participation of human patients in research studies. Before study onset, the 
protocol, informed consent, advertisements to be used for the recruitment of study patients, 
and any other written information regarding this study to be provided to the patient or the 
patient’s legal guardian must be approved by the IRB/IEC. Documentation of all IRB/IEC 

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approvals and of the IRB/IEC compliance with ICH E6(R1) will be maintained by the site 
and will be available for review by the sponsor or its designee. 
All IRB/IEC approvals should be signed by the IRB/IEC chairman or designee and must 
identify the IRB/IEC name and address, the clinical protocol by title or protocol number or 
both, and the date approval or a favorable opinion was granted. 
The investigator is responsible for providing written summaries of the progress and status of 
the study at intervals not exceeding 1 year or otherwise specified by the IRB/IEC. The 
investigator must promptly supply the sponsor or its designee, the IRB/IEC, and, where 
applicable, the institution, with written reports on any changes significantly affecting the 
conduct of the study or increasing the risk to patients. 
8.2 Ethical Conduct of the Study 
The study will be performed in accordance with the ethical principles that have their origin in 
the Declaration of Helsinki, ICH E6(R1), CFR, and all other applicable regulations. 
8.3 Patient Information and Consent 
Fully informed consent will be obtained before any study-specific procedures are performed. 
Country-specific regulations regarding the collection of informed consent and personal data 
will be followed at each site. It is anticipated by the very nature of the study that many 
patients who will be eligible for this protocol will not be able to give fully informed consent 
themselves due to various reasons including sedation or unconscious state. In a situation 
where a patient is unable to provide consent, the patient’s legally authorized representative 
may provide written consent, as approved by the institutional-specific guidelines. Informed 
consent may be obtained from an independent consulting physician or obtained on the basis 
of emergency study protocol by the investigator in countries where regulation and institution 
guidelines permit. This form of consent can only be used when the patient and legally 
authorized representative are unable to provide consent. In cases where the initial informed 
consent is obtained from a legal representative, an independent consulting physician, or by 
the investigator, the patient must also give written informed consent as soon as they are able.  
The investigator shall retain the signed original ICF(s) and give a copy of the signed original 
form to the patient or legal guardian. 

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9 Investigator’s Obligations 
The following administrative items are meant to guide the investigator in the conduct of the 
study but may be subject to change based on industry and government standard operating 
procedures, working practice documents, or guidelines. Changes will be reported to the 
IRB/IEC but will not result in protocol amendments. 
9.1 Confidentiality 
All laboratory specimens, evaluation forms, reports, and other records will be identified in a 
manner designed to maintain patient confidentiality. All records will be kept in a secure 
storage area with limited access. Clinical information will not be released without the written 
permission of the patient (or the patient’s legal guardian), except as necessary for monitoring 
and auditing by the sponsor, its designee, the FDA, the European Medicines Agency, other 
regulatory national authorities, or the IRB/IEC. 
The investigator and all employees and coworkers involved with this study may not disclose 
or use for any purpose other than performance of the study any data, record, or other 
unpublished, confidential information disclosed to those individuals for the purpose of the 
study. Prior written agreement from the sponsor or its designee must be obtained for the 
disclosure of any said confidential information to other parties. 
9.2 Financial Disclosure and Obligations 
Investigators are required to provide financial disclosure information to allow the sponsor to 
submit the complete and accurate certification or disclosure statements required under 
21 CFR 54. In addition, the investigator must provide to the sponsor a commitment to 
promptly update this information if any relevant changes occur during the course of the 
investigation and for 1 year following the completion of the study. 
Neither the sponsor nor PPD is financially responsible for further testing or treatment of any 
medical condition that may be detected during the screening process. In addition, in the 
absence of specific arrangements, neither the sponsor nor PPD is financially responsible for 
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9.3 Investigator Documentation 
Prior to beginning the study, the investigator will be asked to comply with ICH E6(R1) 8.2 
and Title 21 of the CFR by providing the following essential documents, including but not 
limited to: 
IRB/IEC approval 
Original investigator-signed investigator agreement page of the protocol 
Form FDA 1572, fully executed, and all updates on a new fully executed Form FDA 1572 
Curriculum vitae for the investigator and each sub-investigator listed on Form FDA 1572 
Financial disclosure information to allow the sponsor to submit complete and accurate 
certification or disclosure statements required under 21 CFR 54. In addition, the investigators 
must provide to the sponsor a commitment to promptly update this information if any 
relevant changes occur during the course of the investigation and for 1 year after the 
completion of the study. 
IRB/IEC-approved informed consent and any other written information regarding this study 
that is to be provided to the patient or legal guardian 
Laboratory certifications and normal ranges for any local laboratories used by the site, in 
accordance with 42 CFR 493 
9.4 Study Conduct 
The investigator agrees that the study will be conducted according to the principles of 
ICH E6(R1). The investigator will conduct all aspects of this study in accordance with all 
national, state, and local laws or regulations. Study information from this protocol will be 
posted on publicly available clinical trial registers before enrollment of patients begins. 
9.5 Adherence to Protocol 
The investigator agrees to conduct the study as outlined in this protocol in accordance with 
ICH E6(R1) and all applicable guidelines and regulations.  
9.6 Adverse Events and Study Report Requirements 
By participating in this study the investigator agrees to submit reports of SAEs according to 
the timeline and method outlined in the protocol. In addition, the investigator agrees to 
submit annual reports to the study site IRB/IEC as appropriate. 

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9.7 Investigator’s Final Report 
Upon completion of the study, the investigator, where applicable, should inform the 
institution; the investigator/institution should provide the IRB/IEC with a summary of the 
study’s outcome and the sponsor and regulatory authority(ies) with any reports required. 
9.8 Records Retention 
Essential documents should be retained until at least 2 years after the last approval of a 
marketing application in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region or at least 2 years have elapsed since the formal 
discontinuation of clinical development of the investigational product. These documents 
should be retained for a longer period, however, if required by the applicable regulatory 
requirements or by an agreement with the sponsor. It is the responsibility of the sponsor to 
inform the investigator/institution as to when these documents no longer need to be retained. 
9.9 Publications 
After completion of the study, the data will be reported at scientific meetings and/or 
submitted and published in a scientific journal, regardless of the outcome. In these cases, a 
publication committee will be responsible for these activities and will work with the 
investigators to determine how the manuscript is written and edited, the number and order of 
authors, the publication to which it will be submitted, and other related issues. 
In principle the company supports publication of results, regardless of the outcome. In order 
to prevent subgroup publications prior to main publication, data are the property of the 
sponsor and cannot be published without prior authorization from the sponsor, but data and 
publication thereof will not be unduly withheld.  
10 Study Management 
Table 10–1 presents the study administrative details. 

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Table 10–1 
Study Administrative Table 
Role 
Name/Affiliation/Address 
Sponsor 
AM-Pharma B.V. 
Sponsor Signatory and Sponsor Medical Officer 
Jacques Arend MD DiMD 
Vice President Clinical Development and Chief 
Medical Officer 
AM-Pharma B.V. 
Rumpsterweg 6 
3981 AK Bunnik 
The Netherlands 
Phone: 31 (0) 302598836 
Contract Research Organization 
PPD 
Worldwide Headquarters 
929 North Front Street 
Wilmington, NC 28401-3331  
Phone: +910-251-0081 
Medical Monitor 
European Union: 
Hanna Orr, MD 
Associate Medical Director, Pharmacovigilance 
PPD Office Warsaw (Home Based) 
49 Domaniewska Street 
Trinity Park III; 1st floor 
02-672 Warsaw, Poland  
Phone: +48 781811328 
 
United States: 
William Crafford, MD, FACC 
Medical Director, Pharmacovigilance 
PPD 
929 North Front Street 
Wilmington, NC 28401-3331 
Phone: 1-800-201-8725 
Study Drug Manufacturing Facilities 
Manufacturing, Preparation, and Dispensing: 
Nova Laboratories Ltd  
Martin House, Gloucester Crescent Wigton 
Leicestershire, UK 
Phone: +44 (0) 1162230100 
Fax: +44 (0) 1162230101 
Labeling and Shipping: 
PPD Ireland Depot  
Building C, Garycastle Business & Technology 
Park Athlone 
Co Westmeath, Ireland 
Phone: +35 3906460300 

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Role 
Name/Affiliation/Address 
Central Laboratories 
PPD Global Central Laboratory 
2 Tesseneer Drive 
Highland Heights, KY 41076 
Phone: 859-781-8877 
 
PPD Global Central Laboratory 
Cluster Park 
Kleine Kloosterstraat 19 
B-1932 Zaventem, Belgium 
Phone: +32 2 725 2127 
Laboratory for PK Analyses 
PRA 
Bioanalytical Laboratory Netherlands 
Early Development Services 
Westerbrink 3, 9405 BJ Assen, The Netherlands 
Phone: +31 (0) 592303222 
Fax: +31 (0) 592303223 
Laboratory for Iohexol Analyses 
Biomarkers Core Laboratory 
O'Brien Center for AKI Research 
UC San Diego Department of Medicine 
Division of Nephrology-Hypertension 
214 Dickinson Street, San Diego 
CA 92103, USA 
CTF-C Building # 205 B, 210 & 211, 
Hillcrest Medical Center Mail Code 8342, 
Phone: +1 619 471 0407 
Fax: +1 619 543 7769 
Laboratory for ATP, ADP, AMP, cAMP, and 
adenosine analyses 
Radboud University Medical Center 
149 Farmacologie-Toxicologie 
Geert Grooteplein 21 
6525 EZ Nijmegen, the Netherlands 
 
10.1 Monitoring 
10.1.1 External Data Monitoring Committee 
An independent DMC will review the results of the interim analysis and select the optimum 
recAP dose for Part 2 of the study (see Section 7.7.5). The DMC will conduct three 
additional reviews of the safety data by teleconference once the first 7 days of laboratory data 
are available for the following: 75 patients in Part 1, 60 patients in Part 2, and 125 patients in 
Part 2. In each case, the milestone will be patients with at least 7 days of laboratory data. 
Additional electronic reviews will be conducted of unblinded AE listings after 25, 50 and 
100 patients in Part 1 and 30 and 90 patients in Part 2. The DMC can also request ad hoc 

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reviews. Accumulating safety and efficacy data will be reviewed at predefined milestones 
during Part 1 and Part 2 of the study by the independent DMC as described in the DMC 
charter as follows: 
 Electronic Review 25 subjects 
 Electronic Review 50 subjects 
 Teleconference 75 subjects 
 Electronic Review 100 subjects 
 Face to Face Meeting-interim analysis-120 subjects 
 Ad hoc Review- (if needed) between 90-120 additional subjects 
  Teleconference 60 additional subjects from Part 2 (at least 180 total) 
  Electronic Review 90 additional subjects from Part 2 (at least 210 total) 
  Teleconference 125 additional subjects from Part 2 (at least 245 total) 
  Ad hoc Review- (if needed) between 125-170 subjects from Part 2 (at least 245-290 
total). 
10.1.2 Monitoring of the Study 
The clinical monitor, as a representative of the sponsor, has the obligation to follow the study 
closely. In doing so, the monitor will visit the investigator and study site at periodic intervals, 
in addition to maintaining necessary phone and letter contact. The monitor will maintain 
current personal knowledge of the study through observation, review of study records and 
source documentation, and discussion of the conduct of the study with the investigator and 
personnel. 
All aspects of the study will be carefully monitored, by the sponsor or its designee, for 
compliance with applicable government regulation with respect to current ICH E6(R1) and 
current standard operating procedures. 
10.1.3 Inspection of Records 
Investigators and institutions involved in the study will permit study-related monitoring, 
audits, IRB/IEC review, and regulatory inspections by providing direct access to all study 
records. In the event of an audit, the investigator agrees to allow the sponsor, representatives 
of the sponsor, or a regulatory agency (e.g., FDA or other regulatory agency) access to all 
study records. 

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The investigator should promptly notify the sponsor and PPD of any audits scheduled by any 
regulatory authorities and promptly forward copies of any audit reports received to the 
sponsor. 
10.2 Management of Protocol Amendments and Deviations 
10.2.1 Modification of the Protocol 
Any changes in this research activity, except those necessary to remove an apparent, 
immediate hazard to the patient, must be reviewed and approved by the sponsor or its 
designee. Any protocol amendments will be prepared by the sponsor/contract research 
organization. Protocol amendments will be submitted to the IRB/EC and to regulatory 
authorities in accordance with local regulatory requirements. Approval must be obtained 
from the IRB/EC and regulatory authorities (as locally required) before implementation of 
any changes, except for changes necessary to eliminate an immediate hazard to patients or 
changes that involve logistical or administrative aspects only (e.g., change in Medical 
Monitor or contact information). 
10.2.2 Protocol Deviations 
The investigator or designee must document and explain in the patient’s source 
documentation any deviation from the approved protocol. The investigator may implement a 
deviation from, or a change of, the protocol to eliminate an immediate hazard to study 
patients without prior IRB/IEC approval. As soon as possible after such an occurrence, the 
implemented deviation or change, the reasons for it, and any proposed protocol amendments 
should be submitted to the IRB/IEC for review and approval, to the sponsor for agreement, 
and to the regulatory authorities, if required. 
A deviation from the protocol is an unintended or unanticipated departure from the 
procedures or processes approved by the sponsor and the IRB/IEC and agreed to by the 
investigator. A significant deviation (violation) occurs when there is non-adherence to the 
protocol by the patient or investigator that may result in an additional risk to the patient or 
which may confound analysis of study results. Significant deviations can include non-
adherence to inclusion or exclusion criteria, enrollment of the patient, or non-adherence to 
FDA regulations or ICH E6(R1) guidelines, and may  lead to the patient being withdrawn 
from the study (see Section 4.2). 

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Protocol deviations (and violations) will be documented by the clinical monitor throughout 
the course of monitoring visits. Investigators will be notified in writing by the monitor of 
deviations. The IRB/IEC should be notified of all protocol deviations in a timely manner. 
10.3 Study Termination 
Although AM-Pharma B.V. has every intention of completing the study, AM-Pharma B.V. 
reserves the right to discontinue the study at any time for clinical or administrative reasons. 
The end of the study is defined as the date on which the last patient completes the final 
assessments (includes follow-up assessments). 
10.4 Final Report 
Whether the study is completed or prematurely terminated, the sponsor will ensure that the 
clinical study reports are prepared and provided to the regulatory agency(ies) as required by 
the applicable regulatory requirement(s). The sponsor will also ensure that the clinical study 
reports in marketing applications meet the standards of the ICH E6(R1): Structure and 
content of clinical study reports. 
Where required by applicable regulatory requirements, an investigator signatory will be 
identified for the approval of the clinical study report. The investigator will be provided 
reasonable access to statistical tables, figures, and relevant reports and will have the 
opportunity to review the complete study results. 
Upon completion of the clinical study report, the sponsor will provide the investigator with 
the full summary of the study results. The investigator is encouraged to share the summary 
results with the study patients, as appropriate. The study results will be posted on publicly 
available clinical study registers. 
11 Quality Control and Good Clinical Practice Audits 
11.1 Quality Control 
Quality control for this study will be performed in compliance with PPD’s standard operating 
procedures. 

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11.2 Good Clinical Practice Audits 
The ICH E6(R1) and CFR audits for this study will be performed in compliance with PPD’s 
standard operating procedures. 

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12 Reference List 
AM-Pharma B.V. Recombinant alkaline phosphatase (recAP). Investigator’s brochure, 
version 2.1. AK Bunnik, The Netherlands; 2014. 
Angus DC, Birmingham MC, Balk RA, et al. E5 murine monoclonal antiendotoxin antibody 
in gram-negative sepsis: a randomized controlled trial. E5 Study Investigators. JAMA. 
2000;283(13):1723-30. 
Annane D, Sébille V, Troché G, et al. A 3-level prognostic classification in septic shock based 
on cortisol levels and cortisol response to corticotropin. JAMA. 2000;283(8):1038-45. 
Bagshaw SM, Lapinsky S, Dial S, et al. Acute kidney injury in septic shock: clinical 
outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy. 
Intensive Care Med. 2009;35(5):871-81. 
Bauer P, Köhne K. Evaluation of experiments with adaptive interim analyses. Biometrics. 
1994;50(4):1029-41. 
Bellomo R, Kellum JA, Ronco C. Acute kidney injury. Lancet. 2012;380(9843):756-66. 
Bentala H, Verweij WR, Huizinga-Van der Vlag A, et al. Removal of phosphate from lipid A 
as a strategy to detoxify lipopolysaccharide. Shock. 2002;18(6):561-66. 
Beumer C, Wulferink M, Raaben W, et al. Calf intestinal alkaline phosphatase, a novel 
therapeutic drug for lipopolysaccharide (LPS)-mediated diseases, attenuates LPS toxicity in 
mice and piglets. J Pharmacol Exp Ther. 2003;307(2):737-44. 
Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of 
Critical Care Medicine Consensus Conference: definition for sepsis and organ failure and 
guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864-74. 
Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease 
process. Chest. 1997;112(1):235-43. 
Bonventre JV, Yang L. Cellular pathophysiology of ischemic acute kidney injury. J Clin 
Invest. 2011;121(11):4210-21. 

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Centers for Disease Control (CDC). Increase in National Hospital Statistics Discharge 
Survey rates for septicemia – United States, 1979-1987. JAMA. 1990;263(7):937-8. 
Chawla LS, Amdur RL, Amodeo S, et al. The severity of acute kidney injury predicts 
progression to chronic kidney disease. Kidney Int. 2011;79(12):1361-9. 
Cohen J. The immunopathogenesis of sepsis. Nature. 2002;420(6917):885-91. 
Day YJ, Huang L, Ye H, et al. Renal ischemia-reperfusion injury and adenosine 2A 
receptor-mediated tissue protection: the role of CD4+ T cells and IFN-gamma. J Immunol. 
2006;176(5):3108-14. 
Department of Health and Human Services (DHHS), Food and Drug Administration, Center 
for Drug Evaluation and Research (US). Guidance for industry: Bioanalytical Method 
Validation. May 2001. Available from: 
http://www.fda.gov/downloads/Drugs/.../Guidances/ucm070107.pdf 
DeSilva B, Smith W, Weiner R, et al. Recommendations for the bioanalytical method 
validation of ligand-binding assays to support pharmacokinetic assessments of 
macromolecules. Pharm Res. 2003; 20(11):1885-900. 
European Medicines Agency (EMA). Committee for Medicinal Products for Human Use 
(CHMP). Guideline on bioanalytical method validation. 21 July 2011. 
EMEA/CHMP/EWP/192217/2009 Rev.1 Corr.2. Available from: 
http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2011/08/WC5
00109686.pdf  
European Medicines Agency (EMA). Committee for Medicinal Products for Human Use 
(CHMP). Concept paper on immunogenicity assessment of monoclonal antibodies intended 
for in vivo clinical use. 19 March 2009 . EMEA/CHMP/BMWP/114720/2009. Available 
from: 
http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC5
00003910.pdf 
European Medicines Agency (EMA). Committee for Medicinal Products for Human Use 
(CHMP). Guideline on immunogenicity assessment of biotechnology-derived therapeutic 
proteins. 13 December 2007. EMEA/CHMP/BMWP/14327/2006. Available from: 

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http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC5
00003946.pdf 
European Medicines Agency (EMA). Committee for Medicinal Products for Human Use 
(CHMP). Guideline on comparability of biotechnology-derived medicinal products after a 
change in the manufacturing process: non-clinical and clinical issues. 24 January 2007. 
EMEA/CHMP/BMWP/101695/2006. Available from: 
http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC5
00003937.pdf 
Gomez H, Ince C, De Backer D, et al. A unified theory of sepsis-induced acute kidney injury: 
inflammation, microcirculatory dysfunction, bioenergetics, and the tubular cell adaptation to 
injury. Shock. 2014;41(1):3-11. 
Heemskerk S, Masereeuw R, Moesker O, et al. Alkaline phosphatase treatment improves 
renal function in severe sepsis or septic shock patients. Crit Care Med. 2009;37(2):417-23. 
ICH Expert Working Group. Guideline for Preclinical Safety Evaluation Of Biotechnology -
Derived Pharmaceuticals S6(R1): ICH harmonised tripartite guideline. International 
Conference on Harmonisation. 12 June 2011. 
Kapojos JJ, Poelstra K, Borghuis T, et al. Induction of glomerular alkaline phosphatase after 
challenge with lipopolysaccharide. Int J Exp Pathol. 2003;84(3):135-44. 
Khundmiri SJ, Asghar M, Khan F, et al. Effect of reversible and irreversible ischemia on 
marker enzymes of BBM from renal cortical PT subpopulations. Am J Physiol. 
1997;273(6 Pt 2):F849-56. 
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. 
KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 
2012;2:1-138. 
Kiffer-Moreira T, Sheen CR, Gasque KC, et al. Catalytic signature of a heat-stable, chimeric 
human alkaline phosphatase with therapeutic potential. PLoS One. 2014;9(2):e89374. 

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Koyama I, Matsunaga T, Harada T, et al. Alkaline phosphatases reduce toxicity of 
lipopolysaccharides in vivo and in vitro through dephosphorylation. Clin Biochem. 
2002;35(6):455-61. 
Marshall JC, Foster D, Vincent JL, et al. Diagnostic and prognostic implications of 
endotoxemia in critical illness: results of the MEDIC study. J Infect Dis. 2004;190(3):527-34. 
Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States 
from 1979 through 2000. N Engl J Med. 2003;348(16):1546-54. 
Neyer L, Hiller J, Gish K, et al. Confirming human antibody responses to a therapeutic 
monoclonal antibody using a statistical approach. J Immunol Methods.2006; 315:80-87. 
Oppert M, Engel C, Brunkhorst FM, et al. Acute renal failure in patients with severe sepsis 
and septic shock--a significant independent risk factor for mortality: results from the German 
Prevalence Study. Nephrol Dial Transplant. 2008;23(3):904-9. 
Parrillo JE, Parker MM, Natanson C, et al. Septic shock in humans. Advances in the 
understanding of pathogenesis, cardiovascular dysfunction, and therapy. Ann Intern Med. 
1990;113(3):227-42. 
Picher M, Burch LH, Hirsh AJ, et al. Ecto 5’-nucleotidase and nonspecific alkaline 
phosphatase. Two AMP-hydrolyzing ectoenzymes with distinct roles in human airways. 
J Biol Chem. 2003;278(15):13468-79. 
Pickkers P, Heemskerk, S, Schouten J, et al. Alkaline phosphatase for treatment of 
sepsis-induced acute kidney injury: a prospective randomized double-blind 
placebo-controlled trial. Crit Care. 2012;16(1):R14. 
Rackow EC. Clinical definition of sepsis and septic shock. In: Sibbald WJ, Sprung CL, eds. 
New horizons; perspectives on sepsis and septic shock. Fullerton, CA: Society of Critical 
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Shankar G, Shores E, Wagner C, Mire-Sluis A. Scientific and regulatory considerations on 
the immunogenicity of biologics. Trends Biotechnol. 2006,24(6):274-280. 
Su F, Brands R, Wang Z, et al. Beneficial effects of alkaline phosphatase in septic shock. Crit 
Care Med. 2006;34(8):2182-7. 
VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal 
support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7-20. 
Vaara ST, Korhonen AM, Kaukonen KM, et al. Fluid overload is associated with an increased 
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Verweij WR, Bentala H, Huizinga-van der Vlag A, et al. Protection against an Escherichia 
coli-induced sepsis by alkaline phosphatase in mice. Shock. 2004;22(2):174-9.  
Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: results of the 
SOAP study. Crit Care Med. 2006; 34(2):344-53. 
Viswanathan CT, Bansal S, Booth B, et al. Quantitative bioanalytical methods validation and 
implementation: best practices for chromatographic and ligand binding assays. Pharm Res. 
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Wen X, Peng Z, Kellum JA. Pathogenesis of acute kidney injury: effects of remote tissue 
damage on the kidney. Contrib Nephrol. 2011;174:129-37. 
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monophosphoryl lipid A in newborn rats. Biol Neonate. 2000;77(3):191-5. 
 

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13 Appendices

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13.1 Appendix 1: Schedule of Assessments 
Table 13-1 
Schedule of Assessments 
Assessment 
Screening 
(≤ 24 h) 
Baseline 
(≤ 24 h) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
(± 1 
day) 
Day 
14 
(± 2 
days) 
Day 
21 
(± 3 
days) 
Day 
28 
(± 3 
days) 
Day 
60 
(± 5 
days) 
Day 
90 
(± 10 
days) 
AKI diagnosisa (pre-screening) 
Record site of infection and pathogen 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion and exclusion criteria 
X 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Child-Pugh scorec 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recent hematology and clinical 
chemistry results, if available 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recent microbial test results, if 
available 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test (urine or blood)d 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Local laboratory confirmatory serum 
creatinine samplee, or confirmatory 
assessment of continuation of decreased 
urine output 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomizationf 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Vital signs (BP, HR, OS, RR, T)g 
 
X 
Xh 
Xh 
Xh 
X 
X 
X 
X 
X 
X 
X 
 
 
Physical examination 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
APACHE II score 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
SAPS-2 score 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 

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Assessment 
Screening 
(≤ 24 h) 
Baseline 
(≤ 24 h) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
(± 1 
day) 
Day 
14 
(± 2 
days) 
Day 
21 
(± 3 
days) 
Day 
28 
(± 3 
days) 
Day 
60 
(± 5 
days) 
Day 
90 
(± 10 
days) 
SOFA scorei 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
EQ-5Dj 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Alkaline phosphatase 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Time from first diagnosis of SA-AKI to 
start of recAP treatment 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment 
 
 
X 
Xk 
Xk 
 
 
 
 
 
 
 
 
 
Arterial partial pressure of O2 (in ICU 
or intermediate care unit only) for 
mechanically ventilated patients 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Blood: serum creatinine and BUNl 
 
Xe 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine (6 ± 1 h collection) creatinine, 
BUNm 
 
Xn 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Volume of urineo 
 
Xp 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Pharmacokineticsq 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
ECG (12-lead)r 
 
X 
 
 
X 
 
 
 
 
X 
 
 
 
 
Hematology (Hgb, Hct, leukocytes, diff 
leukocytes, erythrocytes, thrombocytes, 
and APTT)d 
 
X 
X 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
Clinical chemistry (CRP, ALT, AST, 
GGT, urea, LDH, creatinine, bilirubin, 
CPK, total protein, albumin, glucose, 
sodium, potassium, chloride, 
bicarbonate, and lactate)d 
 
X 
X 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
Biomarkers for systemic inflammation 
(e.g., IL-6, CRP, LBP)s 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 

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Assessment 
Screening 
(≤ 24 h) 
Baseline 
(≤ 24 h) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
(± 1 
day) 
Day 
14 
(± 2 
days) 
Day 
21 
(± 3 
days) 
Day 
28 
(± 3 
days) 
Day 
60 
(± 5 
days) 
Day 
90 
(± 10 
days) 
Serology (IgG, IgE, and total 
immunoglobulin)s 
 
X 
 
 
 
 
 
 
 
X 
 
X 
 
 
Anti-drug antibodies 
 
X 
 
 
 
 
 
 
 
X 
 
X 
Xt 
Xt 
Tubular injury biomarkers (e.g., 
KIM-1, IL-18, GST-alpha) in urines 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Kidney function markers (urine 
creatinine, BUN/urea clearance, 
fractional excretion of urea and urine 
output)s 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Kidney function markers (sodium and 
fractional excretion of sodium)s 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Kidney function markers (serum 
creatinine and proteinuria)s 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant medication 
Xu 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Patient on RRT, and start or stop date 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Need for dialysis dependency 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Name, start or stop date, and dose of 
vasopressor and inotropic therapyv 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Mechanical ventilation and lung 
functionw (start or stop date, FiO2, 
PEEP, tidal volume, P/F ratio), 
ventilated patients only 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Adverse events 
X 
X 
X 
Mortality 
X 
X 
X 

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Assessment 
Screening 
(≤ 24 h) 
Baseline 
(≤ 24 h) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
(± 1 
day) 
Day 
14 
(± 2 
days) 
Day 
21 
(± 3 
days) 
Day 
28 
(± 3 
days) 
Day 
60 
(± 5 
days) 
Day 
90 
(± 10 
days) 
Discharge from ICU or intermediate 
care unit / admission or discharge from 
hospitalx 
X 
X 
X 
Abbreviations: AKI = acute kidney injury; ALT = alanine aminotransferase; APACHE = acute physiology and chronic health evaluation; APTT = activated partial thromboplastin 
time; AST = aspartate aminotransferase; BP = blood pressure; BUN = blood urea nitrogen; CPK = creatine phosphokinase; CRP = c-reactive protein; diff = differential; 
ECG = electrocardiogram; FiO2 = fraction of inspired oxygen; GGT = gamma-glutamyl transpeptidase; GST-alpha = alpha-glutathione s-transferase; h = hour; Hct = hematocrit; 
Hgb = hemoglobin; HR = heart rate; ICU = intensive care unit; IgE = immunoglobulin E; IgG = immunoglobulin G; IL-6 = interleukin-6; IL-18 = interleukin-18; KIM-1 = kidney 
injury molecule-1; LBP = lipopolysaccharide binding protein; LDH = lactate dehydrogenase; OS = oxygen saturation; PEEP = positive end expiratory pressure; P/F ratio = fraction 
PaO2/FiO2; RR = respiratory rate; RRT = renal replacement therapy; SAPS-2 = simplified acute physiology score 2; SOFA = sequential organ failure assessment; T = temperature. 
a. 
The AKI diagnosis can be made according to one of the AKIN serum creatinine criteria (absolute or relative increase, see inclusion criteria 5.a and 5.b), or according to the 
AKIN urine output criteria (urinary output < 0.5 mL/kg/h for > 6 hours, see inclusion criterion 5.c), the oliguria or anuria should still meet the AKIN urine output criteria prior 
to randomization and study drug administration. 
b. Confirmatory. 
c. 
Only for patients with liver disease. 
d. Local laboratory. 
e. 
See flowchart (Section 13.2, Figure 13-1) for options and preference for reference serum creatinine value. The reference creatinine value is the serum creatinine value 
according to the following order of preference: 1) lowest value within 3 months of the hospital admission. If not available, 2) at hospital admission. If not available, 3) at ICU 
or intermediate care unit admission. If not available, 4) lowest value between 3 and 12 months prior to hospital admission. 
f. 
When the diagnosis of AKI is made according to one of the AKIN serum creatinine criteria (absolute or relative increase, see inclusion criteria 5.a and 5.b), patients will be 
eligible for the study and can be randomly assigned when the volume-corrected serum creatinine sample, taken at screening confirms the continuation of AKI according to the 
AKIN criteria for serum creatinine. When the AKI diagnosis was made according to the AKIN urine output criteria (urinary output < 0.5 mL/kg/h for > 6 hours, see inclusion 
criterion 5.c), the oliguria or anuria should still meet the AKIN urine output criteria prior to randomization and study drug administration. 
g. Vital signs in ambulant patients will be obtained with the patient in a sitting position and after 5 minutes rest. Blood pressure will be monitored non-invasively. In patients who 
already have an arterial line placed as part of standard or care, readings from invasive blood pressure monitoring are to be recorded.  
h. Additionally, vital signs (excluding temperature) will also be monitored during study drug infusion on all treatment days at the following times: a) immediately before the 
administration of the study drug, b) within 5 minutes of the start of the study drug infusion, c) 30 minutes after the start of the study drug infusion, d) immediately after the 
completion of the administration of the study drug, which includes post-dose saline flushing, e) 30 and 60 minutes after completion of study drug administration, f) 2 hours, 3 
hours, 4 hours, and 5 hours after completion of study drug administration (Day 1 only). 
i. 
SOFA score to be obtained on each visit day as long as the patient is in the ICU or intermediate care unit, and at discharge from ICU or intermediate care unit . 
j. 
EQ-5D will be performed at baseline, at discharge from the ICU or intermediate care unit, and at the Day 90 visit. In case the patient is unconscious, EQ-5D questionnaire will 
be completed by a next of kin.  
k. At 24 ± 1 hour after the previous drug administration. 

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l. 
Creatinine and BUN will be measured by a central laboratory. At Days 60 and 90, only serum creatinine will be measured. When patients have a Foley catheter, serum 
creatinine samples should be collected prior to and immediately after each urine collection for at least up to Day 7. If the patient is discharged from the ICU or intermediate 
care unit , the Foley catheter might be removed. In this case, a patient might urinate spontaneously and all efforts should be undertaken to start collecting urine produced from 
this time point onward. Approximately 6 hours later (exact duration needs to be recorded) the patient might urinate again and this urine will be used for analysis, and a blood 
sample will be drawn at this time too. The urine volume produced over approximately 6 hours will be entered in the eCRF. 
m. 
Urine creatinine and urea will be measured by a central laboratory. The central laboratory will calculate blood urea nitrogen (BUN) clearance at all visits from Day 1 to 
Day 7, inclusive, and on subsequent visit days if reliable urine collection is possible. Urine will be collected within a 6 ± 1 hour period at all visits from Day 1 to Day 28, 
only if reliable urine collection is possible (i.e., patient remains in the ICU or intermediate care unit or hospital). 
n. These assessments will be performed before treatment if possible. Treatment should not be delayed because of these assessments. 
o. Urine volume collection in a 6 ± 1 hour collection period, only if reliable urine collection is possible (i.e., patient remains in the ICU or intermediate care unit or hospital). The 
volume should be corrected to account for the volume of samples previously taken from the total urine initially collected. 
p. Only when possible within the 24-hour time window from first AKI diagnosis to treatment. 
q. Assays will be performed by a central reference laboratory. See Section 6.3.8.3 for sampling details. 
r. 
A 12-lead ECG with at least 30-second rhythm strip will be recorded after the patient has rested supine or semi-recumbent for at least 5 minutes. 
s. 
Central reference laboratory. 
t. 
Samples taken on Days 60 and 90 will only be analyzed in case of a positive result on Day 28. 
u. Verification that no concomitant medications that should be avoided are taken. 
v. The actual stop date is collected for calculation of shock-free days. Only required when the patient is in the ICU or intermediate care unit. 
w. Daily, as long as the patient requires mechanical ventilation. As appropriate, record start and stop dates and times of mechanical ventilation, including the settings required and 
the O2 in the blood.  
x. Actual admission dates and both planned and actual discharge dates from the ICU or intermediate care unit and hospital (planned meaning when decision is taken to discharge 
the patient, not necessarily being the same as the actual discharge date, e.g., because of lack of beds on the regular ward). 
 

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13.2 Appendix 2: Flowchart of Assessments 
Figure 13-1 
Flowchart of Assessments 

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Admission to ICU or 
intermediate care unit
Pre screen pt
Obtain 
informed 
consent
Pt eligibility
Perform 
baseline 
assessments
Randomize pt
Pt eligibility
Perform day 1 
assesements
Start day 1 
treatment < 24 
hrs of AKI 
diagnoses
AKI diagnoses based on serum creatinine ↑ 26.2 µmol/L or 150% < 48 hrs or UO < 0.5 ml/kg/
hr > 6 hrs
Creatinine increase of local serum creatinine vs reference creatinine results 
(reference in order of preference: 1) Lowest value within 3 months of the hospital admission. 
If not available, 2) at hospital admission. If not available, 3) at ICU or intermediate care unit 
admission. If not available, 4) lowest value between 3 and 12 months prior to hospital 
admission)
Consent patient, legal representative or independant physician, retrieve IVRS pt screening 
number
Score APACHE, SAPS-2, SOFA, EQ-5D
Vital signs and physical examination, ECG
Local lab hematology and clinical chemistry panel 
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, proteinuria, and 
urine biomarkers 
Central lab: serum creatinine and BUN if possible before and after urine collection interval, 
else one sample, AP
Central lab: serology, ADA, serum biomarker sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Concomitant medication
Vasopressor and inotropic therapy
Confirm compliance with inclusion/exclusion criteria
Local laboratory fluid corrected confirmation of serum creatinine ↑ if AKI diagnose is 
based on creatinine criterion
Confirmation of UO< 0.5 ml/kg/hr last 6 hrs if AKI diagnose is based on UO criterion 
Call IVRS to randomly assign the patient a treatment number
Retrieve pt medication kit
Prepare medication < 3 hrs of administration
Time from first diagnosis of SA-AKI to start of recAP treatment
Central lab PK
Administer per instructions provided
Confirm compliance with inclusion/exclusion criteria
Day 0
Screen pt
Medical history, Child-Pugh only if hepatic disease
Demographics
Local lab pregnancy test 
Concomitant medication (verification that no forbidden concomitant medication are taken)
Local lab confirmatory serum creatinine sample 
If available: 
Recent hematology & clinical chemistry panel
Recent Microbial test results
Day 1
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, proteinuria, 
and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
CRRT?
▲
Obtain 
randomization 
number
Call IVRS to obtain patient number
 

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Start day 2 
treatment
24±1 hrs post 
day 1 dose
Perform day 2 
assessments
Score SOFA
Vital signs and physical examination
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Central lab PK through
Administer per instructions provided
Day 2
Start day 3 
treatment
Central lab PK through
Administer per instructions provided
Perform day 3 
assessments
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Day 3
CRRT?
▲
Perform day 4 
assessments
Perform Day 5 
assessments
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
▲
Day 4
Day 5
ICU or intermediate care unit Discharge: Score EQ-5D
Determine length of ICU or intermediate care unit stay 
Hospital Discharge: Score EQ-5D
Central creatinine and BUN
Determine length of hospital stay
Stop CRRT if at least one of the following criteria is met:
Diuresis > 30 ml/hr
Endogenous creatinine clearance over 6 hrs interval > 20 
ml/min
▲
Start CRRT if at least one of the following criteria is met:
Anuria >6 hrs
Oliguria < 200 ml / 12 hrs
Hyperkalemia > 6.5 mmol/L
Metabolic Acidosis pH<7.2 with normal pCO2
Volume Overload
Azotemia Urea > 30 mmol/L or creat > 300 µmol/L
Symptomatic Uraemia
Score SOFA
Vital signs and physical examination
Day 5 only: local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK through
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
 

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Day 14 Visit
Day 21 Visit
Day 28 Visit
Score ventilator-free days, shock-free days
Vital signs and physical examination
Local lab hematology and clinical chemistry panel
Central lab ADA, serology and biomarker serum sample, and biomarker urine and 
proteinuria samples
Central lab serum creatinine and BUN (i.a. before and after urine sampling 
interval)
If still on ICU or intermediate care unit:
Score SOFA
6 ± 1 hrs interval urine collection central lab creatinine, sodium, BUN and urine 
biomarkers
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients 
Vital signs and physical examination
ECG
Local lab hematology and clinical chemistry panel
Central lab ADA, serology and biomarker serum, and biomarker urine and urine 
samples
Central lab serum creatinine and BUN (i.e. before and after urine sampling 
interval, else one sample)
If still on ICU or intermediate care unit:
Score SOFA
6 ±1 hrs interval urine collection for central lab creatinine, sodium, BUN and urine 
biomarkers
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Vital signs and physical examination
Local lab hematology and clinical chemistry
Central lab Biomarker serum, and Biomarker urine and proteinuria samples
Central lab serum creatinine and BUN (i.e.before and after urine sampling 
interval, else one sample)
If still on ICU or intermediate care unit:
Score SOFA
6 ± 1 hrs interval urine collection for central lab creatinine, sodium and BUN
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Perform Day 7 
assessments
Perform Day 6 
assessments
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection 
interval
Central lab PK through 
Central lab Biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
▲
▲
Day 6
Day 7
Score SOFA
Vital signs and physical examination
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection 
interval
Central lab PK through 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
 

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Day 60 Follow- 
Up Visit
Day 90 Follow- 
Up Visit
Central lab ADA sample
Central lab serum creatinine
Central lab proteinuria
Need for chronic dialysis
Central lab ADA sample
Central lab serum creatinine
Central lab proteinuria
Score EQ-5D
Need for chronic dialysis
Every Visit until Day 28:
Concomitant Medication
Vasopressor Infusion Rate
Every Visit until Day 90: 
Adverse Events
Mortality
Complete
 
Abbreviations: ADA = anti-drug antibodies; AKI = acute kidney injury; AP = alkaline phosphatase; APACHE = acute 
physiology and chronic health evaluation; BUN = blood urea nitrogen; CRRT = continuous renal replacement therapy; 
ECG = electrocardiogram; FiO2 = fraction of inspired oxygen; Hosp = hospital; hrs = hours; ICU = intensive care unit; 
IVRS = interactive voice response system; lab = laboratory; PD = pharmacodynamics; PEEP = positive end expiratory 
pressure; PK = pharmacokinetics; pt = patient; recAP = recombinant human alkaline phosphatase; SAPS-2 = simplified 
acute physiology score 2; SOFA = sequential organ failure assessment; UO = urine output. 
 

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13.3 Appendix 3: Fluid-Corrected Serum Creatinine Assessment 
Fluid-corrected serum creatinine will be assessed following the methodology provided by 
Macedo et al (2010): 
Adjusted creatinine = serum creatinine × correction factor 
Correction factor = (hospital admission weight [kg] × 0.6 + Σ [daily cumulative fluid 
balance (L)])/(hospital admission weight × 0.6). 
Serum creatinine measures are not to be taken from the beginning of when a bolus is given 
until 30 minutes following completion, as the increased dilution during this period is not 
considered in the formulas provided (Pickering et al 2013). 
 
References: 
Macedo E, Bouchard J, Soroko SH, et al. Fluid accumulation, recognition and staging of 
acute kidney injury in critically-ill patients. Crit Care. 2010;14(3):R82. 
Pickering JW, Ralib AM, Endre ZH. Combining creatinine and volume kinetics identifies 
missed cases of acute kidney injury following cardiac arrest. Crit Care. 2013;17(1):R7. 
 

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13.4 Appendix 4: Weight Ranges and Pre-calculated Corresponding Volumes 
Table 13-2 
Weight Ranges and Pre-calculated Corresponding Volumes 
Body 
weight 
(kg) 
Body 
weight (lb) 
Volume drawn 
from 4 vials 
(mL) 
Volume discarded 
from syringe 
(mL) 
IMP retained 
in syringe (mL) 
Saline added to  
reconstitute 
(mL) 
Total volume 
in syringe 
(mL) 
35 < 40 
77 < 88 
20 
12 
8 
42 
50 
40 < 45 
88 < 99 
20 
11 
9 
41 
50 
45 < 50 
99 < 110 
20 
10 
10 
40 
50 
50 < 55 
110 < 121 
20 
9 
11 
39 
50 
55 < 60 
121 < 132 
20 
8 
12 
38 
50 
60 < 65 
132 < 143 
20 
7 
13 
37 
50 
65 < 70 
143 < 154 
20 
6 
14 
36 
50 
70 < 75 
154 < 165 
20 
5 
15 
35 
50 
75 < 80 
165 < 176 
20 
4 
16 
34 
50 
80 < 85 
176 < 187 
20 
3 
17 
33 
50 
85 < 90 
187 < 198 
20 
2 
18 
32 
50 
90 < 95 
198 < 209 
20 
1 
19 
31 
50 
95 - 115 
209 - 253 
20 
0 
20 
30 
50 
Abbreviation: IMP = investigational medical product. 
 

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13.5 Appendix 5: Iohexol and Exogenous Creatinine Clearance Protocol 
(Including Pharmacodynamics) for Selected Sites Only  
13.5.1 Introduction 
Accurate measurement of glomerular filtration rate (GFR) is valuable for evaluating kidney 
function and nephrotoxicity in a variety of clinical research and patient care settings. 
Accurate GFR determinations are recommended to appropriately assess the value of 
pharmacotherapeutic interventions aimed at improving tubular microvascular hemodynamics, 
inflammation and slowing the progression of renal disease.  
The measure mostly used for the determination of the kidney function is the creatinine 
clearance as proxy for GFR. However, creatinine clearance is not fully representative in 
unstable situations, such as acute kidney injury, because it is influenced by various factors 
(e.g., diet, muscle mass, physical activity, and excretion and resorption in the kidney) and 
therefore results of creatinine clearance can be an over- or under-estimation. Creatinine 
clearance is routinely used to determine the function of the kidneys irrespective of the 
drawbacks, since it is inexpensive, non-invasive, and easy to perform.  
Marker compounds such as iothalamate, iohexol, or inulin have been used extensively to 
measure GFR. Although renal clearance of these markers during continuous infusion is 
considered the gold standard, simplified methods using limited sampling after intravenous 
bolus administration with and without urine collection have been proposed.  
The GFR estimation methods using creatinine concentration have been described as 
unreliable in some subgroups of the general population, especially in patients with 
non-steady state renal function. As iohexol has the main characteristics of a convenient 
marker of GFR, its plasma clearance seems to be the best choice to determine GFR in 
controlled laboratory settings. Contrary to determination of renal clearance of inulin, iohexol 
plasma clearance does not require continuous intravenous infusion. 
It is generally assumed that endogenous creatinine clearance is not influenced by continuous 
renal replacement therapy. In order to reliably determine potential changes in endogenous 
creatinine clearance, any change in creatinine clearance needs to be excluded. To evaluate if 
renal replacement therapy (RRT) has an effect on endogenous creatinine clearance, the 
exogenous creatinine clearance by RRT equipment will be assessed by measuring the 

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creatinine concentration in the effluent and effluent volume during the 6 ± 1 hour urine 
collection interval. 
13.5.2 Iohexol Dosing 
A single intravenous bolus injection of 5 mL iohexol (Omnipaque 240 mg/mL) will be 
administered over 5 minutes on Day 1 and on Day 7 or discharge from the ICU, whichever 
comes first. The bolus will be administered at the start of the 6 ± 1 hour urine collection 
interval. 
13.5.3 Iohexol Sampling 
For the measurement of iohexol, 2-mL blood samples will be collected in EDTA 
anticoagulated Vacutainer® tubes at the following time points: prior to iohexol bolus 
administration and at 60, 120, and 360 minutes. After centrifugation (500 × g, 10 minutes), 
the remaining approximately 1mL of plasma will be divided into 2 Micronic 1.4-mL 
cryotubes and stored at –80ºC, until batched shipments to the central laboratory are sent and 
further processing of one of each cryotubes at the Hillcrest Medical Center, United States, 
can be done. 
Five-milliliter urine samples will be collected prior to the bolus infusions, and the urine bag 
will be emptied. Starting with freshly produced urine, 5-mL samples will be taken at 60, 120, 
and 360 minutes directly from the Foley catheter. An additional 5-mL sample will be taken 
from the combined total volume that was collected during the 6 ± 1 hour urine collection 
interval. The volumes of urine produced at the 60-, 120-, and 360-minute time points will be 
entered in the electronic case report form (eCRF). The total volume of urine collected in the 
6 ± 1 hour interval will be corrected for the volume of samples taken during this interval and 
also entered in the eCRF. Urine tubes will be stored at –80ºC, until batched shipments to the 
central laboratory are sent and further processing of the urine at the Hillcrest Medical Center 
can be done. 
The sample time points of effluent will be at t = 360 minutes of the urine collection interval, 
analogous to the time points for serum creatinine determinations, as needed for endogenous 
creatinine clearance calculations. Two samples of 1 mL will be taken from the effluent and 
stored in Micronic 1.4-mL cryotubes at –80ºC, until batched shipments to the central 

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laboratory are sent and further processing of one of each cryotube at the Hillcrest Medical 
Center can be done. The total volume of effluent will be recorded in the eCRF. 
Although urine collection for 6 hours is preferred, a time window of ± 1 hour is allowed for 
pragmatic reasons adding flexibility to the schedule. In case the urine sampling interval is not 
exactly 6 hours, the last urine and blood sampling time points will have to match, e.g., with a 
5-hour urine collection interval the last urine and blood sample will be obtained at 
t = 300 minutes. 
13.5.4 Pharmacodynamic Assessments 
A urine sample for pharmacodynamic assessment will be taken from the 6 ± 1 hour urine 
collection as required for calculation of the time-corrected endogenous creatinine clearance: 
pre-dose and post-dose on Day 1, post-dose on Day 2 and Day 3, and on Day 4, 5, 6, and 7. 
Urinary levels of adenosine triphosphate (ATP), adenosine diphosphate (ADP), adenosine 
monophosphate (AMP), cyclic AMP (cAMP), and adenosine will be analyzed centrally from 
this sample. 
13.5.5 Statistical Data Analyses 
13.5.5.1 
Iohexol and Creatinine Clearance 
Results from the measurement of iohexol and endogenous and exogenous creatinine 
clearance will be investigated in an exploratory manner with more details provided in the 
statistical analysis plan (SAP) (e.g., measured GFR, endogenous creatinine clearance in 
relation to exogenous creatinine clearance).  
Iohexol clearance (ClIohexol), as a gold standard measure of GFR, will be correlated to 
creatinine clearance at the different time points in a subset of patients.  
The ClIohexol will be calculated by a 2-compartment model where ClIohexol = dose/area under 
the curve from 0 to infinity, with extrapolation from 6 hours to infinity, and potentially a 
more refined model. 
Only descriptive methods will be applied for assessing exogenous creatinine clearance. 
Effective renal plasma flow will be correlated with the iohexol clearances and creatinine 
clearances. 

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13.5.5.2 
Pharmacodynamics 
Endpoints for pharmacodynamics will be urinary levels of ATP, ADP, AMP, cAMP, and 
adenosine. 
Urinary levels of ATP, ADP, AMP, cAMP, and adenosine will be analyzed in an exploratory 
fashion. 
13.5.6 References 
Castagnet S, Blasco H, Vourc’h P, et al. Routine determination of GFR in renal transplant 
recipients by HPLC quantification of plasma iohexol concentrations and comparison with 
estimated GFR. J Clin Lab Anal. 2012;26(5):376-83.   
Laroute V, Lefebvre HP, Costes G, et al. Measurement of glomerular filtration rate and 
effective renal plasma flow in the conscious beagle dog by single intravenous bolus of 
iohexol and p-aminohippuric acid. J Pharmacol Toxicol Methods. 1999;41(1):17-25. 

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13.5.7 Schedule of Assessments for Iohexol and Exogenous Creatinine Clearance (Including 
Pharmacodynamics) 
Table 13-3 
Schedule of Assessments for Iohexol and Exogenous Creatinine Clearance 
 
Day 1 
Day 2 to Day 6 
Day 7 or ICU discharge 
Just prior to 
bolus iohexol 
0 min 
60 min 
120 min 
360 min 
0 min 
360 min 
Just prior to 
bolus iohexol  0 min 
60 min 
120 min 
360 min 
Iohexol bolus 
 
X 
 
 
 
 
 
 
X 
 
 
 
Urine sample from 
collection bag 
(5 mL) 
X 
 
 
 
X 
 
X 
X 
 
 
 
X 
6 ± 1 hour urine 
collection 
 
Xa 
X 
 
Xa 
Direct sample from 
Foley catheter 
(5 mL) 
 
 
X 
X 
X 
 
 
 
 
X 
X 
X 
Blood sampling 
iohexol 
X 
 
X 
X 
X 
 
 
X 
 
X 
X 
X 
Regular blood 
sampling creatinine 
/BUNb 
X 
 
 
 
Xa 
X 
X 
X 
 
 
 
Xa 
RRT effluent 
samplec 
 
 
 
 
X 
 
X 
 
 
 
 
X 
Abbreviations: BUN = blood urea nitrogen; ICU = intensive care unit; min = minute; RRT = renal replacement therapy. 
a. 
For any deviation of 6 ± 1 hour urine sampling, the regular blood sample for central laboratory creatinine/BUN assessment should be taken at the same deviating time point. 
b. 
Creatinine and BUN will be measured by a central laboratory. At Days 60 and 90, only serum creatinine will be measured. When patients have a Foley catheter, serum 
creatinine samples should be collected prior to and immediately after each urine collection for at least up to Day 7. If the patient is discharged from the ICU, the Foley 
catheter might be removed. In this case, a patient might urinate spontaneously and all efforts should be undertaken to start collecting urine produced from this time point 
onward. Approximately 6 hours later the patient might urinate again and this urine will be used for analysis, and a blood sample will be drawn at this time too. The urine 
volume produced over the approximately 6 hours will be entered in the electronic case report form.  

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c. 
When the patient is on RRT, a sample of the effluent of the RRT machine should be taken at the end of the time interval of the urine collection period. 
 
Table 13-4 
Schedule of Assessments for Pharmacodynamics 
Assessment 
Screening 
(≤ 24 h) 
Baseline 
(≤ 24 h) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
(± 1 
day) 
Day 
14 
(± 2 
days) 
Day 
21 
(± 3 
days) 
Day 
28 
(± 3 
days) 
Day 
60 
(± 5 
days) 
Day 
90 
(± 10 
days) 
Pharmacodynamics, central laboratory 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Abbreviation: h = hour. 
 

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13.5.8 Flowchart of Assessments for Iohexol and Exogenous Creatinine 
Clearance (Including Pharmacodynamics) 
Figure 13-2 
Flowchart of Assessments for Iohexol and Exogenous Creatinine 
Clearance (Including Pharmacodynamics) 

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Admission to ICU or 
intermediate care unit
Pre screen pt
Obtain 
informed 
consent
Pt eligibility
Perform 
baseline 
assessments
Randomize pt
Pt eligibility
Perform day 1 
assesements
Start day 1 
treatment < 24 
hrs of AKI 
diagnoses
AKI diagnoses based on serum creatinine ↑ 26.2 µmol/L or 150% < 48 hrs or UO < 0.5 ml/kg/
hr > 6 hrs
Creatinine increase of local serum creatinine vs reference creatinine results 
(reference in order of preference: 1) Lowest value within 3 months of the hospital admission. 
If not available, 2) at hospital admission. If not available, 3) at ICU or intermediate care unit 
admission. If not available, 4) lowest value between 3 and 12 months prior to hospital 
admission)
Consent patient, legal representative or independant physician, retrieve IVRS pt screening 
number
Score APACHE, SAPS-2, SOFA, EQ-5D
Vital signs and physical examination, ECG
Local lab hematology and clinical chemistry panel 
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, proteinuria, and 
urine biomarkers 
Central lab: serum creatinine and BUN if possible before and after urine collection interval, 
else one sample, AP
Central lab: serology, ADA, serum biomarker sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Concomitant medication
Vasopressor and inotropic therapy
Confirm compliance with inclusion/exclusion criteria
Local laboratory fluid corrected confirmation of serum creatinine ↑ if AKI diagnose is 
based on creatinine criterion
Confirmation of UO< 0.5 ml/kg/hr last 6 hrs if AKI diagnose is based on UO criterion 
Call IVRS to randomly assign the patient a treatment number
Retrieve pt medication kit
Prepare medication < 3 hrs of administration
Time from first diagnosis of SA-AKI to start of recAP treatment
Central lab PK and PD
Administer per instructions provided
Confirm compliance with inclusion/exclusion criteria
Day 0
Screen pt
Medical history, Child-Pugh only if hepatic disease
Demographics
Local lab pregnancy test 
Concomitant medication (verification that no forbidden concomitant medication are taken)
Local lab confirmatory serum creatinine sample 
If available: 
Recent hematology & clinical chemistry panel
Recent Microbial test results
Day 1
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
Administer iohexol bolus
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, proteinuria, 
and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak
Central lab PD 
Central lab biomarker serum sample, iohexol serum and urine samples, and effluent 
RRT sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
CRRT?
▲
Obtain 
randomization 
number
Call IVRS to obtain patient number
 

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Start day 2 
treatment
24±1 hrs post 
day 1 dose
Perform day 2 
assessments
Score SOFA
Vital signs and physical examination
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak, effluent RRT sample
Central lab PD 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Central lab PK through
Administer per instructions provided
Day 2
Start day 3 
treatment
Administer per instructions provided
Perform day 3 
assessments
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK peak, effluent RRT sample
Central lab PD 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Day 3
CRRT?
▲
Perform day 4 
assessments
Perform Day 5 
assessments
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
▲
Day 4
Day 5
ICU or intermediate care unit Discharge: Score EQ-5D
Determine length of ICU or intermediate care unit stay
Hospital Discharge: Score EQ-5D
Central creatinine and BUN
Determine length of hospital stay
Stop CRRT if at least one of the following criteria is met:
Diuresis > 30 ml/hr
Endogenous creatinine clearance over 6 hrs interval > 20 
ml/min
▲
Start CRRT if at least one of the following criteria is met:
Anuria >6 hrs
Oliguria < 200 ml / 12 hrs
Hyperkalemia > 6.5 mmol/L
Metabolic Acidosis pH<7.2 with normal pCO2
Volume Overload
Azotemia Urea > 30 mmol/L or creat > 300 µmol/L
Symptomatic Uraemia
Score SOFA
Vital signs and physical examination
Day 5 only: local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection interval
Central lab PK through, effluent RRT sample
Central lab PD 
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
 

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Day 14 Visit
Day 21 Visit
Day 28 Visit
Score ventilator-free days, shock-free days
Vital signs and physical examination
Local lab hematology and clinical chemistry panel
Central lab ADA, serology and biomarker serum sample, and biomarker urine and 
proteinuria samples
Central lab serum creatinine and BUN (i.a. before and after urine sampling 
interval)
If still on ICU or intermediate care unit:
Score SOFA
6 ± 1 hrs interval urine collection central lab creatinine, sodium, BUN and urine 
biomarkers
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients 
Vital signs and physical examination
ECG
Local lab hematology and clinical chemistry panel
Central lab ADA, serology and biomarker serum, and biomarker urine and urine 
samples
Central lab serum creatinine and BUN (i.e. before and after urine sampling 
interval, else one sample)
If still on ICU or intermediate care unit:
Score SOFA
6 ±1 hrs interval urine collection for central lab creatinine, sodium, BUN and urine 
biomarkers
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Vital signs and physical examination
Local lab hematology and clinical chemistry
Central lab Biomarker serum, and Biomarker urine and proteinuria samples
Central lab serum creatinine and BUN (i.e.before and after urine sampling 
interval, else one sample)
If still on ICU or intermediate care unit:
Score SOFA
6 ± 1 hrs interval urine collection for central lab creatinine, sodium and BUN
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
Perform Day 7 
assessments
Perform Day 6 
assessments
RRT or 
ICU/ Intermediate 
care unit/Hosp 
discharge?
Score SOFA
Vital signs and physical examination
Local lab hematology and clinical chemistry panel excluding AP
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Administer iohexol bolus
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection 
interval
Central lab PK through 
Central lab PD
Central lab Biomarker serum sample
Central lab iohexol serum and urine samples, effluent RRT sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
RRT or 
ICU/Intermediate 
care unit/Hosp 
discharge?
▲
▲
Day 6
Day 7
Score SOFA
Vital signs and physical examination
6 ± 1 hrs interval urine collection for central lab creatinine, sodium, BUN, 
proteinuria, and urine biomarkers
Volume of urine
Central lab: serum creatinine and BUN, before and after urine collection 
interval
Central lab PK through, effluent RRT sample 
Central lab PD
Central lab biomarker serum sample
PaO2, FiO2, PEEP and tidal volume for mechanically ventilated patients
 

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Day 60 Follow- 
Up Visit
Day 90 Follow- 
Up Visit
Central lab ADA sample
Central lab serum creatinine
Central lab proteinuria
Need for chronic dialysis
Central lab ADA sample
Central lab serum creatinine
Central lab proteinuria
Score EQ-5D
Need for chronic dialysis
Every Visit until Day 28:
Concomitant Medication
Vasopressor Infusion Rate
Every Visit until Day 90: 
Adverse Events
Mortality
Complete
 
Abbreviations: ADA = anti-drug antibodies; AKI = acute kidney injury; AP = alkaline phosphatase; APACHE = acute 
physiology and chronic health evaluation; BUN = blood urea nitrogen; CRRT = continuous renal replacement therapy; 
ECG = electrocardiogram; FiO2 = fraction of inspired oxygen; Hosp = hospital; hrs = hours; ICU = intensive care unit; 
IVRS = interactive voice response system; lab = laboratory; PEEP = positive end expiratory pressure; 
PK = pharmacokinetics; pt = patient; recAP = recombinant human alkaline phosphatase; RRT = renal replacement therapy; 
SAPS-2 = simplified acute physiology score 2; SOFA = sequential organ failure assessment; UO = urine output. 

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14  Protocol Amendments 
The original Protocol Version 1.0 was dated 27 May 2014. Additions to the study protocol 
are shown in bold and deletions are shown in strike through text. Corrections of obvious 
typing errors or omissions and other editorial changes are not highlighted. 
14.1 Amendment 1 
The following changes from the original protocol were included in Protocol Version 2.0, 
including Amendment 1, dated 08 Oct 2014. In addition, some spelling mistakes and 
abbreviations have been corrected. 
14.1.1 Change Number 1 
The IND number was added to the protocol. 
14.1.1.1 
Reason: 
To provide the IND number, which was obtained after Protocol Version 1.0 dated 
27 May 2014 was finalized. 
14.1.1.2 
Protocol Section: 
Cover page 
Change to or Section Deleted: 
IND number: not available 117605 
14.1.2 Change Number 2 
Study design section has been amendment in regards to inclusion and exclusion criteria. 
14.1.2.1 
Reason:  
To clarify that all inclusion criteria and none of the exclusion criteria are to be met. 
14.1.2.2 
Protocol Section: 
Synopsis (Study Design) 

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Change to or Section Deleted: 
As soon as possible when all inclusion and none of the exclusion criteria are met, and after 
confirmation of continuing (i.e., not resolving) AKI by a fluid-corrected serum creatinine 
assessment or urine output, eligible patients will be randomly assigned to a treatment group 
(Day 0), undergo baseline determinations, and start treatment with study drug (Day 1). 
14.1.2.3 
Protocol Section: 
Section 3.1 Study Design 
Change to or Section Deleted: 
As soon as possible when all inclusion and none of the exclusion criteria are met (see 
Section 4.1), and after confirmation of continuing (i.e., not resolving) AKI by a fluid-
corrected serum creatinine assessment (see Section 13.3) or urine output, eligible patients 
will be randomly assigned to a treatment group (Day 0), undergo baseline determinations, 
and start treatment with study drug (Day 1). 
14.1.3 Change Number 3 
Safety reporting requirements in Section 6.3 and Sections 6.3.14 to 6.5 (inclusive) have been 
amended in the study protocol and all exemptions to AE or SAE reporting have been 
removed. Consequently, investigators will be required to report all AEs, regardless of 
causality, occurring since the informed consent form has been signed until Day 30 after last 
dose of study drug or later for events possibly, probably, or definitely related to study drug. 
14.1.3.1 
Reason:  
Per FDA request, all AEs and SAEs must be recorded in the eCRF. 
14.1.3.2 
Protocol Section: 
Section 6.3 Study Procedures 
Change to or Section Deleted: 
Details of AE reporting and exceptions are provided in Section 6.3.14.3 6.3.14.6. 

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14.1.3.3 
Protocol Section: 
Section 6.3.14 Adverse Events 
Change to or Section Deleted: 
The investigator is responsible for reporting all treatment-emergent AEs (TEAEs) that are 
observed or reported during the study, regardless of their relationship to study drug or their 
clinical significance. However, because the patients participating in this study will experience 
clinical events that are related to severe sepsis, events leading to clinical outcomes related to 
severe sepsis are exempt from (S)AE reporting, unless the investigator considers the event(s) 
to have been caused by recAP. See Section 6.3.14.6 for details regarding events exempt from 
AE reporting. 
14.1.3.4 
Protocol Section: 
Section 6.3.14.1 Definitions of Adverse Events 
Change to or Section Deleted: 
An AE is defined as any untoward medical occurrence in a patient enrolled into a clinical 
study regardless of its causal relationship to study drug.  
A TEAE is defined as any event not present before exposure to study drug or any event 
already present that worsens in either intensity or frequency after exposure to study drug. 
However, in this study conducted in patients with severe sepsis, many medical events related 
to the underlying condition are expected to occur irrespective of treatment. Reporting all 
“events” will pose a burden on the investigators and staff and will likely not contribute to, 
and even complicate, the safety evaluation. Therefore, events leading to clinical outcomes 
that are related to severe sepsis are exempt from (S)AE reporting, as described in Section 
6.3.14.6. 
14.1.3.5 
Protocol Section: 
Section 6.3.14.2 Eliciting and Documenting Adverse Events 

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Change to or Section Deleted: 
Treatment-emergent aAdverse events will be collected and assessed from the time the patient 
signs the ICF until exit from the study or 30 days after the last dose of the study drug, 
whichever is later or later for events possibly, probably, or definitely related to study 
drug. Any AE that occurs during or after the first dose of study drug is considered treatment 
emergent. 
… 
In addition to patient observations, TEAEs will be documented from any data collected on 
the AE page of the eCRF (e.g., laboratory values, physical examination findings) or 
identified from review of other documents (e.g., patient diaries) that are relevant to patient 
safety. 
Events leading to clinical outcomes related to severe sepsis are exempt from (S)AE recording 
in the eCRF, unless the investigator considers the event(s) to have been possibly, probably, or 
definitely caused by recAP. See Section 6.3.14.6 for details regarding events exempt from 
(S)AE reporting. 
14.1.3.6 
Protocol Section: 
Section 6.3.14.3 Reporting Adverse Events 
Change to or Section Deleted: 
All TEAEs reported or observed after the patient signs the ICF, except those described in 
Section 6.3.14.6, will be recorded on the AE page of the eCRF. 
… 
Any AE that meets SAE criteria (see Section 6.3.14.1) must be reported to the PPD 
Pharmacovigilance Department immediately (i.e., within 24 hours) after the time site staff 
first learn about the event., unless it is exempt from reporting as per Section 6.3.14.6.  
14.1.3.7 
Protocol Section: 
Section 6.3.14.5 Assessment of Causality 

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Change to or Section Deleted: 
The investigator’s assessment of an AE’s relationship to study drug is part of the 
documentation process, and only for events described in Section 6.3.14.6 will be a factor in 
determining what is or is not reported in the study. If there is any doubt as to whether a 
clinical observation is an AE or whether it is related to study drug, the event should be 
reported. For events specified in Section 6.3.14.6, only those considered related to study drug 
(both AEs and SAEs) are required to be reported. 
14.1.3.8 
Protocol Section: 
Section 6.3.14.6 Exemptions from Adverse Event Reporting 
Change to or Section Deleted: 
Entire section deleted. 
14.1.3.9 
Protocol Section: 
Section 6.3.14.7 Follow-up of Patients Reporting Adverse Events 
Change to or Section Deleted: 
Renumbered to Section 6.3.14.6. 
All TEAEs, except those exempt from reporting as per Section 6.3.14.6, must be reported in 
detail on the appropriate page of the eCRF and followed to satisfactory resolution, until the 
investigator deems the event to be chronic or not clinically significant, or until the patient is 
considered to be stable. 
14.1.3.10 Protocol Section: 
Section 6.5 Laboratory Analyses 
Change to or Section Deleted: 
Any clinically significant safety and laboratory assessments that are associated with the 
underlying disease, i.e., severe sepsis, are not to be reported as (S)AEs, unless judged by the 

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investigator to be more severe than expected for the patient’s condition or considered 
possibly, probably, or definitely related to study drug (see Section 6.3.14.6). 
Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or other 
safety assessments (e.g., ECGs, vital sign measurements), including those that worsen from 
baseline, felt to be clinically significant in the medical and scientific judgment of the 
investigator, are to be recorded as (S)AEs, except those exempt from reporting as per Section 
6.3.14.6. 
14.1.3.11 Protocol Section: 
Section 13.1 Appendix 1: Schedule of Assessments; Table 13-1 Schedule of Assessments 
Change to or Section Deleted: 
Deleted footnote: 
X 
See Section 6.3.14.6 for exemptions. 
14.1.4 Change Number 4 
The following changes to vital sign measurements were implemented: 1) Vital sign 
monitoring requirements were amended to include at least hourly monitoring up to 6 hours 
after the start of infusion of IMP on Day 1; 2) Oxygen saturation was added to the vital sign 
assessments; 3) It was specified that blood pressure will be monitored non-invasively, or 
invasively via arterial line in patients who already have an arterial line placed as part of 
standard or care. 
14.1.4.1 
Reason:  
Because postural hypotension was reported 3 hours after dosing of recAP in the Phase 1 
study, monitoring of vital signs has been extended until 6 hours after the start of the study 
infusion on Day 1. Additionally, oxygen saturation has been added to the vital sign 
assessments because capturing measurements of this parameter during infusion and 
afterwards would not be associated with any risk to patients, while it would provide useful 
data on the safety of recAP infusion in a critically ill population, assist causality assessment 
for any associate drug reactions (especially cardiovascular and respiratory) that occur in close 
proximity to infusion, and help exclude hypoxia as cause of dizziness (which was observed 

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in the Phase 1 study but which mechanism is unknown). If the study demonstrated no effect 
on oxygen saturation of IMP infusion, this would provide additional support for safety of use 
of recAP in the critically ill patient population. Finally, text has been amended to clarify that 
blood pressure will be monitored non-invasively, or invasively via arterial line in patients 
who already have an arterial line placed as part of standard or care, as it is expected that a 
significant proportion of patients in this study will undergo invasive blood pressure 
monitoring via arterial line; thus, these readings should be acceptable.  
14.1.4.2 
Protocol Section: 
Synopsis (Safety Assessments) 
Change to or Section Deleted 
The following assessments will be considered as safety measurements: 
• 
Vital signs, including blood pressure, heart rate, oxygen saturation, respiratory rate, 
and body temperature at baseline and at all visits from Day 1 to Day 28. During the 3 dosing 
days (Day 1 to Day 3), repeated vital sign measurements will be performed. 
14.1.4.3 
Protocol Section: 
Section 6.2.2 Baseline Assessments 
Change to or Section Deleted 
The following assessments will be performed at baseline after randomization (i.e., at study 
inclusion, not necessarily at ICU admission date): 
• 
Vital signs (temperature, heart rate, respiratory rate, oxygen saturation, and blood 
pressure) 
14.1.4.4 
Protocol Section: 
Section 6.2.4 Safety Assessments 
Change to or Section Deleted: 
The following assessments will be considered as safety measurements: 

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• 
Vital signs, including blood pressure, heart rate, oxygen saturation, respiratory rate, 
and body temperature at baseline and at all visits from Day 1 to Day 28. During the 3 dosing 
days (Day 1 to Day 3), repeated vital sign measurements will be performed (see Section 
6.3.4). 
14.1.4.5 
Protocol Section: 
Section 6.3.4 Vital Signs 
Change to or Section Deleted: 
Vital signs, including temperature, heart rate, oxygen saturation, respiratory rate and blood 
pressure, will be measured at baseline, and at all subsequent visits from Day 1 to Day 28 (see 
Section 13.1 [Table 13-1] and Section 13.2 [Figure 13-1]). Vital signs in ambulant patients 
will be measured with the patient in a sitting position and after 5 minutes rest. Blood 
pressure will be monitored non-invasively. In patients who already have an arterial line 
placed as part of standard or care, readings from invasive blood pressure monitoring 
are to be recorded. 
On visit days when study drug is administered (Days 1, 2 and 3), vital signs (excluding 
temperature) will be measured and recorded as follows: 
Immediately before the administration of the study drug 
Within 5 minutes of the start of the study drug infusion  
30 minutes after the start of the study drug infusion 
Immediately after the completion of the administration of the study drug, which includes 
post-dose saline flushing 
Approximately 30 and 60 minutes after completion of study drug administration.  
Additionally, on Day 1 only, vital signs will be measured and recorded as follows:  
2 hours, 3 hours, 4 hours, and 5 hours after the completion of study drug 
administration 
14.1.4.6 
Protocol Section: 
Section 13.1 Appendix 1: Schedule of Assessments; Table 13 1 Schedule of Assessments 

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Change to or Section Deleted: 
Vital signs (BP, HR, OS, RR, T)g 
 
… 
Footnotes: 
Abbreviations: … OS = oxygen saturation 
g 
Vital signs in ambulant patients will be obtained with the patient in a sitting position 
and after 5 minutes rest. Blood pressure will be monitored non-invasively. In patients who 
already have an arterial line placed as part of standard or care, readings from invasive blood 
pressure monitoring are to be recorded. 
h 
Additionally, vital signs (excluding temperature) will also be monitored during study 
drug infusion on all treatment days at the following times: a) immediately before the 
administration of the study drug, b) within 5 minutes of the start of the study drug infusion, 
c) 30 minutes after the start of the study drug infusion, d) immediately after the completion 
of the administration of the study drug, which includes post-dose saline flushing, e) 
approximately 30 and 60 minutes after completion of study drug administration, f) 2 hours, 3 
hours, 4 hours, and 5 hours after completion of study drug administration (Day 1 only). 
14.1.5 Change Number 5 
Accumulating safety and efficacy data during Part 1 of the study will be reviewed 
periodically and ad hoc by the DMC as described in the DMC charter, in addition to the 
already mentioned DMC role of selecting dose. 
14.1.5.1 
Reason:  
Regular interim analyses of the accumulating safety data should be performed to enhance the 
safety of trial participants. 
14.1.5.2 
Protocol Section: 
Section 10.1.1 External Data Monitoring Committee 

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Change to or Section Deleted: 
An independent DMC will review the results of the interim analysis and select the optimum 
recAP dose for Part 2 of the study (see Section 7.7.5). Accumulating safety and efficacy 
data will be reviewed at predefined milestones during Part 1 and Part 2 of the study by 
the independent DMC as described in the DMC charter. 
14.1.6 Change Number 6 
The definition of the primary endpoint was amended from creatinine clearance to area under 
the time-corrected endogenous creatinine clearance curve from Day 1 to Day 7 (AUC1-7). 
The formula for calculation of the AUC1-7 was amended to indicate that this will be the 
average of the time-corrected endogenous creatinine clearance values over the 7 days. 
14.1.6.1 
Reason:  
Clarification required regarding the specific measurement to be used in the primary analysis 
and its calculation 
14.1.6.2 
Protocol Section: 
Synopsis (Rationale, Efficacy Assessments, Sample Size, and Statistical Methods) 
Change to or Section Deleted: 
The primary endpoint, area under the time-corrected endogenous creatinine clearance 
curve, was chosen because… 
… 
Urine and serum creatinine determinations will be performed to enable calculation of time- 
corrected endogenous creatinine clearance, considered as the primary endpoint, at all visits 
from Day 0 to Day 7, and calculated by the central laboratory. The measurements from Day 
1 to Day 7, inclusive, will be used to calculate the primary endpoint. Only if reliable urine 
collection is possible, urine will be collected on Days 14, 21, and 28 for time-corrected 
endogenous creatinine clearance (i.e., patient is in the ICU or hospital). 
… 

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Each scenario assumed a standard deviation of 49 mL/min for the primary endpoint (area 
under the time-corrected endogenous creatinine clearance curve from Day 1 to Day 7 
[AUC1-7])… 
… 
The primary efficacy endpoint, area under the time-corrected endogenous creatinine 
clearance curve from Day 1 to Day 7 (AUC1-7), will be summarized using descriptive 
statistics and analyzed using analysis of variance with treatment and site as explanatory 
variables. 
14.1.6.3 
Protocol Section: 
List of Abbreviations 
Change to or Section Deleted: 
AUC1-7 
area under the time-corrected endogenous creatinine clearance curve 
from Day 1 to Day 7 
14.1.6.4 
Protocol Section: 
Section 3.1.1 Rationale of Study Design 
Change to or Section Deleted: 
Assuming comparable safety profiles, the most effective dose will be selected at the interim 
analysis by an independent DMC. The primary endpoint, area under the time-corrected 
endogenous creatinine clearance curve, was chosen because as a continuous variable it is 
sensitive for detecting relatively small treatment effect differences of recAP versus placebo, 
as well as determination of effect size differences between the different dosages. 
14.1.6.5 
Protocol Section: 
Section 6.2.3 Efficacy Assessments 
Change to or Section Deleted: 
Urine and serum creatinine determinations will be performed to enable calculation of 
time-corrected endogenous creatinine clearance, considered as the primary endpoint, at all 

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visits from Day 0 to Day 7, and calculated by the central laboratory. The measurements 
from Day 1 to Day 7, inclusive, will be used to calculate the primary endpoint. Only if 
reliable urine collection is possible, urine will be collected on Days 14, 21, and 28 for 
time-corrected endogenous creatinine clearance (i.e., patient is in the ICU or hospital). If 
reliable urine collection is not possible, serum creatinine samples still need to be taken for 
eGFR at all visits. 
14.1.6.6 
Protocol Section: 
Section 6.3.8.1 Endogenous Creatinine and Blood Urea Nitrogen Clearance 
Change to or Section Deleted: 
The efficacy of the treatment will be investigated by calculating the time-adjusted corrected 
endogenous creatinine clearance. Blood urea nitrogen clearance will also be measured. To 
calculate the time-corrected endogenous creatinine clearance, timed urine (including 
measurement of volume) and blood samples need to be collected.  
Urine and serum creatinine determinations will be performed to enable calculation of 
time-corrected endogenous creatinine clearance, considered as the primary endpoint, at all 
visits from Day 0 to Day 7, and calculated by the central laboratory. The measurements 
from Day 1 to Day 7, inclusive, will be used to calculate the primary endpoint. Only if 
reliable urine collection is possible, urine will be collected on Days 14, 21, and 28 for 
time-corrected endogenous creatinine clearance (i.e., patient is in the ICU or hospital).  
14.1.6.7 
Protocol Section: 
Section 6.3.8.6 Pharmacodynamic Assessments 
Change to or Section Deleted: 
For a limited number of sites, a urine sample for pharmacodynamic (PD) assessment will be 
taken from the 6 ± 1 hour urine collection as required for calculation of the time-corrected 
endogenous creatinine clearance. Detailed instructions to these sites for PD assessments are 
provided in Section 13.5. 

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14.1.6.8 
Protocol Section: 
Section 7.1 Primary Endpoint 
Change to or Section Deleted: 
The primary endpoint will be calculated from is time-adjusted corrected endogenous 
creatinine clearance measurements on Day 1 (first measurement after treatment) to 
Day 7, inclusive. Time-corrected endogenous creatinine clearance is assessed on each 
day during a 6 ± 1 hour period and calculated in mL/min as the mean creatinine 
clearance over the period, which is expected to be representative of the full 24 hours for 
that day. The primary endpoint is the area under the time-corrected endogenous 
creatinine clearance curve from Day 1 to Day 7 (AUC1-7), i.e., area under the creatinine 
clearance curve from Day 1 [first measurement after treatment] to Day 7, inclusive), with the 
creatinine clearance curve being the mean creatinine clearance on each day. AUC1-7 is 
calculated as a weighted the average of the time-corrected endogenous creatinine clearance 
values over the 7 days. Specifically, dDenoting Ci as the mean time-corrected endogenous 
creatinine clearance on Dayi, AUC1-7 is defined as: 
 
 
… 
14.1.6.9 
Protocol Section: 
Section 7.7.1 Analysis of Primary Efficacy Endpoint 
Change to or Section Deleted: 
The primary efficacy endpoint is the area under the time-corrected adjusted endogenous 
creatinine clearance curve from Day 1 to Day 7, i.e., the AUC1-7. 
Area under the time-corrected endogenous creatinine clearance curve from Day 1 to Day 7 
will be summarized using descriptive statistics and analyzed using an analysis of variance 
(ANOVA) with treatment and site as explanatory variables. 

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14.1.6.10 Protocol Section: 
Section 13.5.4 Pharmacodynamic Assessments 
Change to or Section Deleted: 
A urine sample for pharmacodynamic assessment will be taken from the 6 ± 1 hour urine 
collection as required for calculation of the time-corrected endogenous creatinine 
clearance… 
14.1.6.11 Protocol Section: 
Figure 3-1 Study Design 
Change to or Section Deleted: 
 

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Abbreviations: AUC = area under the concentration time curve; ICF = informed consent form; ICU = intensive 
care unit; IV = intravenous; recAP = recombinant human alkaline phosphatase; RRT = renal replacement 
therapy; SA-AKI = sepsis-associated acute kidney injury.

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14.1.7 Change Number 7 
The following changes were made to the statistical methods: 1) The 
 in the combination 
test is now specified as follows: for the single hypothesis, 
 is the unadjusted p-value to 
compare optimal dose with placebo in Part 1, while for the intersection hypotheses, 
 is the 
Dunnett-adjusted p-value in Part 1; 2) Any missing Ci values will be handled by linear 
interpolation where possible, otherwise they will be imputed by last observation carried 
forward or imputed as the baseline measurement from Day 0 (when there are no preceding 
post-baseline measurements to use); 3) n1 and n2 in the formula for the combination test are 
specified as the sample size per group in Parts 1 and 2 respectively. 
14.1.7.1 
Reason:  
This is a proof-of-concept trial where strong control of type I error rate is not necessary 
because it is purely for learning. A learning trial provides an opportunity for fully exploring 
dose response from which a dose or doses can be selected with good precision for study in 
Phase 3 trials. Clarification is required to specify where the 
 in the combination test should 
correspond to the Dunnett-adjusted p-value in Part 1. In addition, there should be baseline 
measurements available for all patients, which should be used for the imputation of 
 when 
such cases arise. Clarification is also needed to specify that n1 and n2 in the formula for the 
combination test represent the sample size per group in Parts 1 and 2 respectively, rather than 
the overall sample size in Part 1 or 2. 
14.1.7.2 
Protocol Section: 
Synopsis (Statistical Methods) 
Change or Section Deleted: 
The analysis will be performed separately for Parts 1 and 2: for Part 1, AUC1-7 will be 
compared between the 4 treatment groups using Dunnett test and a closed testing procedure 
3 recAP doses and placebo. 
… 

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Confirmatory testing of the single hypothesis comparing optimal dose with placebo will 
be based on a closed-testing procedure. This hypothesis will be rejected at level α if it 
and all intersection hypotheses involving it are all rejected at local level α. The testing 
strategy used to combine results from Parts 1 and 2 will be The results from Parts 1 and 2 
will be combined using a combination test based on the inverse normal method. 
14.1.7.3 
Protocol Section: 
Section 7.1 Primary Endpoint 
Change to or Section Deleted: 
Any missing Ci values will be handled by linear interpolation within the AUC calculation 
where possible, otherwise they will be imputed by last observation carried forward (LOCF). 
or imputed as zero (Wwhen there are no preceding post-baseline measurements to carry 
forward).use, the baseline measurement from Day 0 (i.e., prior to treatment) will be 
carried forward. 
14.1.7.4 
Protocol Section: 
Section 7.7.1 Analysis of Primary Efficacy Endpoint 
Change to or Section Deleted: 
The analysis will be performed separately for Parts 1 and 2: for Part 1, AUC1-7 will be 
compared between the 4 3 recAP doses and placebo. treatment groups using Dunnett test 
and a closed testing procedure. This analysis will be considered in conjunction with the 
safety data to determine the optimal recAP dose for use in Part 2. For Part 2, the optimal 
recAP dose will be compared with placebo. Confirmatory testing of the single hypothesis 
comparing optimal dose with placebo will be based on a closed-testing procedure. This 
hypothesis will be rejected at level α if it and all intersection hypotheses involving it are 
all rejected at local level α. The testing strategy used to combine results from Parts 1 
and 2 will be The results from Parts 1 and 2 will be combined using a combination test based 
on the inverse normal method, with the test statistic of the combination test calculated as 
(Bauer and Köhne 1994): 

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where 
 and 
 are the sample sizes per group in Parts 1 and 2, respectively, 
, 
Φ refers to the standard normal distribution, and 
 and 
 are the p-values from Parts 
1 and 2, respectively. For the single hypothesis, 
 is the unadjusted p-value to compare 
optimal dose with placebo in Part 1. For the intersection hypotheses, 
 is the Dunnett-
adjusted p-value in Part 1, and 
 is the unadjusted p-value to compare optimal dose 
with placebo in Part 2 for all hypotheses. and 
 and 
 are the unadjusted p-values from 
Parts 1 and 2, respectively, and Φ refers to the standard normal distribution. 
14.1.8 Change Number 8 
Updates were made to the criteria leading to withdrawal from the study and discontinuation 
of study drug, and updates were made to the procedures followed after a patient withdraws or 
is discontinued from the study. 
14.1.8.1 
Reason:  
To clarify that withdrawal from the study is not equivalent to discontinuation of study drug, 
and to clarify the procedures to follow when a withdrawal/discontinuation criterion is met. 
14.1.8.2 
Protocol Section: 
Section 4.2.1 Reasons for Withdrawal/Discontinuation 
Change to or Section Deleted: 
Patients may withdraw from the study at any time and for any reason without prejudice to 
their future medical care by the investigator or at the study site. Every effort should be made 
to keep patients in the study. The reasons for patients not completing the study will be 
recorded. Investigators should attempt to determine the cause of withdrawal and, if 
desired by the patient, to let the patient return for the Day 90 visit (last safety only 
follow-up visit). The extent of a patient’s withdrawal from the study (i.e., withdrawal 
from further study treatment, withdrawal from active participation in the study, 
withdrawal from any further contact) should be documented. Every effort should be 

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taken to follow all randomized patients, to the extent that the patient will allow, for the 
full follow-up period.  
A patient may be withdrawn from the study Treatment with study drug will be stopped for 
any of the following reasons: 
1. Any clinical adverse event (AE), laboratory abnormality, or intercurrent illness which, in 
the opinion of the investigator, indicates that continued participation in the study 
treatment with study drug is not in the best interest of the patient. 
2. Protocol non-compliance or violations. The patient withdraws consent or the 
investigator or sponsor decides to discontinue the patient’s participation in the 
study. 
3 The patient withdraws consent or the investigator or sponsor decides to discontinue the 
patient’s participation in the study. AM-Pharma B.V. terminates the study. 
4. AM-Pharma B.V. terminates the study. 
Additionally, treatment with study drug may be stopped in case of protocol non-
compliance or violations. In this case, the investigator will contact the Medical Monitor 
to discuss risk/benefit balance of continued treatment with study drug.  
In case study drug is discontinued early, the patient will continue follow-up in the study as 
per protocol to allow for intent-to-treat (ITT) analysis. If interrupted for any reason, 
re-starting of study drug should be discussed with the Medical Monitor. 
The reason for and date of study drug discontinuation and the reason for and date of 
withdrawal from the study must be recorded in the electronic case report form (eCRF). 
If study drug is discontinued because of an AE or a clinically significant abnormal 
laboratory test result, evaluations will continue until the event has resolved or stabilized 
or until a determination of a cause unrelated to the study drug or study procedure is 
made. The specific event or laboratory finding(s) must be documented. 
14.1.9 Change Number 9 
It was clarified that patients who discontinue study drug or withdraw from the study will 
complete the end-of-study visit and, if desired by the patient, the follow-up assessments as 
per the study schedule (Day 60 and Day 90). 

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14.1.9.1 
Reason:  
It is critical to have complete and unbiased follow-up for long-term safety assessments. 
14.1.9.2 
Protocol Section: 
Section 4.2.2 Handling of Withdrawals 
Change to or Section Deleted: 
Enrolled patients who discontinue study drug or active participation in the study will no 
longer receive study drug. When a patient withdraws from the study, the investigator will 
record the reason(s) for withdrawal on the relevant page of the eCRF. All patients who 
discontinue study drug or withdraw from the study prematurely will undergo all end-of-study 
(Day 28) assessments immediately upon discontinuation. Investigators should attempt to 
determine the cause of withdrawal and, if desired by the patient, to let the patient 
return for the Day 90 visit (last safety only follow-up visit). (including follow-up of 
ongoing serious AEs [SAEs]). Patients who fail to return for final assessments will be 
contacted by the site in an attempt to have them comply with the protocol; attempts to contact 
patients will be recorded in the eCRF. 
It is vital to obtain follow-up safety data on any patient withdrawn because of an AE or 
serious adverse event (SAE). In every case, efforts must be made to undertake protocol-
specified, safety, follow-up procedures. 
The reason for withdrawal of a patient must be recorded in the eCRF, if it can be ascertained. 
Any further treatment will be at the investigator’s discretion and should be recorded. Every 
effort must be made to follow-up the patient and obtain information on clinical outcome and 
AEs. All data from withdrawals will be included in the final ITT analyses. 
14.1.10 Change Number 10 
The individual benefit for the patients was specified. 
14.1.10.1 Reason:  
According to § 43a paragraph 1number 4 AMG (Austrian drug law), the benefit for the 
patient must be higher than the risk. The individual benefit is to be given.  

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14.1.10.2 Protocol Section: 
New Section 3.1.3 Individual Benefit/Risk Considerations 
Change to or Section Deleted: 
Benefits for patients with sepsis and AKI are anticipated based on pharmacodynamic 
(PD) data and data from 2 Phase 2 studies described in the investigator’s brochure. In 
the APSEP 02-01 study, BiAP was associated with a non-significant survival benefit 
versus placebo and clinically important benefits on renal function parameters of serum 
creatinine, inflammatory and kidney damage biomarkers and dialysis requirements. In 
the APREN01-01 study, BiAP significantly improved kidney function (determined by a 
composite endpoint of creatinine clearance, requirement for RRT and duration of RRT) 
and significantly reduced the length of ICU stay. There was a non-significant trend 
toward a reduction in the requirement for mechanical ventilation and a significant 
improvement in biomarkers of systemic inflammation, renal function, and renal 
damage in blood and urine, suggesting that a systemic anti-inflammatory effect induced 
by the treatment resulted in fast recovery and prevention of further kidney damage. 
No safety concerns were identified in either of these Phase 2 clinical studies with BiAP 
nor in the Phase 1 study in 51 healthy volunteers with recAP. 
14.1.11 Change Number 11 
The total blood volume collected from patients was specified. 
14.1.11.1 Reason:  
The Austrian ethics committee requested that the total blood volume taken was specified in 
the protocol. 
14.1.11.2 Protocol Section: 
Section 6.3.7 Laboratory Tests Performed by the Local Laboratory 
Change to or Section Deleted: 
Blood samples will be collected for local laboratory measurements at baseline, and at visits 
on Days 1, 3, 5, 7, 14, 21, and 28 (see Section 13.1 [Table 13-1] and Section 13.2 

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[Figure 13-1]). Approximately 178 to 208 mL (35 to 42 teaspoons) of blood will be 
collected per patient in total during the study, including tests performed in the local and 
in the central laboratories. 
14.1.11.3 Protocol Section: 
Section 6.3.8 Laboratory Test Performed by Central Laboratory 
Change to or Section Deleted: 
Urine samples for assessment of creatinine, urea, proteinuria, sodium, renal biomarkers, and 
purines will be shipped in one urine collection sample tube. If required for specific visits, 
further distribution to involved central laboratories will be managed centrally. 
Approximately 178 to 208 mL (35 to 42 teaspoons) of blood will be collected per patient 
in total during the study, including tests performed in the local and in the central 
laboratories. 
14.1.12 Change Number 12 
Additional information regarding risks for women of childbearing potential has been added. 
14.1.12.1 Reason:  
To clarify the risks for women of childbearing potential. 
14.1.12.2 Protocol Section: 
Section 6.4 Pregnancy 
Change to or Section Deleted: 
The effect of recAP on pregnancies or infants is not known;, as the safety of this drug 
during pregnancy has not been tested previously in either human or in animal studies. 
Because AP is present in the human placenta it is theoretically possible that 
anti-placental antibodies are developed after receiving study drug. Such antibodies 
could interfere with the ability to have a successful pregnancy. While development of 
anti-drug antibodies has not been seen to date in human studies, the safety experience 

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with this drug is limited to only 37 subjects who received study drug and no data are 
available regarding effect of the drug on human reproduction. 
Ttherefore, female patients who are pregnant or lactating/breastfeeding at time of screening 
or who intend to become pregnant within 28 days of enrolling into the study will be excluded 
from the study (see Section 4.1.2). 
14.1.13 Change Number 13 
References and justification for iohexol and para-aminohippuric acid were added. 
14.1.13.1 Reason:  
Following a discussion on 27 August 2014, the Arnhem-Nijmegen Region Committee of 
Human Subjects Research requested explanation of the added value of the iohexol and para-
aminohippuric acid administration as well as references to literature. 
14.1.13.2 Protocol Section: 
Section 13.5.1 Introduction (Section 13.5 Appendix 5: Iohexol, Para-Aminohippuric Acid, 
and Exogenous Creatinine Clearance Protocol (Including Pharmacodynamics) for Selected 
Sites Only)  
Change to or Section Deleted: 
Accurate measurement of glomerular filtration rate (GFR) and effective renal plasma flow 
(ERPF) are valuable for evaluating kidney function and nephrotoxicity in a variety of clinical 
research and patient care settings. Accurate GFR determinations are recommended to 
appropriately assess the value of pharmacotherapeutic interventions aimed at improving 
tubular microvascular hemodynamics, inflammation and slowing the progression of renal 
disease.  
The measure mostly used for the determination of the kidney function is the creatinine 
clearance as proxy for GFR. However, creatinine clearance is not fully representative in 
unstable situations, such as acute kidney injury, because it is influenced by various 
factors (e.g., diet, muscle mass, physical activity, and excretion and resorption in the 
kidney) and therefore results of creatinine clearance can be an over- or 
under-estimation. Creatinine clearance is routinely used to determine the function of 

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the kidneys irrespective of the drawbacks, since it is inexpensive, non-invasive, and easy 
to perform. 
14.1.14 Change Number 14 
Sample time points of effluent were corrected. 
14.1.14.1 Reason:  
Text was not in agreement with Schedule of Assessments. 
14.1.14.2 Protocol Section: 
Section 13.5.3 Iohexol and Para-Aminohippuric Acid Sampling 
Change to or Section Deleted: 
The sample time points of effluent will be at t = 0 and t = 360 minutes of the urine collection 
interval, analogous to the time points for serum creatinine determinations, as needed for 
endogenous creatinine clearance calculations. Two samples of 1 mL will be taken from the 
effluent and stored in Micronic 1.4-mL cryotubes at –80ºC, until batched shipments to the 
central laboratory are sent and further processing of one of each cryotube at the Hillcrest 
Medical Center can be done. The total volume of effluent will be recorded in the eCRF. 
14.1.14.3 Protocol Section: 
New Section 13.5.6 References (old Section 13.5.6 has been renumbered to 13.5.7, and old 
Section 13.5.7. has been numbered to 13.5.8) 
Change to or Section Deleted: 
Castagnet S, Blasco H, Vourc’h P, et al. Routine determination of GFR in renal 
transplant recipients by HPLC quantification of plasma iohexol concentrations and 
comparison with estimated GFR. J Clin Lab Anal. 2012;26(5):376-83.   
Hirata-Dulas CA, Awni WM, Matzke GR, et al. Evaluation of two intravenous single-
bolus methods for measuring effective renal plasma flow. Am J Kidney Dis. 
1994;23(3):374-81. 

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Laroute V, Lefebvre HP, Costes G, et al. Measurement of glomerular filtration rate and 
effective renal plasma flow in the conscious beagle dog by single intravenous bolus of 
iohexol and p-aminohippuric acid. J Pharmacol Toxicol Methods. 1999;41(1)17-25. 
Prescott LF, Freestone S, McAuslane JA. The concentration-dependent disposition of 
intravenous p-aminohippurate in subjects with normal and impaired renal function. Br 
J Clin Pharmacol. 1993;35(1):20-9. 
14.1.15 Change Number 15 
Address was added for PPD Global Central Laboratory in Belgium. 
14.1.15.1 Reason: 
Administrative change. 
14.1.15.2 Protocol Section: 
Table 10-1 Study Administrative Table 
Change to or Section Deleted: 
Central Laboratoryies 
PPD Global Central Laboratory 
2 Tesseneer Drive 
Highland Heights, KY 41076 
Phone: 859-781-8877 
 
PPD Global Central Laboratory 
Cluster Park 
Kleine Kloosterstraat 19 
B-1932 Zaventem, Belgium 
Phone: +32 2 725 2127 
 
14.1.16 Change Number 16 
Addition of recent microbiological test results to the assessments done at screening in the 
Schedule of Assessments Table. 
14.1.16.1 Reason: 
To provide clarification on missing information from the Schedule of Assessments. 

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14.1.16.2 Protocol Section: 
Section 13.1 Appendix 1: Schedule of Assessments; Table 13 1 Schedule of Assessments 
Change to or Section Deleted: 
Assessment 
Screening (≤ 24 h) 
… 
 
Recent microbial test results, if available 
X 
 
14.2 Amendment 2 
The following changes from Protocol Version 2.0, including Amendment 1, dated 
08 Oct 2014 were included in Protocol Version 3.0, including Amendment 2, dated 
03 Feb 2016.  Additions to the study protocol are shown in bold and deletions are shown in 
strike through text. Corrections of obvious typing errors or omissions and other editorial 
changes are not highlighted.  
14.2.1 Change Number 1 
Addition of new countries and sites and inclusion of text on analysis of patients during 
interim analysis period. 
14.2.1.1 
Reason:  
Addition of new countries and sites projected for the study. Clarification on analysis of 
patients during interim analysis period.  
14.2.1.2 
Protocol Section: 
Synopsis (Study Sites, Study design), Section 3.1 Study Design, Section 4.1 Selection of 
Study Population, Section 7.4 7.4 Sample Size Calculations 
Change to or Section Deleted: 
Approximately 50 100 sites will participate in the study; approximately 75 in the European 
Union and approximately 25 in the United States and Canada. Recruitment will continue 
during the interim analysis.  

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A minimum of 290 patients with SA-AKI will be enrolled in the study. The study involves 
2 parts (Part 1, Part 2) with an interim analysis between the parts, with potentially continued 
recruitment during this interim analysis. Of the 290 planned patients, at least 120 patients 
will enroll in Part 1 and 170 patients will enroll in Part 2 with an estimated 50 patients 
during the interim analysis. Patients enrolled during Part 1 and during the interim 
analysis will be randomly assigned to receive, by 1-hour intravenous (IV) infusion, either 
placebo (Part 1; n1 = 30) or one of 3 different doses of recAP (Part 1; n1 = 30 in each dosing 
arm; i.e., 0.4 mg/kg [250 U/kg], or 0.8 mg/kg [500 U/kg], or 1.6 mg/kg [1000 U/kg]) using a 
1:1:1:1 allocation ratio. Patients will receive study drug by 1-hour IV infusion once daily for 
3 days (Days 1, 2, and 3). The interim analysis on the primary endpoint will be performed on 
all data collected after all the patients the 120th patient of Part 1 has completed the first 
7 days in Part 1 Day 7 visit of the study to select the dose to be administered in Part 2. The 
dose chosen will be the optimal dose of recAP on the primary endpoint in Part 1, provided 
there are no safety issues with that dose as judged by the DMC. In Part 2, patients will be 
randomly assigned to receive, by 1-hour IV infusion, either placebo (n2 = 85) or the dose of 
recAP (n2 = 85) selected during the interim analysis. Patients recruited during the interim 
anaysis period to the dose selected in Part 2 will form part of the Part 2 populations, but 
those recruited to the doses that are not selected will be included in the Part 1 
population. 
14.2.2 Change Number 2 
Study design section has been amended with regard to inclusion and exclusion criteria. 
14.2.2.1 
Reason:  
To fine tune the eligibility criteria in order to make the study more clear and workable for 
sites. 
14.2.2.2 
Protocol Section: 
Section 4.1.1 Inclusion Criteria 
Change to or Section Deleted: 
2. Is aged 18 to 80 85 years, inclusive  
3. Is admitted to the ICU or intermediate care unit. 

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4. Has diagnosis of sepsis (<9672 hours prior to first study drug administration or <72 hour 
prior to AKI diagnosis), according to criteria defined by the American College of Chest 
Physicians/Society of Critical Care Medicine (Bone 1992]), based on: 
b. Have at least 2 of the following 4 SIRS criteria within the a timeframe of 48 
72 hours at time of screening AKI diagnosis and 72 hours prior to first drug 
administration. Note: it is not required that symptoms are not required to be 
present simultaneously at study randomization: 
5. Has first diagnosis of AKI at screening, defined as follows any of the following: 
AKI Stage 1 or greater, according to the following Acute Kidney Injury Network (AKIN) 
criteria (Note: adjusted in regards to time-window):  
a. Increase (absolute) in serum creatinine > 26.2 µmol/L (0.30 mg/dL) compared 
with a serum creatinine value within the previous 24 48 hours prior to 
screening, or presumed to have occurred in the previous 48 hours when 
compared to a reference* creatinine value  
b. Increase (relative) in serum creatinine to > 150% (> 1.5–fold) compared with a 
serum creatinine value in the previous 48 hours or presumed to have 
occurred in the previous 48 hours, when from compared to a reference* 
creatinine value within the previous 24 hours prior to screening (in the absence 
of primary underlying renal disease). The reference creatinine value is a the 
serum creatinine value according in to the following order of preference: 
6. AKI is likely attributable to the sepsis condition and not to other causes, e.g., contrast 
fluid, non-steroidal anti-inflammatory drugs (NSAIDs), or others. 
6. When the diagnosis of AKI was is made according to one of the AKIN serum creatinine 
criteria (absolute or relative increase, see inclusion criteria 5a and 5b), continuing AKI 
needs to be confirmed by a confirmative serum creatinine measure (that is corrected for 
fluid administrations), defined as no decrease in serum creatinine ≥ 26.2 µmol/L 
(≥0.30 mg/dL). The result must be available prior to randomization, within 24  hours 
after the primary AKI diagnosis so that administration of the first study treatment can be 
started within 24  hours after the first AKI diagnosis. 
 
 

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Section 4.1.2 Exclusion Criteria 
Change to or Section Deleted: 
2. Weighs more than 100 115 kg (220 253 lb). 
6. Is already on dialysis (RRT) or anticipated to receive  a decision has been made to 
initiate RRT within 24 hours after planned start of study drug administration due to 
underlying disease. 
21.  
No confirmed diagnosis of continuing AKI within 24 hours after primary diagnosis 
(see inclusion criteria 7 and 8 for serum creatinine and urine output criteria, 
respectively). 
21. Improvement in serum creatinine of at least 0.30 mg/dL or (26.2 µmol/L) prior to 
administration of the study drug. 
25. Has active hematological malignancy. 
14.2.3 Change Number 3 
Pharmacokinetic assessments were amended to reflect the subset of patients in whom they 
would be performed.  
14.2.3.1 
Reason:  
Clarification was added that PK assessments would be performed for the first 120 patients in 
Part 1 only. 
14.2.3.2 
Protocol Section: 
Synopsis (Exploratory Assessments) 
Change to or Section Deleted: 
PK analyses performed at all visits from Day 1 to Day 7 (inclusive) in the first 120 patients 
from Part 1 only 
Section 2.2 Secondary Objectives 

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To investigate the pharmacokinetics (PK) of recAP in a subset (Part 1) of patients with SA-
AKI (in the first 120 patients from Part 1 only). 
Section 3.1.1 Rationale of Study Design 
In the first 120 patients from Part 1 only, PK samples will be taken to assess the 
pharmacological properties of recAP in patients, in addition to the information previously 
derived from the healthy volunteers. 
Section 6.3.8.3 Pharmacokinetic Assessments 
Change to or Section Deleted: 
The following PK samples will be taken from Day 1 to Day 7 (inclusive) in the first 
120 patients from Part 1 only and exact sampling clock times will be recorded: 
14.2.4 Change Number 4 
Recording of concomitant medication use in the eCRF has been amended to introduce use of 
mean dosing by the system.   
14.2.4.1 
Reason:  
Recording of concomitant medication use in the eCRF has been amended to introduce use of 
mean dosing by the system to avoid sites performing multiple manual calculations as much 
as possible. The list of IV medications has been updated. 
14.2.4.2 
Protocol Section: 
Section 5.7 Concomitant Therapy, 6.3.12 Concomitant Medication 
Change to or Section Deleted: 
Concomitant medication use, including the drug name (brand or generic), dose, and dates of 
administration, will be recorded in the eCRF beginning on Day 1 baseline to Day 28. 
Changes in dosage of any concomitant medication will be recorded in the eCRF, except for 
IV medications that undergo frequent adjustments during the same day or over time, such as 
insulin, vasopressors, inotropics, diuretics, sedatives, metoprolol and potassium. In these 
cases, only estimated mean daily dose or mean daily dose as calculated by the system used 

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will be recorded. Concomitant medications will include all prescription drugs, including 
vitamins and, minerals, herbal products, and over-the-counter medications. Only brand 
names of nutritional products are to be recorded, while the single constituents of 
nutritional products need not be recorded. 
Administered resuscitation fluids should only be recorded as total daily volume in the 
concomitant medication section in the eCRF. Blood products should be recorded 
separately. 
14.2.5 Change Number 5 
Addition of height.  
14.2.5.1 
Reason:  
Addition of height for calculation of the body mass index (BMI). 
14.2.5.2 
Protocol Section: 
Section 6.3.1 Demographics and Medical History  
Change to or Section Deleted: 
Demographics and medical history should be recorded at baseline (see Section 13.1 
[Table 13-1] and Section 13.2 [Figure 13-1]). Height will be collected at baseline for 
calculation of body mass index (BMI; body weight (kg) / [height (m)]2). 
14.2.6 Change Number 6 
Clarification in weight.  
14.2.6.1 
Reason:  
Clarification in weight for calculation of study drug dose and treatment administered. 
14.2.6.2 
Protocol Section: 
Synopsis (Study Drug, Dosage, and Route of Administration), Section 5.2 
Change to or Section Deleted: 

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Patients weighing between 95 to 115 kg will receive the same dose as that for patients 
weighing 100 kg. 
Section 6.3.5 Weight  
Change to or Section Deleted: 
For determination of study drug dosage, body weight (in kg or lb) will be measured or 
estimated at screening. The hospital admission weight (in kg or lb) will be used for study 
drug preparation and and dosing during the 3 days of study drug administration for 
calculation of fluid-corrected serum creatinine. 
14.2.7 
Change Number 7 
Addition of a new analysis set (ITT Part 1 interim set). Addition of other analysis sets to 
reflect the current SAP. 
14.2.7.1 
Reason:  
Added a new analysis set to adequately distinguish between the Part 1 patients and the subset 
of these that are included in the interim analysis. 
14.2.7.2 
Protocol Section: 
Section 7 Analysis Set 
Change to or Section Deleted: 
 ITT Part 1 interim set:  all patients who were randomly assigned to a study drug 
prior to the conclusion of Part 1 of the study and were included in the interim 
analysis. Patients will be analyzed according to the treatment they were 
randomly assigned to. 
 Per-protocol (PP) Day 1-7 combined set: all patients who were randomly assigned to 
a study drug, had no significant protocol deviations (e.g., wrong drug volume 
received, administration of prohibited concomitant medication, patient did not meet 
all inclusion criteria or met 1 or more exclusion criteria) and had complete data for 

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the primary endpoint. The primary endpoint will be analyzed for the PP Day 1-7 
combined set, with patients analyzed according to the treatment they received.  
 Per-protocol (PP) Day 1-7 Part 2 set: all patients who were randomly assigned to 
a study drug after the conclusion of Part 1 of the study, had no significant 
protocol deviations (e.g., wrong drug volume received, administration of 
prohibited concomitant medication, patient did not meet all inclusion criteria or 
met 1 or more exclusion criteria) and had complete data for the primary 
endpoint. The primary endpoint will be analyzed for the PP Day 1-7 Part 2 set, with 
patients analyzed according to the treatment they received. 
14.2.8 Change Number 8 
Change in cut-off date for capture of unrelated AEs and SAEs. 
14.2.8.1 
Reason:  
Change in cut-off date for capture of unrelated AEs and SAEs to the end of study day. 
14.2.8.2 
Protocol Section: 
Section 6.3.14.2 Eliciting and Documenting Adverse Events 
Change to or Section Deleted: 
Adverse events will be collected and assessed from the time the patient signs the ICF until 30 
days after the last dose of study drug or later Day 28 visit for all AEs (including SAEs) 
possibly, probably, or definitely related to study drug regardless of its relationship to study 
drug. Any AE that occurs during or after the first dose of study drug is considered treatment 
emergent. 
14.2.9 Change Number 9 
Update to data to be reviewed by DMC 
14.2.9.1 
Reason:  
Clarification in data to be reviewed by DMC 

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14.2.9.2 
Protocol Section: 
Section 10.1.1 External Data Monitoring Committee 
Change to or Section Deleted: 
An independent DMC will review the results of the interim analysis and select the optimum 
recAP dose for Part 2 of the study (see Section 7.7.5). The DMC will conduct three 
additional reviews of the safety data by teleconference once the first 7 days of 
laboratory data are available for the following: 75 patients in Part 1, 60 patients in Part 
2, and 125 patients in Part 2. In each case, the milestone will be patients with at least 7 
days of laboratory data. Additional electronic reviews will be conducted of unblinded 
AE listings after 25, 50 and 100 patients in Part 1 and 30 and 90 patients in Part 2. The 
DMC can also request ad hoc reviews. Accumulating safety and efficacy data will be 
reviewed at predefined milestones during Part 1 and Part 2 of the study by the independent 
DMC as described in the DMC charter as follows: 
 Electronic Review 25 subjects 
 Electronic Review 50 subjects 
 Teleconference 75 subjects 
 Electronic Review 100 subjects 
 Face to Face Meeting-interim analysis-120 subjects 
 Ad hoc Review- (if needed) between 90-120 additional subjects 
  Teleconference 60 additional subjects from Part 2 (at least 180 total) 
  Electronic Review 90 additional subjects from Part 2 (at least 210 total) 
  Teleconference 125 additional subjects from Part 2 (at least 245 total) 
  Ad hoc Review- (if needed) between 125-170 subjects from Part 2 (at least 245-
290 total). 
14.2.10 Change Number 10 
Address was updated for PPD Medical Monitor in European Union. 
14.2.10.1 Reason: 
Administrative change. 

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14.2.10.2 Protocol Section: 
Cover page, Table 10-1 Study Administrative Table 
Change to or Section Deleted: 
European Union: 
Hanna Orr, MD 
Associate Medical Director, Pharmacovigilance, 
PPD Office Warsaw (Home Based) 
49 Domaniewska Street, Trinity Park III; 1st floor  
02-672 Warsaw, Poland  
Phone: +48 781811328 
European Union: 
Hanna Orr, MD 
Associate Medical Director, Pharmacovigilance, 
PPD 
Fleming House, Strathclyde Business Park 
Bellshill, Lanarkshire, ML4 3NJ, UK 
Phone: +44 (1223) 374240 
14.2.11 Change Number 11 
References to para-aminohippuric acid (PAH) were deleted. 
14.2.11.1 Reason 
References to para-aminohippuric acid (PAH) were deleted as it is commercially not 
available anymore. 
14.2.11.2 Protocol Section: 
Section 6.3.8.7 Glomerular Filtration Rate 
Change to or Section Deleted: 
A limited number of sites only will simultaneously determine GFR with iohexol 
administration and blood sampling (considered the golden standard) to globally compare and 
assess correlation of GFR and calculated endogenous creatinine clearance. Para-

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aminohippuric acid (PAH) will be administered and samples taken to assess renal blood flow. 
In addition, at these sites samples from the effluent from patients on RRT will be taken to 
assess exogenous (machine) creatinine clearance. Detailed instructions to these sites for 
iohexol and PAH assessments and exogenous creatinine clearance are provided in 
Section 13.5. 
Section 13.5 Appendix 5: Iohexol and Exogenous Creatinine Clearance Protocol 
(Including Pharmacodynamics) for Selected Sites Only (Section 13.5.1, Section 13.5.2, 
Section 13.5.3, Table 13-3 [Section 13.5.7], Section 13.5.8) 
Change to or Section Deleted: 
Accurate measurement of glomerular filtration rate (GFR) and effective renal plasma flow 
(ERPF) are is valuable for evaluating kidney function and nephrotoxicity in a variety of 
clinical research and patient care settings. 
Marker compounds such as iothalamate, iohexol, or inulin have been used extensively to 
measure GFR, while ERPF is most commonly measured using para-aminohippuric acid 
(PAH). 
Para-aminohippuric acid is an ideal marker for estimating ERPF since it is freely filtered at 
the glomerulus and undergoes extensive secretion and negligible reabsorption within renal 
tubules. However, approximately 20% of PAH is metabolized to acetyl-para-aminohippuric 
acid, which is also extensively secreted. 
Iohexol and Para-Aminohippuric Acid Dosing 
PAH: A single intravenous bolus injection of 400-mg PAH will be given over 5 minutes on 
Day 1 and on Day 7 or discharge from the intensive care unit (ICU), whichever comes first. 
The bolus will be administered at the start of the 6 ± 1 hour urine collection interval. 
Iohexol and Para-Aminohippuric Acid Sampling 
For the simultaneous measurement of both iohexol and PAH, 2-mL blood samples will be 
collected in EDTA anticoagulated Vacutainer® tubes at the following time points: prior to 
PAH and iohexol bolus administration and at 60, 120, and 360 minutes.