Safety, Feasibility and Efficacy of Sulforaphane (Avmacol) in Chronic Kidney Disease
Phase: PHASE1
Conditions: Chronic Kidney Disease stage3, Chronic Kidney Disease stage4
Sponsor: University of Rochester

Safety, Feasibility and Efficacy of Sulforaphane
(Avmacol Extra Strength) in Chronic Kidney Disease – Phase I
Principal Investigator – Thu H. Le, MD
1. PURPOSE OF STUDY
We hypothesize that daily intake of sulforaphane (Avmacol Extra Strength (ES)) can decrease kidney
disease progression rate and decrease markers of oxidative stress and inflammation in chronic kidney
disease (CKD) patients. We will test our hypothesis in a randomized, double-blind, placebo-controlled
Phase 1/2 clinical trial in a single center, two sites, 3-year study. This proposed study was submitted as an
R01 application in response to FOA PAS-20-160 that encourages submission of pilot and feasibility
clinical trials that will lay the foundation for larger clinical trials related to the prevention/treatment of
CKD within the mission of NIDDK. We have received a Notice of Award for this study from
NIH/NIDDK.
There are two phases to our study; each will have a separate Consent Form. This proposal is only for
Phase I study. Once Phase I is complete, a new study will be submitted for Phase II. Please see study
design below for details:
1. Phase I: Establish pharmacokinetics of Avmacol ES in patients with CKD Stages 3-4
(first 6 months of the study). Subjects who participate in the first phase of the study may be
eligible to participate in the second phase of the study.
We seek approval for the Phase I of the study which will establish the dosing for the second phase
of the study.
2. BACKGROUND AND RATIONALE
In the United States (U.S.), the prevalence of chronic kidney disease (CKD) in adults is ~14%. The
mainstay of therapy for CKD are angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin
receptor blockers (ARBs), but many CKD patients still progress to end stage kidney disease (ESKD) – the
ultimate in failed prevention. The prevalence of ESKD is ~ 700,000, and is projected to increase to
between 971,000 – 1,259,000 patients by 2030 1.
Increased oxidative stress is a major molecular underpinning of CKD progression. In humans, a
common deletion variant of the glutathione-S-transferase μ-1 (GSTM1) gene, the GSTM1 null allele
(GSTM1(0)), results in decreased GSTM1 enzymatic activity and is associated with higher levels of
oxidative stress. GSTM1 belongs to the superfamily of GSTs that are phase II antioxidant enzymes and
are regulated by nuclear factor erythroid 2-related factor 2 (Nrf2). Our laboratory made the discovery that
the highly prevalent GSTM1(0) is associated with more rapid CKD progression in the African American
Study of Kidney Disease (AASK) trial participants 2. This association has been replicated in the
Atherosclerosis Risk in Communities (ARIC) study 3. In experimental mouse models of CKD or
hypertension, we found Gstm1 knockout (KO) mice have increased renal oxidative stress, inflammation,
and kidney injury, compared to wild-type (WT) littermate controls 4.
Cruciferous vegetables in general, and broccoli in particular, are rich in glucoraphanin, a precursor of
sulforaphane (SFN) that has been shown to have protective effects against oxidative damage through
activation of Nrf2. We found that dietary supplementation of sulforaphane-rich broccoli powder
ameliorated kidney disease only in Gstm1 KO mice. Similarly, in the ARIC study of nearly 11,000
patients, high intake of cruciferous vegetables was associated with lower risks of kidney failure, with
stronger effects in those homozygous for the null allele (GSTM1(0/0)). Our recently published paper
reporting these findings 4 was selected for news release based on “its overall excellence in furthering the
field of nephrology”, and was highlighted in several news outlets, including Science Daily and Reuters
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Health.
SFN is currently in clinical trials for cancer of the breast, lung, and prostate, as well as autism and
schizophrenia, and cardiotoxicity from chemotherapy (Clinicaltrials.gov). However, very few studies
have assessed the effect of SFN in kidney disease in pre-clinical experimental models; and, to the best of
our knowledge, no clinical study has been performed to assess the effect of SFN in CKD. Our
overarching objective is to test the safety, feasibility and efficacy of SFN in delaying CKD progression,
and, if so, whether its effect is dependent on GSTM1 genotype.
Once Phase I is completed and an appropriate dose is established, we will move to our Phase II pilot
study in which patients will be randomized to the study drug Avmacol ES and placebo for 6 months. We
hope that at the conclusion of the 3-year study, SFN will be demonstrated to be safe and well tolerated,
with measurable pharmacodynamic actions. The results would provide a sound rationale for Phase III and
a future large multicenter clinical trial to randomize CKD patients to standard care ± SFN to determine its
efficacy in slowing the rate of decline of eGFR in patients with CKD Stages 3-4 and its interaction with
GSTM1 genotype. Positive results in our study will also reinforce and establish further mechanistic
evidence for future research on the effects of regulation of the Nrf2-GSTM1 pathway on kidney function.
3. ADMINISTRATIVE ORGANIZATION
This is a multi-site collaborative study funded by the National Institutes of Health (NIH). The Nephrology
Division at Strong Memorial Hospital (SMH) will conduct the study to enroll patients. Subjects will be
recruited from the Kidney Clinic in AC-3, located at SMH, and from Highland Hospital. University of
Virginia will serve as a data analysis site (see Section #17). URMC will securely transfer de-identified
data to UVA for analysis.
4. STUDY DESIGN
Phase 1 study that will be conducted to establish pharmacokinetics of Avmacol ES in patients with
CKD Stages 3-4 and includes the following end-points:
Aim: To determine the pharmacokinetics of Avmacol ES in patients with CKD Stages 3-4
and the influence of GSTM1 genotype on bioavailability. Nutramax has expressed willingness to
provide Avmacol ES, a commercially available glucoraphanin packaged with the active enzyme
myrosinase to convert glucoraphanin to SFN. Regular Strength Avmacol has been tested in 16 clinical
trials, https://clinicaltrials.gov/ct2/results?cond=&term=Avmacol&cntry=&state=&city=&dist=, 9 of
which are still active. We will first establish an optimal dose for CKD Stages 3 and 4 patients to achieve
similar pharmacokinetic (PK) profile observed in non-CKD patients. We will also test our hypothesis
that there is higher bioavailability of SFN in CKD 3-4 patients carrying the GSTM1(0/0) genotype
compared to those carrying the active GSTM1 allele.
4.1 STUDY INTERVENTIONS
STUDY DRUG: Avmacol Extra Strength capsules
IND # 158689
IND HOLDER: Thu H. Le, MD
For Phase I, we will only use Avmacol ES, no placebo, to determine the PK of Avmacol ES in CKD to
guide the dose used for Phase II.
Nutramax Laboratories, Consumar Care, Inc., will provide Avmacol ES capsules free of charge in
bottles shipped directly to University of Rochester Medical Center (URMC) Clinical Research
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Once a Day
GSTM1 Genotype
Caucasians     African Americans
GSTM1 (1/1 or 1/0)
50%
73%
GSTM1 (0/0)
50%
27%
Pharmacy Investigational Drug Services (IDS). The IDS will store, monitor, and dispense the drug
directly to subjects. Data from the study will be shared with Nutramax.
It should be noted that, compared to control, SFN at “low dose” or 0.5 µM concentration, ex vivo, is able
to induce expression of the genes in human peripheral blood mononuclear cells (PBMCs) that encode the
enzymes AKR1C1 and NQO1 that play a role in reducing radical species 5. Higher doses of 2 µM and 5
µM of SFN induce higher expression of AKR1C1 and NQO1, as well as HO-1. Other human trials with
SFN have reported higher peak plasma concentrations of 1-2 µM 6.
GSTM1 genotype will first be determined for the PK analysis to assess whether the genotype influences
drug metabolism. Stratified by GSTM1 group, patients will
be assigned randomly to 2 or 4 Avmacol Extra Strength
Table 1: Number of Avmacol Extra Strength Tablets
tablets once a day, taken orally with food, as depicted in
GSTM1 Genotype
2 Tablets
4 Tablets
Table 1.
The groups are categorized into GSTM1 null
GSTM1 (1/1 or 1/0)                 6                         6
(GSTM1 (0/0) or GSTM1 non-null (GSTM1 (1/1) or
GSTM1 (0/0)                            6                         6
(1/0)) genotype based on the dominant model we observed in AASK and ARIC cohorts 2,3.
Between 800-900 patients are seen monthly in the 
Table 2
Prevalence
URMC Kidney Clinic in AC-3 and Highland Hospital.
Among these patients, ~ 60% have CKD Stage 3 or 4,
and ~ 40% of the total patients are African American.
The null genotype is quite common in human populations, with 50% Caucasians and 27% African
Americans being homozygous for the GSTM1 (0/0) allele (see Table 2 for prevalence of GSTM1
genotypes) 7. We saw similar prevalence of genotypes in AASK and ARIC 2-4. Therefore, we do not
anticipate difficulty identifying those with null versus non-null genotypes.
Rather than using a dose escalation approach which would take more time, we will be assessing 2
different doses simultaneously in different participants in each group to assess for the degree of variation
in PK. We will choose the highest dose that achieves similar t1/2 concentration and AUC0-8 of SFN levels
as observed in non-CKD patients (1-2 µM) 5,6 for our safety and efficacy study in Phase II.
Toxicities and guidelines for adjustments, withdrawals, etc.
In case of any significant side effects, adverse events or unusual changes, dosage will first be halved, and
if patient’s signs/symptoms do not improve after 3 days, treatment will be stopped. If signs/symptoms are
resolved, the treatment will be resumed at the lower dose for 7 days. On Day 7 when the patient comes in
for PK study. Otherwise, the study treatment will be stopped. If symptoms recur after resuming the lower
dose, Avmacol ES will be discontinued.
Reporting of Side Effects. Participants will be given instructions and contact information to report any
side effects, new symptoms or worsening of preexisting symptoms to the research coordinator or their
primary nephrologist (who will be made aware of the patient’s participation) during work hours. After
work hours, including nights and weekends, they will contact Dr. Le who is available 24 hours a day. If
Dr. Le is away, the Nephrology physician on call will take the calls for Dr. Le, so that 24/7 medical
coverage will be available for study participants. Any serious unexpected adverse effects will be
immediately reported to the IRB, the DSMB, and the NIH Office of Biotechnology Activities.
4.2 SUBJECT POPULATION
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We will enroll 24 adult patients followed in the Kidney Clinic in AC-3 with chronic kidney disease.
Evaluable subjects who withdraw from the study will be replaced to meet the enrollment goal. We will
recruit patients of any gender, race, and socioeconomic status.
Vulnerable Subjects: We do not plan to include vulnerable subjects such as children, pregnant women,
fetuses, or prisoners. Employees (physicians/fellows) will be assured that taking part in research is not a
part of their duties, and refusing to participate in the study will not affect their job. To ensure their
autonomy, the research coordinator (rather than the PI) will consent them.
5. INCLUSION AND EXCLUSION CRITERIA
Inclusion Criteria:
•
Age ≥ 18 years and ≤ 80 years
•
Estimated glomerular filtration rate (eGFR) ≥ 25 and < 45 mL/min/1.73m2
•
Able to provide consent
•
Able to swallow Avmacol ES capsules
Exclusion Criteria:
•
Significant co-morbid conditions with life expectancy of < 1 year
•
Uncontrolled hypertension; an average recorded blood pressure ≥140/90 mmHg in the past 6
months
•
Serum potassium of > 5.5 mEq/L at screening
•
New York Heart Association Class 3 or 4 heart failure symptoms, known EF ≤ 30% or hospital
admission for heart failure within the past 3 months
•
Factors judged to limit adherence to interventions based on appointment attendance and
medication treatment compliance; PI will make this determination
•
Current participation in another study
•
Known to be pregnant or planning to become pregnant or currently breastfeeding; determined by
self-report and medical record history. A urine pregnancy test will be completed for individuals
of childbearing potential before administering the study drug.
•
History of dementia documented in the medical record
•
On anticoagulants or immunosuppression
•
Under treatment for cancer
Non-English-speaking individuals will be not be included in Phase I of the study, but will be included in
Phase II. If a patient cannot read, the consent form will be read to them by the research coordinator.
6. RECRUITMENT METHODS
Once eligible patients are identified, our research coordinator will reach out to each provider to ask them
if we may speak with their patients for the study.
Phone/Video Call: The research coordinator will contact eligible patients by phone to introduce the study
and gauge interest.

If the patient is interested in participating, a follow-up phone or Zoom video call will be
scheduled with the patient 7 to 10 days after the initial call and recruitment email is sent.
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Email: One recruitment email will be sent to eligible patients after the study is introduced by phone and
the patient has verbally agreed to receive recruitment email communications. The study team member
will obtain their permission to use email, per the following: “Because URMC can’t control the security of
email messages once we send them, we need your permission to email you. Do you want to receive the
link to the consent via email?”. Permission will be obtained before a PDF of the IRB approved consent
form and study flyer is sent via email for their review.
The email will include a copy of the informed consent; a study flyer; an agreed time for a follow-
up call, to occur either by phone or Zoom video, for the research coordinator to review the consent form
and discuss the patient’s participation further.
While the subject is on the phone, our research coordinator will provide the option of reviewing
the consent form either by phone or via zoom. However, obtained/documented consent will occur in
person as noted in Section 7.
Mail: Mailing the informed consent form with a cover letter that will instruct the potential subject not to
sign/date the consent form as follow up phone or Zoom call will be made by the study coordinator to
review with them. The consent will not be signed/returned via US postal; all consent will be obtained in
person; refer to Section 7. Consent Process.
Flyer: Study flyers will be posted in Kidney Clinic in AC-3 and Highland Hospital clinic waiting area
and restrooms. Subjects who contact the study team directly and leave voice mail will receive follow up
phone call by the study coordinator, per the follow up recruitment phone script submitted for IRB review.
7. CONSENT PROCESS
o Informed consent will be obtained by the research coordinator and documented via a signed
consent form, and stored in a cabinet in a locked room.
o The consent will be obtained in-person when the patient presents to the Kidney Clinic for
their routine follow up.
o To minimize coercion, the research coordinator, and not the patient’s nephrologist, will
explain to the patient the purpose of the study and go over the consent form, and give them
the opportunity to ask questions. The patient will also be given the opportunity to take the
consent form home with them and take as much time needed to look over the consent form.
o If more time is requested by the patient, further follow-ups will occur over the phone to
answer questions, concerns, and discuss participation.
o The research coordinator will ask the patient to summarize the study to ensure their
understanding.
o The Investigator or research coordinator will give a copy of the signed consent form to the
subject and store the original appropriately in a cabinet in a locked room.
o A check-box for consent to contact subjects for future research will be an option with consent for
this study.
Certificate of Confidentiality:
The study is funded by the National Institute of Health, and therefore the Certificate of
Confidentiality (CoC) is automatically included as part of the notice of award. Language
regarding the Certificate of Confidentiality will be included in the consent form.
8. STUDY PROCEDURES
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SCREENING PROCEDURES:
Avmacol ES has not been tested in patients with CKD. Since sulforaphane (SFN) and its metabolites are
cleared by the kidney, to establish a safe dose for our study participants, for Phase I of the study, we will
first perform PK analysis in CKD Stage 3B to 4 patients with eGFR between 25 – 45 mL/min/1.73m2
who meet the inclusion criteria below. The eGFR result should be within a 2 week window at the time of
screening. If eGFR testing was performed longer than 2 weeks, the research coordinator will reach out to
the patient’s provider to ask for repeat testing.
Our research coordinator will use eRecord EMR to screen patients for enrollment based on inclusion and
exclusion criteria listed above in #5. Each week, the research coordinator (RC) will screen subjects
scheduled to visit to the Kidney Clinic in the upcoming 1 to 2 weeks for enrollment. The RC will discuss
with Dr. Le, who will make the final decision for inclusion and exclusion.
If eligible and after subject consent is obtained:
A total of 2 in-person study visits will occur for the Phase I study. The first visit (AC3 or Highland
Hospital) is expected to last for 1 hour. The second visit will only occur at the Clinical Research Center in
Strong Memorial Hospital (SMH) and will take place on day 7 of taking the study drug and is expected to
last up to 9-hours to allow biospecimen collections at 5 separate intervals.
RANDOMIZATION:
As noted in Section 4.1 Study Interventions, groups will be stratified by GSTM1 group, patients will be
assigned randomly to 2 or 4 Avmacol Extra Strength tablets once a day, taken orally with food, as
depicted in Table 1 (below). The groups are categorized into GSTM1 null (GSTM1 (0/0) or GSTM1 non-
null (GSTM1 (1/1) or (1/0)) genotype based on the dominant model we observed in AASK and ARIC
cohorts. We do not anticipate difficulty obtaining the different genotype groups, as 75% of Caucasians
are either GSTM1 (1/1) or (1/0), and 25 % are GSTM1 (0/0). Approximately 65% of patients in our
Kidney Clinic are Caucasians. In African Americans/blacks, approximately 25% are GSTM1 (1/1), 50%
are GSTM1 (1/0), and 25 % are GSTM1 (0/0). Approximately 30% of patients in our Kidney Clinic are
African Americans. Randomization will be performed by the IDS who will be provided the patients’
eGFR and GSTM1 genotypes. Since this is a PK study, the investigators will not be blinded to the
randomization.
Visit 1 (1 hour) at AC3 or Highland Hospital Procedures:
Buccal Swab: A buccal (cheek) swab will be obtained from the subject to extract DNA for GSTM1
genotyping for assignment to groups as outlined in Table 1. (below). Genotyping will be performed as
previously done 2. The processing of DNA and genotyping will be completed within 5 business days.
Drug Dosing: In-person at the time of their study visit, patients in each dose group will be provided 2 or
4 tablets to be taken at home once a day with food for 7 days.
Table 1: Number of Avmacol Extra Strength Tablets
Once a Day
GSTM1 Genotype
2 Tablets
4 Tablets
GSTM1 (1/1 or 1/0)                  6                         6
NIH
PROMIS
GSTM1 (0/0)
6
6
Questionnaire:
For
each
subject, clinical status and symptoms will be monitored using this questionnaire for gastrointestinal
symptoms. Paper copies of this survey will be administered to the subject at Visit 1 and each form is
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expected to take 20 minutes to complete. The questionnaire will be completed in-person as part of Visit 1,
at home on Day 3, and returned with the next in-person visit on Day 7 (Visit 2).
Kansas City Cardiomyopathy Questionnaire (Modified): For each subject, clinical status and
symptoms will be monitored using this questionnaire for heart failure symptoms. Paper copies of
this survey will be provided to the subject at Visit 1 and are expected to take about 30 minutes
each to complete. The questionnaire will be completed in-person as part of Visit 1, at home on Day 3,
and returned with the next in-person visit on Day 7 (Visit 2).
General Questionnaire: Each patient will also complete a brief questionnaire of how they feel each day,
including any new symptoms. Subjects are expected to complete the general questionnaire once each day
throughout the 7-day period.
Subject Tracking Chart: For each subject, a chart will be provided to help track daily study drug intake
and questionnaires. The form will also include the subject’s study drug dosage and 7-day study timeline.
Visit 2/Day 7 Procedures (8-Hours) at Clinical Research Center in Strong Memorial Hospital:
On day 7, subjects will come to the Clinical Research Center at SMH, take their dose with food. This visit
will last for about 8-hours in duration so samples of urine and blood samples can be obtained at scheduled
time intervals. Food and drink will be provided for lunch during the 8-hour visit.
Subjects will be asked to return the drug package so the study team can account for the number of
tablets taken during the 7-day period.
Blood Samples: Blood collection will involve one venipuncture 4 mL blood sample obtained at 0, 1 hour,
2, 4, and 8 hours. The samples may be obtained by a phlebotomist in the Clinical Research Center or
Strong Memorial Hospital Outpatient Lab. An IV-line will be placed for the blood draws to minimize
needle sticks. A total number of two collection attempts will be allowed for each time interval.
Urine Samples: Urine collection will involve one sample of a minimum of 1 mL of urine in a sterile cup
obtained at 0, 1 hour, 2, 4, and 8 hours. Water will be provided between each sample collection.
Blood and urine will be obtained at 5 separate intervals listed above to determine SFN levels in plasma
and urine, respectively. Whole blood, plasma, and urine at each time point will be obtained, frozen, and
stored at -80oC for later processing and analysis. Levels of SFN and its active metabolites will be
analyzed by our Mass Spectrometry Shared Resources Laboratory (MSRL) Core at the University of
Rochester Medical Center.
Medical Record EMR: No research data (GSTM1 genotype or blood SFN level) will be included in the
subject’s medical record. Laboratory data that are part of the patients’ clinical care will be conveyed to
the patients as standard of care. For the study, we will collect demographic information, including age,
sex, height, weight, race, past medical history – specifically history of hypertension, heart failure, and
etiology of kidney disease, if any - and blood pressure data. Research data will not be conveyed to the
patients. While not anticipated, incidental findings that might have health consequences for the individual
subject will be addressed as clinically indicated.
As this is conducted under an IND, the samples will be stored for 2 years after marketing approval or for
5 years, whichever is later. Should additional tests be deemed informative or mechanistic to enhance
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further understanding, we will contact the subjects while samples are still available.
Samples will be destroyed after 5 years.
Genetic Research Procedures: As mentioned above, the GSTM1 null genotype is quite common in
human populations, with 50% Caucasians and 27% African Americans being homozygous for the
GSTM1 (0/0) allele. Whole genomic sequencing will not occur. No genetic counseling will be
provided to the subject. We will genotype GSTM1 to assess whether it influences PK/drug
metabolism of SFN from Avmacol.
Completion of the first phase: To ensure patient safety after they have completed or stopped the study
drug, our research coordinator will call subjects after about 2 weeks to ask how they are feeling, and
whether they have developed any new symptoms. If they have new symptoms, Dr. Le will reach out to
the patient to assess if further evaluation is warranted.
9. RISKS TO SUBJECTS
Sulforaphane/Avmacol ES (Study Drug)
There are some potential risks to participants since we are introducing a well-tolerated study drug in other
clinical trials but has not been previously tested in CKD patients. We take careful precautions by first
establishing an optimal dose of Avmacol ES in CKD patients using reported peak plasma concentrations
in trials that were conducted in patients without kidney disease. Based on the multiple clinical trials that
have been done with Avmacol or the actual sulforaphane compound in other diseases, we do not
anticipate any serious risks. The most common side effects are gastrointestinal, including nausea and
dyspepsia, which are ameliorated when taken with food.
Although not reported in any earlier trial, there is the possibility of an allergic reaction to the
study drug. This reaction may be mild, such as a skin rash, or more severe symptoms like swelling of the
throat, low blood pressure, and shortness of breath. In rare cases, a severe reaction could cause death.
Risks of Blood Draw
The most common risk is pain, bleeding, or bruising at the site of the blood draw. Other risks include
redness, and swelling of the vein and infection, and a rare risk of fainting.
Risks of Buccal Swab
The risk is minimal. There is risk of not obtaining adequate sample for DNA extraction.
Risks of Urine Sample
The risk is minimal. There is risk of spilling urine onto clothes.
Risks of Pregnancy: The effect of sulforaphane on the fetus is not known. The patient will be advised to
immediately stop taking the drug if pregnancy is suspected and notify the research team.
Risk of Disclosure of Privacy and Confidentiality
Other potential risks involve violations of confidentiality. Procedures for assuring confidentiality are
discussed below.
Risks to Social/Emotional Well-Being
We do not anticipate any psychological, social or legal risks beyond those related to participation in a
clinical study.
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Risks of Questionnaires
There are no anticipated risks for subjects to complete the requested questionnaires.
Patients will be informed that declining to participate in this study will not impact their care whatsoever.
10. POTENTIAL BENEFITS TO SUBJECTS
You might not benefit from being in this research study. Your participation will enable us to determine
the best dose for the next study in patients with chronic kidney disease in which you would also be
eligible to participate in.
11. COSTS FOR PARTICIPATION
There is no cost for participation of the study. Avmacol ES will be provided by Nutramax without cost to
the patients.
12. PAYMENT FOR PARTICIPATION
Each of the study participants will receive $100.00 in a prepaid Visa card, divided into two payments of
$50.00 at Visit 1 and Visit 2, as payment for their participation and completion of the study. Subjects who
are withdrawn or voluntarily withdraw from the study due to side effects will also receive the full
compensation of $100.
13. SUBJECT WITHDRAWALS
1. Participants’ decision to withdraw from the study for any reason
2. Development of side effects that are not resolved by dose reduction
3. Failure to adhere to the study protocol
4. Relocation resulting in inability to follow up per protocol
5. Become pregnant
6. New diagnosis of heart failure, cardiovascular event, life threatening infection, or cancer
In the event that a patient drops out the study due to reasons listed above, we will recruit an additional
patient to replace.
Once treatment is stopped for any reason, patients will continue to be followed as part of standard of care
for CKD. Long-term follow up data will continue to be collected, including their blood pressure, eGFR,
and proteinuria.
RETURN OF RESULTS:
Once the study is completed, we will send subjects a summary of the results and what they mean.
Subjects will not receive their own individual results.
14. PRIVACY AND CONFIDENTIALITY OF SUBJECTS AND RESEARCH DATA
The research team consists of URMC clinical providers (Nephrologists) and as such have access to all of
the relevant clinic records. Study data will be collected and managed using REDCap electronic data
capture tools hosted at URMC. Study data will be directly entered into REDCap which is a HIPAA
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compliant database. Only de-identified data will be analyzed, and de-identified data will be stored in a
password protected database only available to the research team.
With regard to patient confidentiality, the risk of improper access, use, or disclosure of participant data is
minimized through the following procedures:
1. All study personnel and researchers are required to sign a pledge of confidentiality, committing to
safeguard the study data during its collection, analysis, and after the study is concluded.
2. Physical (paper) questionnaire forms and media containing the electronic data files will be kept in
locked files with restricted access.
3. Data Key- Each subject will be assigned a study ID number which will be used to label their
data/samples and linked to the subject on a separate key. Only Dr Le and the investigative team
will have access to the data key and it will be stored separately from the dataset.
4. The data upon which statistical analysis will be conducted will contain participant numbers as
unique identifiers in lieu of names, medical record number, or social security numbers. These
data are considered identifiable, but not directly identifiable.
When data generated from this study is shared for analysis, only de-identified information will be
exchanged. No protected health information will be shared with any collaborator nor used in any
publications. Only aggregate results, not individual data, will be published in reports or manuscripts.
15. DATA / SAMPLE STORAGE FOR FUTURE USE
Samples will be collected, processed, and stored for future use in an approved -800C freezer. To minimize
costs, they will be run in batches based on the number of samples that can be loaded on commercially
available kits. As this is conducted under an IND, the samples will be stored for 2 years after marketing
approval or for 5 years, whichever is later. Only Dr. Le and the investigative team will have access to the
stored data and samples.
The investigative team may elect to share with other researchers and/or utilize subject data and
biospecimens collected during this study for future research purposes. This includes subject samples,
health information, and genotype GSTM1 data. Subjects will be provided the opportunity to opt-in or opt-
out of permitting the study team to utilize their data and biospecimens during the ICF process. Should
subjects agree to allow the study team to utilize data and biospecimens for future research, the data and
biospecimens would be used to further understand kidney disease and other related topics.
The clinical data and associated biospecimens will be identified only by the Subject ID used in the current
study. Computers housing the data are secured in locked rooms when not in use. All data files and derived
analytic data files are encrypted for storage and transport. Study data will be kept on password protected
computers at URMC, REDCap and UR Box program. Signed consent forms will be stored in a cabinet in
a locked room.
16. DATA AND SAFETY MONITORING PLAN
Medical Supervision and Surveillance of Study Subjects. The PI, Dr. Le, will be responsible for
supervision of the entire study. Clinical status and symptoms will be monitored using comprehensive
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health screening tools, including the NIH PROMIS questionnaire for gastrointestinal symptoms, and a
modified Kansas City Cardiomyopathy questionnaire for heart failure symptoms that will be relevant to
both patients with a history of heart failure (NY Heart Association Class 3 and 4 heart failure symptoms
are excluded) and patients without pre-existing history of heart failure.
Data Safety Monitoring Board (DSMB). We have already identified 3 members at URMC who are not
investigators in the study to serve on the DSMB:
1. Ronnie Guillet, MD, PhD, Professor of Pediatrics. Over the course of her career, Dr. Guillet has
been involved in two primary areas of research, both focused on better understanding neonatal
development and injury:
neonatal brain injury (neonatal seizures and hypoxic ischemic
encephalopathy) and their treatment and neonatal acute kidney injury (epidemiology, contributing
and ameliorating factors). These efforts and others have resulted in nearly 100 peer reviewed
publications. She has collaborated with colleagues across the country and around the world, has
been invited as a speaker to a variety of regional and national meetings, and has been asked to
collaborate on a number of multicenter clinical trials. In addition, she has chaired 4 Data Safety
Monitoring Committees, including 2 sponsored by NIH NINDS.
2. David Bushinsky, MD, Professor of Medicine, Pharmacology and Physiology. Dr. Bushinsky has
published nearly 120 peer-reviewed articles and over 60 invited reviews, chapters and editorials
focusing on disorders of divalent ion metabolism. He has conducted large clinical trials, including
“The effects of the potassium-binding polymer patiromer on markers of mineral metabolism
(CJASN 2019)”, “Veverimer versus placebo in patients with metabolic acidosis associated with
chronic kidney disease: a multicenter, randomized, double blind, controlled, phase 3 trial (Lancet
2019)”, and “Long-term safety and efficacy of veverimer in patients with metabolic acidosis in
chronic kidney disease: a multicenter, randomized blinded placebo-controlled, 40-week extension
(Lance 2019)”.
3. Dongmei Li, PhD, Associate Professor Public Health Sciences, in the Clinical and Translational
Science Institute (CTSI). She has more than ten years of experience conducting statistical
methodology research, teaching, mentoring public health students, and providing consulting
services for biomedical research. She is serving as Program Director of the Biomedical Data
Science Certificate Program co-sponsored by CTSI and Department of Public Health Sciences.
She also serves as the Biostatistics and Informatics Core Director of an FDA/NCI funded 19
million U54 center grant on flavored tobacco products. For her biostatistics methodology
research, she has worked on both genetic and genomic data analysis (gene expression, SNP, DNA
methylation, ChIP-seq, ATAC-seq, and proteomics) for more than ten years, and has developed
new statistical analysis methods and corresponding analysis packages in R/Bioconductor for
DNA methylation array and RNA-Seq data analysis. She also developed a new method and R
package to control for multiple testing error rates in genomic and genetic data analysis.
The DSMB will meet at the beginning of the Phase I and at the end of Phase I which is anticipated to be
completed in 6 months, and sooner if there are unanticipated side effects and adverse events. The DSMB
will follow the NIH National Center for Research Resources guidelines including:
1. Review subject recruitment, attrition, and minority involvement
2. Monitor safety of research participants by reviewing unblinded data for side effects and
adverse events
3. Assuring compliance with requirements relating to reporting of adverse events
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4. Assuring data accuracy and protocol compliance, and that any action that results in the
temporary or permanent suspension of the protocol is reported to all appropriate monitoring
bodies, including the IRB, and the NIH Office of Biotechnology Activities.
Should any serious adverse event occur, we will convene a meeting with the DSMB to determine whether
the study should be suspended until additional review can be properly performed.
17. DATA ANALYSIS PLAN – To be performed at UVA
Data harmonization, management and analysis
1. Develop data management and statistical analysis plan.
2. Work with the team and CTSI at URMC closely to design a unified management system for data
collection, transfer between the study site and management.
3. Data oversight and monitoring during data collection and integration.
4. Harmonize the study data elements and variables from clinical and laboratory and biochemical
data
5. Validate data quality and perform cleaning process.
6. Work closely with the PI and clinical investigators to determine appropriate statistical methods
and machine learning algorithms for the clinical hypotheses. Cutting-edge statistical methods and
innovative data science tools will be considered or adopted.
7. Prepare the analytical datasets and perform pre-stated statistical analyses.
8. Prepare the final results for manuscript writing and submission, conference presentations and
publications.
The data for safety and feasibility assessment will be summarized descriptively with respect to adverse
events and compliance with Avmacol ES intake. The group-specific data will be summarized and
reported as mean ± SD for continuous measures and as frequency and percentage for categorical measures
and their differences will be compared using two-sample t-tests or Chi-square test.
18. PI oversight for multi-site research
The UR PI will be responsible for the following:
A. Communication: The UR Pi will notify the Site PI of the RSRB site approval and provide
site approval letter as well as copies of the most current version of the study materials via
email. The UR PI is responsible throughout the course of the study to provide all modified
documents and IRB approval letters to UVA site PI.
B. Supervision of study activities at the site: The UR PI will conduct regular meetings with the
site PI to review study activities. Meetings will occur every 3 months or sooner as soon as
any issue arises by zoom. During the meeting, the UR PI will troubleshoot study-related
issues, answer study-related questions, and provide verbal/written direction for all study
activities. Meetings will be documented via meeting minutes in the regulatory binder.
C. Training: The UR PI will ensure that all study personnel have completed required institution-
specific and protocol-specific trainings and that these trainings are documented appropriately
via CITI certification. When study personnel are added/removed, the UR PI will ensure
UVA submits these changes to the local IRB for institutional review and approval. If
applicable, these changes will be appropriately documented on the Delegation of
Responsibilities Log.
D. Reporting: The UR PI will submit required information for reporting, progress reports,
reportable events, non-compliance, Data and Safety Monitoring reports and provide the site
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with any RSRB determinations regarding the submitted reports.
E. Site Files and Documentation: As per Policy 901 Investigator Responsibilities, all sites will
maintain a regulatory file with current and accurate records of all study documentation as
required by applicable regulatory requirements. These files are maintained electronically in
secure BOX URMC servers and shared with study members only.
19. REFERENCES
1.
McCullough, K.P., Morgenstern, H., Saran, R., Herman, W.H. & Robinson, B.M.
Projecting ESRD Incidence and Prevalence in the United States through 2030. J Am Soc
Nephrol 30, 127-135 (2019).
2.
Chang, J., et al. Loss of GSTM1, a NRF2 target, is associated with accelerated
progression of hypertensive kidney disease in the African American Study of Kidney
Disease (AASK). Am J Physiol Renal Physiol 304, F348-355 (2013).
3.
Tin, A., et al. The Loss of GSTM1 Associates with Kidney Failure and Heart Failure. J
Am Soc Nephrol 28, 3345-3352 (2017).
4.
Gigliotti, J.C., et al. GSTM1 Deletion Exaggerates Kidney Injury in Experimental Mouse
Models and Confers the Protective Effect of Cruciferous Vegetables in Mice and
Humans. J Am Soc Nephrol 31, 102-116 (2020).
5.
Liu, H., et al. Biomarker Exploration in Human Peripheral Blood Mononuclear Cells for
Monitoring Sulforaphane Treatment Responses in Autism Spectrum Disorder. Scientific
reports 10, 5822 (2020).
6.
Ye, L., et al. Quantitative determination of dithiocarbamates in human plasma, serum,
erythrocytes and urine: pharmacokinetics of broccoli sprout isothiocyanates in humans.
Clin Chim Acta 316, 43-53 (2002).
7.
Garte, S., et al. Metabolic gene polymorphism frequencies in control populations. Cancer
Epidemiol Biomarkers Prev 10, 1239-1248 (2001).
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