Natural History of Infection Caused by BK Virus (and Other Opportunistic Viral Pathogens) in Renal Transplant Recipients
Conditions: BK Virus (BKV) Viremia
Sponsor: University of Alabama at Birmingham

 
 
 
Natural History of Infection Caused by BK Virus (and other Opportunistic Viral 
Pathogens) in Renal and Renal-Pancreas Transplant Recipients 
 
 
DMID Protocol Number:  11-0071 
 
DMID Funding Mechanism: HHSN272201100036C 
 
Sponsor:  National Institutes of Health/NIAID 
 
Principal Investigator:  Richard J. Whitley, MD 
 
University of Alabama at Birmingham 
 
 
DMID COR:  Walla Dempsey, PhD 
NIH/NIAID 
 
Protocol Chair:   
John W. Gnann, Jr., MD 
Medical University of South Carolina 
 
Protocol Statistician: 
Inmaculada B. Aban, PhD 
University of Alabama at Birmingham 
 
UAB Central Unit Administration: 
Penelope M. Jester, BSN, MPH 
Ilet Dale, BSN, MSc.M, CCRP 
University of Alabama at Birmingham 
 
Version Number: 2.0 
 
22 March 2016 
 
 
 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
ii 
 
 
 
STATEMENT OF COMPLIANCE 
 
Each investigator must adhere to the protocol as detailed in this document.  Each investigator will be 
responsible for enrolling only those study participants who have met protocol eligibility criteria.  This 
study will be conducted in compliance with the protocol and in accordance with Good Clinical 
Practices (GC) as required by the following:   
 
 
International Conference on Harmonization Good Clinical Practice E6 (ICH-E6 GCP) and the 
following applicable regulatory requirements: 
 
 
U.S. Code of Federal Regulators applicable to clinical studies (45 CFR 46 and 21 CFR 11 
including parts 50 and 56 concerning informed consent and IRB regulations). 
 
 
NIH Terms of Award 
 
All key personnel (all individuals responsible for the design and conduct of this study) have completed 
Human Subjects Protection Training. 
 
 
 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
iii 
 
 
PROTOCOL SIGNATURE PAGE 
 
 
By my signature below, I, ____________________________________, agree to conduct this protocol 
“Natural History of Infection Caused by BK Virus (and other Opportunistic Viral Pathogens) in 
Renal and Renal-Pancreas Transplant Recipients” and provide the necessary assurances that this 
study  will be conducted according to all stipulations of the protocol, including all statements regarding 
confidentiality, and according to local legal and regulatory requirements and applicable U.S. federal 
regulations and ICH guidelines.  I understand that no deviations from the protocol may be made 
without permission of the sponsor.  I also understand that information in this protocol is proprietary and 
therefore, I agree to maintain the confidentiality of the protocol and data generated from the protocol 
until permission to publicize results is granted by the NIH.   
 
 
 
SITE PRINCIPAL INVESTIGATOR:  
 
 
 
________________________________________ 
 _______________  
 
Signature 
 
Date 
 
 
_______________________________________ 
Title 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
iv 
 
 
TABLE OF CONTENTS  
 
STATEMENT OF COMPLIANCE ........................................................................................................................................ II 
PROTOCOL SIGNATURE PAGE ........................................................................................................................................ III 
LIST OF ABBREVIATIONS .............................................................................................................................................. VII 
PROTOCOL SUMMARY .................................................................................................................................................. IX 
SCHEMATIC OF STUDY DESIGN ...................................................................................................................................... XI 
1.  KEY ROLES ................................................................................................................................................................ 12 
2.  BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ...................................................................................... 15 
2.1.  BACKGROUND INFORMATION .............................................................................................................................................. 15 
2.1.1.  BK Virus (BKV) and BKV‐Associated Nephropathy (BKVN) .................................................................................. 15 
2.2.  SCIENTIFIC RATIONALE ....................................................................................................................................................... 17 
2.2.1.  Renal (or Renal‐Pancreas Transplant) Patients ................................................................................................... 17 
2.3.  POTENTIAL RISKS AND BENEFITS .......................................................................................................................................... 17 
2.3.1  Potential Risks ...................................................................................................................................................... 17 
2.3.2.  Potential Benefits ................................................................................................................................................ 17 
3.  OBJECTIVES .............................................................................................................................................................. 18 
3.1.  STUDY OBJECTIVES ........................................................................................................................................................... 18 
3.1.1.  Primary Objectives ............................................................................................................................................... 18 
3.1.2.  Secondary Objectives ........................................................................................................................................... 18 
3.1.3.  Tertiary (Exploratory) Objectives ......................................................................................................................... 18 
3.2.  STUDY OUTCOME MEASURES ............................................................................................................................................. 18 
3.2.1.  Primary Endpoints ............................................................................................................................................... 18 
3.2.2.  Secondary endpoints ........................................................................................................................................... 18 
3.2.3.  Exploratory Endpoints ......................................................................................................................................... 19 
4.  STUDY DESIGN .................................................................................................................................................... 21 
4.1.  INFORMED CONSENT AND ENROLLMENT ............................................................................................................................... 21 
4.2.  PROSPECTIVE SCREENING PHASE ......................................................................................................................................... 22 
4.3.  INTENSIVE SAMPLING PHASE ............................................................................................................................................... 22 
4.4.  POST‐VIREMIA FOLLOW‐UP ............................................................................................................................................... 23 
4.5.  SPECIMENS FOR BIOMARKER STUDIES ................................................................................................................................... 23 
4.6.  DOCUMENTING SPECIAL EVENTS ......................................................................................................................................... 23 
4.7.  ADVERSE EVENTS ............................................................................................................................................................. 24 
4.8.  CLINICAL LABORATORY DATA .............................................................................................................................................. 24 
4.9.  STUDY VISITS ................................................................................................................................................................... 24 
5.  STUDY POPULATION ................................................................................................................................................ 25 
5.1.  STUDY POPULATION SELECTION ........................................................................................................................................... 25 
5.2.  INCLUSION OF WOMEN, CHILDREN AND MINORITIES ............................................................................................................... 25 
5.3.  INCLUSION/EXCLUSION CRITERIA ......................................................................................................................................... 25 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
v 
 
 
5.3.1.  Inclusion Criteria .................................................................................................................................................. 25 
5.3.2.  Exclusion Criteria ................................................................................................................................................. 25 
6.0.  SCHEDULE OF EVENTS ........................................................................................................................................... 26 
6.1.  ENROLLMENT VISIT  (DAY 1) ............................................................................................................................................... 26 
6.2.  SCREENING STUDY VISITS  .................................................................................................................................................. 27 
6.3.  INTENSIVE MONITORING PHASE FOR BK VIREMIC SUBJECTS ..................................................................................................... 28 
6.4.  SUBJECT EARLY TERMINATION ............................................................................................................................................. 29 
6.5.  MANAGEMENT OF SUBJECT WITHDRAWALS .......................................................................................................................... 29 
6.6.  TERMINATION OF STUDY .................................................................................................................................................... 29 
7.0.  STUDY PROCEDURES ............................................................................................................................................. 30 
7.1.  DEMOGRAPHICS, BASELINE MEDICAL‐SURGICAL HISTORY, CLINICAL OUTCOMES .......................................................................... 30 
7.2.  LABORATORY – SPECIMEN COLLECTION ................................................................................................................................ 30 
7.2.1.  At Each Screening Visit: ....................................................................................................................................... 30 
7.2.2.  At Each Intensive Follow‐up Visit for Viremic Subjects: ....................................................................................... 30 
7.3.  REPORTING OF CONCOMITANT MEDICATIONS ........................................................................................................................ 31 
7.4.  DOSING OF IMMUNOSUPPRESSIVE DRUGS ............................................................................................................................. 31 
7.5.  MEASUREMENT OF VIRAL DNA........................................................................................................................................... 31 
7.6.  SPECIMEN PREPARATION, HANDLING AND SHIPPING ............................................................................................................... 32 
8.  STATISTICAL CONSIDERATIONS................................................................................................................................. 33 
8.1.  STUDY HYPOTHESIS ........................................................................................................................................................... 33 
8.2.  SAMPLE SIZE CONSIDERATIONS ........................................................................................................................................... 33 
8.2.1.  Sample Size .......................................................................................................................................................... 33 
8.2.2.  Estimated Annual Accrual ................................................................................................................................... 34 
8.3.  DEMOGRAPHIC ANALYSIS ................................................................................................................................................... 34 
8.4.  FINAL ANALYSIS PLAN........................................................................................................................................................ 35 
8.4.1.  Primary Outcome Analysis ................................................................................................................................... 35 
8.4.2.  Secondary Endpoints ........................................................................................................................................... 36 
8.4.3.  Exploratory Endpoints ......................................................................................................................................... 36 
9.  SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/ DOCUMENTS ....................................................................... 37 
10.  QUALITY CONTROL AND QUALITY ASSURANCE ....................................................................................................... 38 
11.  ETHICS AND PROTECTION OF HUMAN SUBJECTS ..................................................................................................... 39 
11.1.  ETHICAL STANDARD ........................................................................................................................................................ 39 
11.2.  INSTITUTIONAL REVIEW BOARD ......................................................................................................................................... 39 
11.3.  INFORMED CONSENT PROCESS .......................................................................................................................................... 39 
11.4.  EXCLUSION OF WOMEN, MINORITIES, AND CHILDREN (SPECIAL POPULATIONS) .......................................................................... 41 
11.5  SUBJECT CONFIDENTIALITY ................................................................................................................................................ 41 
11.6.  RECRUITMENT AND COMPENSATION .................................................................................................................................. 41 
11.7  FUTURE USE OF STORED SPECIMENS ................................................................................................................................... 42 
12.  DATA HANDLING AND RECORD KEEPING ................................................................................................................ 43 
12.1  DATA CAPTURE METHODS ................................................................................................................................................ 43 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
vi 
 
 
12.2  TYPES OF DATA ............................................................................................................................................................... 44 
12.3  TIMING/REPORTS ............................................................................................................................................................ 44 
12.4  STUDY RECORDS RETENTION.............................................................................................................................................. 44 
12.5  PROTOCOL DEVIATIONS .................................................................................................................................................... 44 
13.  PUBLICATION POLICY ............................................................................................................................................. 46 
14.  REFERENCES ........................................................................................................................................................... 47 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
vii 
 
 
LIST OF ABBREVIATIONS 
 
ABBREVIATION 
TERM 
 
 
ALT 
Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase 
AUC 
Area Under the Curve 
BKC 
BKV 
BK Cystitis 
BK Virus 
BKVN 
BK Virus-Associated Nephropathy 
BLQ 
Below the Limit of Quantitation 
BMI 
Body Mass Index 
BP 
Blood Pressure 
CDC 
Centers for Disease Control 
Cº 
Celsius/Centigrade 
Cmax 
Maximum Concentration 
CFR 
Code of Federal Regulations 
CLT 
Total Clearance 
CMV 
Cytomegalovirus 
CrCl 
Creatinine Clearance 
CRF 
Case Report Form 
DMID 
Division of Microbiology and Infectious Diseases 
DNA 
Deoxyribonucleic Acid 
EBV 
Epstein Barr Virus 
eCRF 
Electronic Case Report Form 
FDA 
U.S. Food and Drug Administration 
FK506 
Tacrolimus 
FWA 
Federal wide Assurance 
GCP 
Good Clinical Practice 
GI 
Gastrointestinal 
GFR 
Glomerular Filtration Rate
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
HHV-6 
Human herpesvirus 6 
HSCT 
Hematopoietic Stem Cell Transplant  
ICF 
Informed Consent Form 
ICU 
Intensive Care Unit 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
viii 
 
 
IEC 
Institutional Ethics Committee 
IRB 
Institutional Review Board 
IS 
IRB 
Immunosuppressant
Institutional Review Board 
IVIS 
Intravenous Immunosuppressant 
kg 
Kilograms 
mg 
Milligrams 
ml 
Milliliters 
min 
Minute 
MMF 
Mycophenolate Mofetil 
MOP 
Manual of Procedures 
N 
Number (typically refers to subjects) 
NIAID 
National Institute of Allergy and Infectious Diseases Number  
NIH 
National Institutes of Health 
PCR 
Polymerase Chain Reaction 
PI 
Principal Investigator 
pl•BKV DNAPI 
Plasma levels of BKV DNA 
PT 
Prothrombin Time 
PTT 
Partial Thromboplastin Time 
QA 
Quality Assurance 
QC 
Quality Control 
RBC 
Red Blood Cells 
SCT 
Stem Cell Transplant 
SOP 
Standard Operating Procedure 
SOT 
Solid Organ Transplant 
T 
Temperature 
Tmax 
Maximum Time 
Tmax 
Maximum Time 
µg 
Microgram 
ur•BKV DNA 
Urine levels of BKV DNA 
µL 
Microliter 
ur•BKV DNA 
Urine levels of BKV DNA 
UTI 
Infection 
WBC 
White Blood Cells 
WHO 
World Health Organization 
 
 
 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
ix 
 
 
PROTOCOL SUMMARY 
 
Title: 
 
Natural History of Infection Caused by BK Virus (and other Opportunistic 
Viral Pathogens) in Renal and Renal-Pancreas Transplant Recipients 
 
Phase: 
Not Applicable (Natural History Study) 
Study Population: 
Male and female renal or renal-pancreas transplant recipients at risk for 
BK virus infection 
 
Sample Size: 
Approximately 450 subjects will be enrolled for screening for BK viremia 
(15% over-enrollment allowed, to a maximum of 518 screened subjects) 
to allow identification of approximately 40 (to a maximum of 60) subjects 
with viremia.     
Number of Sites:    
Approximately  6
Study Duration: 
  3 years 
Subject Participation  
Duration:   
Maximum of 24 months 
Objectives: 
 
Primary Objectives:  
 
To establish the natural history of BK viremia in a multicenter 
population of renal and renal/pancreas transplant patients, to include 
incidence, time to onset, duration, and quantitation of viral load; 
 
To assess associations between BK viremia and decline in GFR in 
renal transplant recipients. 
 
Secondary Objectives:  
 
To define the donor and recipient-related risk factors for BK viremia 
and BKVN in a multicenter population of renal and renal-pancreas 
transplant patients; 
 
To define the frequency of clinical outcomes that are potentially 
related to BKV infection. 
Tertiary (Exploratory) Objectives: 
 
To compare quantitative measurements of BKV DNA by PCR in 
plasma and (when appropriate) in urine, in order to determine 
biologic significance; 
 
To assess plasma for evidence of other opportunistic viral pathogens, 
including CMV, EBV, HHV-6, and adenovirus; 
 
To assess urine for evidence of other opportunistic viral pathogens, 
including CMV and adenovirus; 

 
 
 
 
 
 
 
 
      
     DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
            22 March 2016 
 
________________________________________________________________________________________________________ 
x 
 
 
 
To compare quantitative BKV PCR results from each site (local or 
reference laboratory) with matched results from the Central Unit 
laboratory;  
 
To explore the potential of biomarkers of tubular injury for predicting 
increased risk of BKVN; 
 
Description of Study 
Design: 
The primary objective is to define the natural history of BK viremia. In 
order to understand the natural history of infection, we will measure the 
time (days post-transplant) to the development of BK viremia and its 
correlation with progression to end-organ disease (BKVN or BK 
hemorrhagic cystitis). Data from this prospective monitoring will allow for 
the identification of the types of high-risk patients who might benefit from 
future studies of therapeutic interventions for BKV infection (when 
effective therapy becomes available).  This will be accomplished by serial 
quantitative BK DNA measurements in blood (plasma), assayed by 
polymerase chain reaction (PCR).  Phases of the study can be 
summarized as follows: 
 
Subject identification and informed consent.  Informed consent 
should be obtained early in the peri-transplant period (between 7 
days pre-transplantation [T-7d] and 100 days post- transplantation 
[T+100 d]). 
 
Prospective screening for BK viremia.  Enrollment and initiation of 
specimen collection should begin no sooner than 4 weeks after 
transplantation.  Enrollment cannot occur later than 100 days after 
transplantation.  Subjects will be screened (collection of blood and 
urine for laboratory studies, including BK PCR) approximately 
monthly for 6 months (timed from the date of transplantation), then 
every other month for 6 months. For those subjects who remain BKV-
negative, screening will terminate approximately 12 months from the 
date of transplantation. 
 
Intensive sampling of subjects identified with BK viremia.  Subjects 
identified with qualifying viremia will be sampled approximately every 
two weeks until resolution of viremia (defined as PCR negative, or 
<1000 copies/ml). 
Note:  Patients who did not participate in the prospective screening 
phase but are identified with BK viremia by standard-of-care testing 
may be enrolled, as long as they are still within 100 days of 
transplantation. 
 
Post-viremia follow-up.  Following resolution of viremia, subjects will 
be sampled (collection of blood and urine) approximately monthly for 
6 months (unless another termination event occurs sooner). 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
      DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
 
 
 
 
 
 22 March 2016 
 
 
 
________________________________________________________________________________________________________________________________________________ 
 
 
xi 
 
 
 
 
SCHEMATIC OF STUDY DESIGN 
 
DMID Protocol # 11-0071 Active Screening/Natural History Phase 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate recruitment and informed consent 
process in the peri-transplant period (T-7 d 
through T+100 d) 
 
Collect approx. 10 mL of whole blood and 100 mL urine every 4 weeks ±7 days 
x 6 months (as measured from date of transplant). 
 
Process whole blood to plasma; ship plasma to UAB Central Lab for BKV PCR 
within 7 days of collection.   
 
Urine will be stored and batch-shipped to UAB Central Lab monthly. 
 
Enrollment visit for consented subjects not <4 weeks post- 
transplant and not >100 days post-transplantation 
 
 
Record demographic, medical-surgical history at 
enrollment 
 
Record selected concomitant medications, drug levels, at 
each visit. 
If no BK viremia detected by 6 months post-transplant, 
switch to blood and urine samples collection 
approximately every 8 weeks + 14 days x 6 months. 
If no BK viremia is detected by approx. 12 months post-
transplant, subject will be discontinued from the study 
If qualifying BK viremia (>10,000 copies/ml) is documented, do the 
following: 
 
Plasma and urine samples are collected approximately every 2 
weeks ± 7 days until viremia has resolved (or until patient meets 
one of the study termination outcomes). 
After resolution of BK viremia, do the following: 
 
plasma and urine samples are collected approximately every 4 
weeks X 6 months (or until subject meets one of the study 
termination outcomes). 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
 
1.  KEY ROLES 
 
For questions regarding this protocol, contact: 
 
 
 
DMID COR:  
Walla Dempsey, PhD 
Division of Virology 
DMID/NIAID/NIH 
Division of Microbiology and Infectious Diseases, NIAID, NIH  
Room 5135 
6610 Rockledge Drive, MSC 6604 
Bethesda, MD  20892-6604 (Zip for express mail is 20817) 
Phone:  301-496-7453 
FAX:   301-480-1594 
e-mail:  wdempsey@niaid.nih.gov 
 
Principal Investigator: 
Richard J. Whitley, MD 
Distinguished Professor 
Loeb Scholar in Pediatrics 
Professor of Pediatrics, Microbiology,  
   Medicine, and Neurosurgery  
The University of Alabama at Birmingham 
1600 Seventh Avenue South, CHB 303 
Birmingham, AL  35233 
Phone: 205-934-5316 
Fax:   205-934-8559 
e-mail:  rwhitley@peds.uab.edu 
 
 
 
Protocol Chair:   
John W. Gnann, Jr., MD 
Professor of Medicine 
Department of Medicine, Division of Infectious Diseases 
Medical University of South Carolina 
135 Rutledge Avenue, Room 1207 
MSC 752 
Charleston, SC   29425 
Telephone:  843-792-4541 
Fax:             843-792-6680 
e-mail:  gnann@musc.edu 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
13 
 
  
 
Program Director: 
Penny Jester BSN MPH CCRC 
UAB Central Unit 
The University of Alabama at Birmingham 
1600 Seventh Avenue South, CHB 303 
Birmingham, AL  35233 
Phone:  205-934-5316 
Fax:   205-934-8559 
e-mail:  pjester@peds.uab.edu  
 
 
Clinical Trials Administrator 
Ilet Dale, BSN, MSc.M, CCRP 
UAB Central Unit 
The University of Alabama at Birmingham 
1600 Seventh Avenue South, CHB 303 
Birmingham, AL  35233 
Phone:  205-934-5316 
FAX:   205-934-8559 
e-mail:  idale@peds.uab.edu  
 
Statistician: 
Inmaculada "Chichi" Aban, PhD 
Associate Professor 
Department of Biostatistics 
School of Public Health 
The University of Alabama at Birmingham 
RPHB 327 
Phone:  205-934-2732 
Fax:      205-975-2541 
e-mail:  CAban@ms.soph.uab.edu  
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
14 
 
 
Investigators/Institutions: 
 
Roslyn B. Mannon 
University of Alabama at Birmingham 
David J Cohen, MD 
Columbia University Medical Center 
Daniel Brennan, MD 
Washington University-St. Louis 
JoAnne Young, MD 
University of Minnesota 
Alexander C. Wiseman, MD 
University of Colorado-Denver 
V.Ram Peddi, MD 
California Pacific Medical Center 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
15 
 
2.  BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE 
 
2.1.  Background Information 
 
2.1.1.  BK Virus (BKV) and BKV-Associated Nephropathy (BKVN) 
 
BK virus (BKV) is a small (45 to 55 nm) non-enveloped polyoma virus, having a circular double-
stranded DNA (dsDNA) genome with approximately 5,000 base pairs.  BKV was first isolated in 
1970 from a renal transplant patient (initials “BK”) with ureteral stenosis.  Seroepidemiologic 
studies have demonstrated that BKV infection is virtually universal and that asymptomatic primary 
infection occurs in early childhood.  In a healthy Swiss cohort aged 20-59 years, the 
seroprevalence for BKV was 82%.1  Following primary infection, BKV appears to preferentially 
establish latent infection in the genitourinary tract.  Four distinct genotypes of BKV have been 
identified which have varying geographic distributions and may not all be equally pathogenic in the 
setting of organ transplantation.  In addition, recent studies suggest that the 4 genotypes may also 
be serologically distinct. 
 
BKV rarely causes disease in immunocompetent adults, but in the setting of immunosuppression 
(such as renal transplantation) BKV can reactivate and cause asymptomatic viruria or symptomatic 
disease.  The donor kidney also appears to be an important source of BKV infection in the graft 
recipient.  Studies have shown that the higher the BKV antibody titer in the donor, the greater the 
incidence of BKV disease in the renal transplant recipient.2  BKV nephropathy (BKVN) and ureteral 
stenosis are the most commonly described clinical manifestations of BKV infection in renal 
transplant recipients.3 Hemorrhagic cystitis due to BKV, another common manifestation, is 
observed most often in hematopoietic stem cell transplant (HSCT) patients, but occurs in renal 
transplant patients as well.   
 
Studies of the natural history of BKV infection have been greatly facilitated by the development of 
reliable PCR assays for BKV DNA.4  Approximately 30 to 60% of all renal transplant recipients will 
have detectable levels of BKV DNA in their urine.5-7  Approximately 10 to 15% of all renal 
transplant recipients will have BKV viremia (preceded in most cases by viruria).5, 8  Among the 
patients who progress to BKVN, virtually all will have BKV viremia.  BK viremia is most frequently 
detected in the first six months following renal transplantation.9,10  Predictors of viremia include 
early onset of BKV viruria, rapid increase in viruria, and high peak titers of BKV DNA in urine.5,11  
Progression to BKVN often occurs without clinical signs or symptoms and is manifest only by a 
progressive increase in serum creatinine.  Histopathologic examination of the renal allograft has 
traditionally been the “gold standard” for the definitive diagnosis of BKVN.  However, recent studies 
have demonstrated that BKV DNA can be readily detected in blood using polymerase chain 
reaction (PCR) methodology in virtually all patients with histologically proven BKVN.  Indeed, BKV 
DNA can often be detected in blood or urine for several months prior to the development of renal 
dysfunction, presenting an opportunity for therapeutic intervention.  Although BKVN was first 
reported in 1978, dramatic increases in the incidence of the syndrome were noted after the 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
16 
 
introduction of third-generation immunosuppressive drugs in the mid-1990s.  Although the 
incidence of BKVN has not been precisely defined, transplant centers have reported rates of BKVN 
ranging from 1 to 10%.12-14 One prospective study reported an 8% incidence of BKVN in renal 
transplant patients who received one or more of the newer immunosuppressive agents, such as 
tacrolimus, mycophenolate mofetil, and sirolimus.15  Two lines of evidence suggest that 
development of BKVN may relate to the intensity of anti-rejection immunosuppressive therapy.  
First, BKVN has been seen much more commonly in the era of more potent immunosuppressive 
agents; most patients with documented BKVN have received one or more of these newer 
immunosuppressive drugs.  Second, some patients with BKVN appear to clear virus from the blood 
and urine after reduction of the intensity of immunosuppressive therapy.5  These observations 
provide only indirect evidence, however, and the natural history of BKV remains incompletely 
described. 
 
BK polyomavirus infection is mediated by direct infection of allograft renal tubular epithelial cells 
(TECs).  Molecular analysis has demonstrated that there is substantial inflammatory injury 
associated with a profibrotic milieu.16 Monitoring for infection is performed by detecting viral copies 
in urine and blood.  However, virus is frequently shed in the urine in the absence of invasion 
leaving the urinary monitoring as a suboptimal screening mechanism in terms of management of 
recipients that are infected. A testable hypothesis is that tubular injury, in the context of viral 
infection, indicates invasive disease.  Detection of this tubular injury may provide an opportunity to 
manage kidney graft recipients at an earlier stage before invasive BK disease.  Coupled with urine 
PCR, detection of renal tubular injury in recipient urine is a simple technique.  Urine markers of 
injury have already been identified in other causes of acute kidney injury and are commercially 
available.  These include cystatin C, renin, clusterin, Kim-1, b2-microglobulin, osteopontin, retinol 
binding protein, and markers of cell apoptosis.   
 
Currently, no antiviral drug is approved for treatment of BKV infection.17 Anecdotal reports have 
claimed benefit from cidofovir, leflunomide, quinolone antibiotics, and intravenous immunoglobulin.  
However, the current standard of care is early screening for BKV viremia and reduction in 
immunosuppressive therapy in an effort to improve graft survival, although it has not been studied 
in a controlled fashion.12,18,19 At some institutions, modulation of immunosuppressive therapy has 
dramatically reduced the rate of allograft loss due to BKVN.14 Reduction in the immunosuppressive 
regimen is not without consequence and can result in graft loss from immune-mediated organ 
rejection.20  Despite reduction in immunosuppression, in some studies 30 to 70% of patients with 
BKVN have progressive deterioration in renal function, eventually resulting in allograft loss.  
Declining renal function typically occurs over months and is thought to result from a combination of 
persistent viral infection, organ rejection (induced by reduction in immunosuppression), and renal 
fibrosis.   
 
This study is being performed to identify the natural history of BK viremia in renal transplant 
patients with the intent to identify high-risk groups that may benefit in the future from therapy with 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
17 
 
safer and more effective antiviral medications.  
 
2.2.  Scientific Rationale      
 
Renal or renal-pancreas transplant patients are at high risk of significant consequences from BKV 
infection, but have limited treatment options.  No antiviral therapies of proven clinical value are 
currently available to treat BKV infection.  The natural history of infection in this population is 
incompletely understood.  Thus, BKV-infected renal or renal-pancreas transplant patients have 
been selected for inclusion in this study as they are an at-risk patient population with an unmet 
medical need.   
 
2.2.1.  Renal (or Renal-Pancreas Transplant) Patients   
 
Approximately 30 – 60% of all renal or renal-pancreas transplant patients will have detectable 
levels of BKV DNA in their urine in the post-transplant period.  Approximately 10 – 15% of renal 
transplant patients will have BK viremia.  Among the patients who progress to BKVN, virtually all 
will have BK viremia. Predictors of viremia include early onset of BK viruria, rapid increase in 
quantitative viruria, and high peak titers of BKV DNA in urine.  In an effort to capture these subjects 
early in the course of the evolving BK infection and avoid subjects who have already developed 
evidence of BKVN, this protocol will emphasize the initiation of screening in the early post-
transplant period. In addition, since BKVN tends to occur most frequently within the first six months 
after transplantation, screening will be more frequent early in the post-transplant period.  
2.3.  Potential Risks and Benefits 
 
2.3.1  Potential Risks 
 
There are no potential risks to participants, other than the minimal risk associated with routine 
phlebotomy. Most data and specimens can be timed for collection at the participants’ standard-of-
care clinic visits. There are no potential benefits for an individual volunteering to take part in this 
natural history study, other than contributing to a better understanding of an infectious disease for 
which he/she is at risk. The participant will be allowing the research to collect data and residual 
blood samples that can be used to research BK infection and provide potentially useful data for 
monitoring and treatment of future transplant patients. 
 
2.3.2.  Potential Benefits 
 
There may not be any direct benefit for individual subjects enrolled in this study.  Some study 
specimens will be batch-shipped and processed, so results will not always be available to inform  
the subjects’ clinical management.  Indirectly, the data from this study will teach the transplant 
community when interventions are most likely to be successful. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
18 
 
3.  OBJECTIVES 
 
3.1.  Study Objectives 
 
3.1.1.  Primary Objectives 
 
 
To establish the natural history of BK viremia in a multicenter population of renal and 
renal/pancreas transplant patients, to include incidence, time to onset, duration, and 
quantitation of viral load; 
 
To assess associations between BK viremia and decline in GFR in renal transplant recipients. 
 
3.1.2.  Secondary Objectives 
  
 
To define the donor and recipient-related risk factors for BK viremia and BKVN in a multicenter 
population of renal and renal-pancreas transplant patients; 
 
To define the frequency of clinical outcomes that are potentially related to BKV infection. 
 
3.1.3.  Tertiary (Exploratory) Objectives 
 
 
To compare quantitative measurements of BKV DNA by PCR in plasma and, when 
appropriate, in urine, in order to determine biologic significance; 
 
To assess plasma for evidence of other opportunistic viral pathogens, including CMV, EBV, 
HHV-6, and adenovirus; 
 
To assess urine for evidence of other opportunistic viral pathogens, including CMV and 
adenovirus; 
 
To compare quantitative BKV PCR results from each site (local or reference laboratory) with 
matched results from the Central Unit laboratory;  
 
To explore the potential of biomarkers of tubular injury for predicting increased risk of BKVN. 
 
Relationship of development of BKVN with immunosuppressive therapy 
 
 
3.2.  Study Outcome Measures 
 
3.2.1.  Primary Endpoints 
 
 
Incidence of BV viremia in the study population of screened renal or renal/pancreas transplant 
subjects.  
 
3.2.2.  Secondary endpoints 
 
 
Timing of onset of BK viremia (number of days post-transplant) 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
19 
 
 
Duration of BK viremia 
 
Incidence of BKVN in the study population 
 
Dynamics of quantitative measurements of BK viremia over time 
 
Frequency of donor and recipient-related risk factors for BV viremia, including: 
a. Donor-derived factors:  
i. Deceased donor – Standard criteria donor (SCD), Donor after cardiac death 
(DCD), Expanded criteria donor (ECD) 
ii. Living donor – related donor or unrelated donor 
iii. ABO incompatibility  
iv. Total HLA mismatches 
v. HLA C7 status  
vi. Race/ethnicity 
vii. Sex 
b. Recipient-derived factors:  
i. Delayed graft function (DGF), defined as use of dialysis within 7 days of the 
transplant  
ii. Cold ischemia time (CIT) 
iii. Warm ischemia time (WIT)  
iv. Use of stents  
v. HLA C7 status 
vi. Type/intensity of immunosuppression, including corticosteroids 
vii. Acute rejection  
viii. Age 
ix. Race/ethnicity  
x. Sex 
 
 Frequency of clinical outcomes that are potentially related to BKV infection, including: 
a. subject death, 
b. loss of graft function as defined by GFR <10 mL/min/1.73 m2 
c. development of urinary outlet obstruction 
d. development of gross hematuria 
e. development of lymphocele  
f. 
acute rejection 
g. initiation of dialysis 
h. re-transplantation 
i. 
renal biopsies  
 
 
3.2.3.  Exploratory Endpoints 
 
 
Frequency of BK viruria (incidence, time of onset, duration, viral load quantitation by PCR) in 
subjects with and without BK viremia 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
20 
 
 
Frequency of CMV, EBV, HHV-6, and adenovirus viremia at multiple time points in subjects 
with and without BK viremia 
 
Frequency of CMV and adenovirus viruria at multiple time points in subjects with and without 
BK viremia 
 
Results of BK PCR assays performed on matched specimens at the participating sites (local or 
reference laboratories) and at the UAB Central Laboratory 
 
Results of urinary biomarkers of tubular injury measured at multiple time points in subjects with 
and without viremia, including any subjects with BKVN.  Potential urinary biomarkers include 
cystatin C, renin, clusterin, Kim-1, b2-microglobulin, osteopontin, retinol binding protein, and 
markers of cell apoptosis. Urine biomarkers will not be resulted in real-time. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
21 
 
4.  STUDY DESIGN 
 
The primary objective is to define the natural history of BK viremia in renal or renal-pancreas 
transplant recipients.   In order to understand the natural history of infection, we will measure the 
time to the development of BK viremia and its correlation with progression to end-organ disease 
(BKVN or BK hemorrhagic cystitis). Data from this intensive natural history monitoring period will 
allow for the identification of the types of high-risk patients who might benefit from future studies of 
therapeutic interventions for BKV infection, when effective therapy becomes available.  This will be 
accomplished by serial quantitative BK DNA measurements by PCR in blood (plasma).  It is 
anticipated that most samples (blood and urine) will be collected during routine standard-of-care 
clinic visits and will not require extra study visits. Phases of the study can be summarized as 
follows: 
 
 
Subject identification and informed consent.  Informed consent should be obtained in the 
peri-transplant period (between 7 days pre-transplantation [T-7d] and 100 days post- 
transplantation [T+100 d]). 
 
Prospective screening for BK viremia.  Enrollment and initiation of specimen collection 
should begin no sooner than 4 weeks after transplantation.  Enrollment cannot occur later 
than 100 days after transplantation.  Subjects will be screened (collection of blood and 
urine for laboratory studies, including BK PCR) approximately monthly for 6 months (timed 
from the date of transplantation), then every other month for 6 months. For subjects who 
remain BKV-negative, screening will terminate approximately 12 months from the date of 
transplantation. 
 
Intensive sampling of subjects identified with BK viremia.  Subjects identified with qualifying 
viremia will be sampled approximately every two weeks until resolution of viremia (defined 
as PCR negative, or <1000 copies). 
Note:  Patients who did not participate in the prospective screening phase but are identified 
with BK viremia by standard-of-care testing may be enrolled, as long as they are still within 
90 days of transplantation. 
 
Post-viremia follow-up.  Following resolution of viremia, subjects will be sampled (collection 
of blood and urine) approximately monthly for 6 months (unless another termination event 
occurs sooner). 
 
4.1.  Informed Consent and Enrollment 
In an effort to capture subjects early in the course of the evolving BK infection and to avoid 
subjects who have already developed evidence of BKV-induced nephropathy (BKVN), this protocol 
will emphasize the natural history of early-onset BK viremia. Obtaining informed consent early in 
the peri-transplant period is encouraged, although enrollment and study-related specimen 
collections will not begin until >4 weeks post-transplant. The consent form will secure the subject’s 
informed consent to participate in the screening phase as well as the intensive monitoring phase (if 
qualifying viremia is subsequently identified). 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
22 
 
Consented subjects can be enrolled as early as 4 weeks and as late as 100 days following 
renal/renal-pancreas transplant surgery. The 4-week delay prior to enrollment and initiation of 
specimen collection will allow post-transplantation stabilization of renal function, 
immunosuppressive dosing, and other clinical parameters.   
 
4.2.  Prospective Screening Phase 
Approximately 450 subjects will be screened for BK viremia (15% over-enrollment allowed, to a 
maximum of 518 screened subjects).  During the screening phase, subjects will submit blood 
(plasma) for quantitative measurement of BKV DNA approximately every 4 weeks, ± 7 days, for 6 
months (timed from the date of transplantation) and then approximately every 8 weeks, ± 14 days 
for 6 months.  Also, urine specimens will be collected at each visit and stored for subsequent 
testing. During the screening phase, the specified intervals between sample collections should be 
followed as closely as possible, but may vary with subject availability. If qualifying BK viremia is not 
detected, surveillance will terminate approximately 12 months after the date of transplantation (or 
when another study termination endpoint is reached, whichever occurs sooner). 
 
NOTE: BKV PCR results of >10,000 from the study central laboratory, the site laboratory, or a 
reference laboratory are acceptable to qualify the patient for inclusion in the Intensive Monitoring 
Phase of the study.   
 
NOTE: Non-study patients who are determined to have a qualifying blood BK viral load (>10,000 
copies/ml) during the course of routine clinical care (i.e., patients not consented and not identified 
by prospective screening/surveillance) will also be eligible for enrollment directly into the intensive 
monitoring surveillance phase after providing consent as long as they remain within the window of 
< 100 days following transplantation. 
 
Subjects will remain in the screening/surveillance phase: 1) for 12 months post-transplantation; 2) 
until qualifying BK viremia is documented; 3) until renal graft failure, re-transplantation, and/or 
initiation of chronic dialysis occurs; 4) death; 5) until subject decides to terminate participation; 6) 
until the investigator decides that the subject should terminate participation; or 7) until the study 
closes (whichever occurs first). Reason for termination of participation in the study will be 
documented.  
 
4.3.  Intensive Sampling Phase 
Approximately 40 viremic subjects (up to a maximum of 60) will be asked to participate in 
more intensive sampling. Those subjects in whom BK viremia is identified (by PCR result 
demonstrating BK DNA >10,000 copies/ml) will be shifted to a more intensive sampling 
schedule.  A review of the informed consent will be initiated by the research staff to 
confirm the subject’s continued willingness and ability to participate in the intensive 
monitoring phase until resolution of viremia or until another discontinuation event occurs.  

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
23 
 
Blood and urine specimen collection will occur every 2 weeks, ± 7 days, until the BK 
viremia has resolved (or another study termination endpoint is reached).  Resolution of BK viremia 
is defined as PCR becoming negative (or viral load <1000 copies/ml).  Start and stop dates for the 
Intensive Sampling Phase will be defined by the date that the qualifying (initial positive and 
subsequent negative) blood samples were drawn.   
 
4.4.  Post-Viremia Follow-Up 
Following resolution of viremia, subjects will return to the previous sampling schedule 
(approximately every 4 weeks, ± 14 days) for an additional 6 months (or until another study 
termination endpoint is reached, whichever occurs sooner). The first follow-up visit should occur 
approximately 4 weeks after the BK viral load was documented to be negative. 
 
Subjects will remain in the post-viremia follow-up phase: 1). for 6 months following resolution of the 
BK viremia; 2). until another study termination endpoint is reached; 3). until death; 4). until they 
decided to terminate participation; 5). until the investigator decides that the subject should 
terminate participation; or 6). until the study closes (whichever occurs first). Reason for termination 
of study participation will be documented. 
 
4.5.  Specimens for Biomarker Studies 
Detection of tubular injury by measurement of biomarkers may provide an opportunity to manage 
renal graft recipients at an earlier stage before invasive BK disease.  Coupled with urine PCR, 
detection of renal tubular injury in recipient urine is a simple technique.  Urine markers of injury 
have already been identified in other causes of acute kidney injury and are commercially available.  
These include cystatin C, renin, clusterin, Kim-1, b2-microglobulin, osteopontin, retinol binding 
protein, and markers of cell apoptosis.  For biomarker studies, approximately 100 mL of urine will 
be collected, aliquoted and stored at -70C on each subjects at each scheduled study visit (see 
MOP for details).  Urine will also be collected at the time of any renal biopsy, if performed.  We will 
retrospectively analyze expression of these urine markers of injury using urine specimens collected 
at the time of detection of BK virus (in urine and/or blood) and at serial time-points. Using 
appropriate control specimens, values will be compared for: 1) Subjects who are BK viremic vs. 
non-viremic; 2) Subjects who subsequently develop BKVN vs. subjects with stable GFR vs. 
subjects with declining GFR attributed to a cause other than BKVN. 
 
4.6.  Documenting Special Events 
Specific clinical events and outcomes that may be related to BKV infection will be recorded, 
including: 
 
subject death 
 
loss of graft function as defined by GFR <10 mL/min/1.73 m2 
 
development of urinary outlet obstruction 
 
development of gross hematuria 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
24 
 
 
development of lymphocele  
 
acute rejection 
 
initiation of dialysis 
 
re-transplantation 
 
renal biopsies – Should renal biopsy be performed per standard-of-care during the 
course of the study, results will be submitted using information from the pathology 
report. 
 
All data will be recorded on source documents, then entered on eCRFs and submitted 
electronically.  
 
4.7.  Adverse Events 
No protocol-defined interventions are included in this study; thus, adverse event recording will not 
be required unless the event is related to a study-mandated procedure (e.g., phlebotomy). 
 
4.8.  Clinical Laboratory Data 
Specimens for laboratory studies will be collected as detailed in Section 7.2. 
 
4.9.  Study Visits  
The study visits for the screening phase will be every 4 weeks ± 7 days for 6 months (timed from 
date of transplantation) and then every 8 weeks ±14 days. The study visits during the intensive 
monitoring period are every 2 weeks ± 7days until resolution of BK viremia and then every 4 weeks 
± 7 days for 6 months.  
 
Because the first year following kidney transplantation is challenging for patients, all post-
enrollment study visits and visit windows are approximations and may fluctuate with study subject 
availability.   
 
Events occurring at each study visit are listed in Appendix A. 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
25 
 
5.  STUDY POPULATION 
 
5.1.  Study Population Selection 
 
All adult renal or renal-pancreas transplant patients who meet protocol inclusion/exclusion criteria 
are eligible for participation in this study.  
  
In an effort to capture subjects early in the course of the evolving BK infection and avoid subjects 
who have already developed evidence of BKVN, this protocol will emphasize consent in the early 
peri-transplant period.  Patients may be consented while hospitalized pre-transplantation (as early 
as 7 days prior to transplantation) or at an outpatient follow-up visit (as late as 100 days post-
transplantation).  The study enrollment visit and initial collection of protocol-defined specimens will 
take place between 4 weeks and 100 days following renal or renal/pancreas transplantation. 
 
5.2.  Inclusion of Women, Children and Minorities  
 
All adult renal or renal/pancreas transplant patients meeting protocol inclusion/exclusion criteria 
will be potentially eligible for participation in this study.  Subjects will not be excluded on the basis 
of gender or ethnicity. Since there is no known gender or ethnic predilection for BKV infection, it is 
expected that the percentage of women and minorities included in the study will reflect the local 
demographics of the renal or renal-pancreas transplant population at the participating sites.  
 
5.3.  Inclusion/Exclusion Criteria  
 
5.3.1.  Inclusion Criteria 
 
 
Renal or renal-pancreas transplant patients who are within the informed consent window (as 
early as 7 days prior to transplantation or as late as 100 days post-transplantation).   
 
Age > 18 years; 
 
Willing and able to understand and provide written informed consent. 
 
5.3.2.  Exclusion Criteria 
 
 
Evidence of proven or suspected BKVN by clinical or pathologic diagnostic criteria; 
 
Initiation of chronic dialysis post-transplantation due to graft failure. 
 
 
 
  

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
26 
 
6.0.  SCHEDULE OF EVENTS 
 
6.1.  Enrollment Visit  (Day 1) 
 
Subjects who meet criteria for the eligibility criteria and have provided informed consent should be 
scheduled for an Enrollment Visit. The enrollment visit should be scheduled no sooner than 4 
weeks after the transplant, but not more than 100 days after the transplant.  At the initial 
Enrollment Visit, the following assessments should be performed: 
 
1. Confirm that informed consent has been obtained and that the subject still wishes to 
participate;   
2. Review the inclusion-exclusion criteria to assure that the patient remains eligible for 
study participation. Subjects who are not willing or eligible to participate in the clinical 
trial should be logged as screen failures and reported on the Failed Screening page 
located on the Central Unit website. 
3. Record donor and recipient demographic and risk factor data, to include: 
a. Donor-derived factors:  
i. Deceased donor – Standard criteria donor (SCD), Donor after cardiac 
death (DCD), Expanded criteria donor (ECD) 
ii. Living donor – related donor or unrelated donor 
iii. ABO incompatibility  
iv. Total HLA mismatches 
v. HLA C7 status  
vi. Age 
vii. Race/ethnicity 
viii. Sex 
b. Recipient-derived factors:  
i. Delayed graft function (DGF), defined as use of dialysis within 7 days of 
the transplant  
ii. Cold ischemia time (CIT) 
iii. Warm ischemia time (WIT)  
iv. Use of stents  
v. HLA C7 status 
vi. Type/intensity of immunosuppression, including corticosteroids 
vii. Acute rejection  
viii. Age 
ix. Race/ethnicity  
x. Sex 
 
4. Document  medical and surgical history  
5. Document use of selected concomitant medications (specifically, antiviral agents, 
immunomodulators, and immunosuppressive medications – see the listing provided in 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
27 
 
the MOP).  Record all immunosuppressive drugs administered since transplantation, 
including peri-operative induction therapy with biological agents; 
6. Document blood concentrations of immunosuppressive drugs measured for clinical 
reasons; 
7. Obtain blood for serum creatinine determination and estimated GFR (if these studies 
were performed for routine standard-of-care within 7 days prior to enrollment, then the 
results of those assays can be recorded for study purposes); 
8. Collect 10 ml of blood for study-specified PCR assays (BK and other viruses), to be 
performed at the UAB Central Laboratory. Blood will collected, separated to plasma, 
then stored and shipped per instructions in the Manual of Procedures; 
9. If blood BK PCR was performed for routine standard-of-care in a local or reference 
laboratory, record the results of that assay as well. (Specimen for PCR will still be 
submitted to the UAB Central Laboratory); 
10.  Optional urinalysis - if UA was performed for routine standard-of-care with 7 days of 
enrollment, then the results of those assays can be recorded; 
11. Obtain a urine sample (approximately 100 ml) for study-specified PCR assays (BK and 
other viruses) and measurements of urinary biomarkers to be performed at the UAB 
Central Laboratory.  Urine will be collected, stored, and shipped per instructions in the 
Manual of Procedures. 
12. Notify the UAB Central Unit if the subject has consented to any other research study. 
 
6.2.  Screening Study Visits (approximately every 4 weeks +/- 7 days for 6 months and then 
approximately every 8 weeks +/- 14 days for 6 months)  
 
At each subsequent protocol-defined screening visit, the following events will occur: 
 
1. Document interval medical history to specifically include: 
a. subject death, 
b. loss of graft function as defined by GFR <10 mL/min/1.73 m2 
c. development of urinary outlet obstruction 
d. development of gross hematuria 
e. development of lymphocele  
f. 
acute rejection 
g. initiation of dialysis 
h. re-transplantation 
i. 
renal biopsies – Should renal biopsy be performed per standard-of-care during the 
course of the study, record the results from the pathology report. 
 
2. Document use of selected concomitant medications (specifically, antiviral agents, 
immunomodulators, and immunosuppressive medications – see MOP for listing); 
3. Record blood concentrations of immunosuppressive drugs obtained for clinical care 
purposes; 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
28 
 
4. Obtain blood for serum creatinine determination and estimated GFR (if these studies were 
performed for routine standard-of-care within 7 days prior to the study visit, then the 
results of those assays can be recorded for study purposes); 
5. Obtain 10 ml of blood for study-specified PCR assays (BK and other viruses), to be 
performed at the UAB Central Laboratory. Blood will collected, separated to plasma, then 
stored and shipped per instructions in the Manual of Procedures;  
If blood BK PCR was performed for routine standard-of-care at a local or reference 
laboratory, record the results of that assay in the research record; 
6. Optional urinalysis - if UA was performed for routine standard-of-care within 7 days of 
enrollment, then the results of those assays can be recorded); 
7. Obtain urine (approximately 100 ml) for subsequent study-specified PCR assays (BK and 
other viruses) and measurements of urinary biomarkers to be performed at the UAB 
Central Laboratory. Urine will be collected, stored, and shipped per instructions in the 
Manual of Procedures. 
8. Notify the UAB Central Unit if the subject has consented to any other research study. 
 
 
6.3.  Intensive Monitoring Phase for BK Viremic Subjects:  (approximately every 2 weeks +/- 
7 days until viremia has resolved (PCR negative or <1000 copies/ml), then approximately 
every 4 weeks +/-14 days for 6 months). 
 
At each protocol-defined study visit, the following events will occur: 
 
1.  Document interval medical history to specifically include: 
a. subject death, 
b. loss of graft function as defined by GFR <10 mL/min/1.73 m2 
c. development of urinary outlet obstruction 
d. development of gross hematuria 
e. development of lymphocele  
f. 
acute rejection 
g. initiation of dialysis 
h. re-transplantation 
i. 
renal biopsies – Should renal biopsy be performed per standard-of-care during the 
course of the study, record the results from the pathology report. 
 
2. Document use of selected concomitant medications (specifically, antiviral agents, 
immunomodulators, and immunosuppressive medications – see MOP for listing); 
3. Record  blood concentrations of immunosuppressive drugs obtained for clinical care purposes; 
4. Obtain blood for determination of creatinine and GFR.  If results of serum creatinine and GFR 
obtained for clinical care purposes (within 7 days) are available, those results may be used 
instead; 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
29 
 
5. Obtain 10 ml of blood for study-specified PCR assays (BK and other viruses), to be performed 
at the UAB Central Laboratory.  Blood will collected, separated to plasma, then stored and 
shipped per instructions in the Manual of Procedures;  
6. If blood BK PCR was performed for routine standard-of-care at a local or reference laboratory, 
record the results of that assay in the research record; 
7. Optional urinalysis – if results of urinalysis obtained for clinical care purposes (within 7 days) 
are available, those results may be recorded; 
8. Obtain urine (approximately 100 ml) for subsequent study-specified PCR assays (BK and other 
viruses) and measurements of urinary biomarkers to be performed at the UAB Central 
Laboratory. Urine will be collected, stored, and shipped per instructions in the Manual of 
Procedures. 
9. Notify the UAB Central Unit if the subject has consented to any other research study. 
 
6.4.  Subject Early Termination  
 
Subjects will be terminated from the study for any of the following reasons: 
 
Death;  
 
Initiation of chronic dialysis for loss of graft function; 
 
Re-transplantation; 
 
Inability or unwillingness to comply with study requirements. 
 
6.5.  Management of Subject Withdrawals 
 
Study subjects may withdraw voluntarily from participation in the study at any time.  If a study 
subject withdraws or is discontinued from the study at any time prior to completion of the study, the 
reason for this decision will be recorded on the study termination page of the eCRF. 
 
6.6.  Termination of Study 
 
The UAB Central Unit (in consultation with DMID) and NIH/NIAID have the right to terminate this 
study at any time.  Reasons for terminating the study may include, but are not limited to, the 
following: 
 
 
Study subject enrollment is unsatisfactory; 
 
Data recording is inaccurate or incomplete; 
 
Investigators do not adhere to the protocol or applicable regulatory guidelines in conducting the 
study. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
30 
 
7.0.  STUDY PROCEDURES  
 
The scheduled study procedures and evaluations are summarized in Appendix A.   
 
7.1.  Demographics, Baseline Medical-Surgical History, Clinical Outcomes 
 
At the time of enrollment, baseline demographics and medical-surgical history (cardiovascular, 
respiratory, musculoskeletal, gastrointestinal, lymphatic, urinary, nervous, endocrine, skin, 
reproductive, EENT)  will be obtained from the medical charts or from subject interviews.  
Transplant-specific history (HLA match, organ source, surgical date and select donor and recipient 
risk factors) will be recorded.  
 
At subsequent visits, changes in the medical and surgical history will be documented (including 
selected concomitant medications, immunosuppressive drug levels and pathology results from 
renal biopsies conducted for clinical care).  Clinical outcomes will be recorded including subject 
death, loss of graft function, acute graft rejection or initiation of dialysis. 
 
7.2.  Laboratory – Specimen Collection 
 
7.2.1.  At Each Screening Visit: 
 
Blood: 
 
Blood (10 ml) for viral PCR submitted as plasma to UAB Central Laboratory).   
 
Serum creatinine and GFR performed at local laboratory (or results of assay performed for 
clinical standard-of-care will be recorded) 
 
Urine: 
 
specimen  (approximately 100 ml) for biomarkers and viral PCR (UAB Central laboratory)  
 
optional urinalysis (dipstick and microscopic, to include: pH, bilirubin, blood, nitrite, protein, 
specific gravity, glucose, ketones, RBC/HPF, WBC/HPF, urobilinogen, leukocyte esterase) 
performed at local laboratory (or results of assay performed for clinical standard-of-care can  
be recorded)   
 
7.2.2.  At Each Intensive Follow-up Visit for Viremic Subjects: 
 
Blood: 
 
Blood (10 ml) for viral PCR submitted as plasma to UAB Central Laboratory.   
 
Serum creatinine and estimated GFR – performed at local laboratory (or results of assay 
performed for clinical standard-of-care will be recorded) 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
31 
 
 
Urine: 
 
Optional urinalysis (dipstick and microscopic, to include: pH, bilirubin, blood, nitrite, protein, 
specific gravity, glucose, ketones, RBC/HPF, WBC/HPF, urobilinogen, leukocyte esterase) 
performed at local laboratory (or results of assay performed for clinical standard-of-care can be 
recorded)   
 
specimen  (approximately 100 ml) for biomarkers and viral PCR (UAB Central laboratory)  
 
7.3.  Reporting of Concomitant Medications 
 
Only selected concomitant medications will be recorded at each subject visit. Only the following will 
be reported:  
 
 
immunosuppressive drugs (including peri-transplant induction therapy), 
 
immunomodulators,  
 
antiviral drugs. 
 
 A list of the selected medications is found in the Manual of Procedures. The generic name of each 
medication, the dosage, the route, and the start/stop dates of administration will be recorded in the 
appropriate sections of the eCRF. Failure to document use of selected concomitant medications 
will be considered a protocol deviation. 
 
7.4.  Dosing of Immunosuppressive Drugs  
 
Immunosuppressive (IS) drug selection and doses will be determined by the site 
physicians/investigator in accordance with best clinical practice and local treatment standards.  
Modification of immunosuppressive drug dosing in response to documented BK viremia (or other 
indications) may be performed at the discretion of the treating physicians/investigator. All doses 
and dose changes should be documented in the concomitant immunosuppressive medications 
section of the eCRF. Failure to document concomitant medication information will be reported as a 
protocol deviation during screening/surveillance and intensive monitoring periods. 
 
Measurements of immunosuppressive drug levels are not a protocol requirement.  However, IS 
levels that are obtained for standard-of-care medical management during the study will be 
recorded on the eCRF.  
 
7.5.  Measurement of Viral DNA  
 
BKV DNA levels will be measured at the UAB Central Lab.  Plasma specimens will be shipped to 
the UAB Central Laboratory once weekly (Monday through Thursday – see Manual of Procedures 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
32 
 
for details) for real-time viral load determinations. The BKV DNA in plasma will be assayed using a 
quantitative PCR assay. Assays will be performed approximately once weekly and results will be 
shared with the site investigators as soon as they are available.  
 
NOTE: BK PCR assays performed on specimens collected during the post-viremia follow-up period 
will not be run in real time; real-time results will not be available to the investigator.  These can be 
batch-shipped at the conclusion of the follow-up period. 
Retrospective analysis of urine for BKV DNA and tubular injury biomarkers will be performed in 
viremic subjects where correlations between viremia and viruria can be made.  PCR of urine for 
BKV DNA will not be performed in real time.  Urine specimens for PCR and for biomarker assays 
will be collected, frozen, and batch-shipped to the UAB Central Laboratory (see Manual of 
Procedures for details). 
Plasma and urine assays for other non-BK viral pathogens will be performed retrospectively.  
These assays will not be performed in real time and results will not be provided to the site 
principal investigators in real time.  
Any blood BKV DNA result obtained at the local (or reference) laboratory for standard-of-care 
purposes will be reported on the eCRF. 
 
7.6.  Specimen Preparation, Handling and Shipping 
 
Guidance for specimen processing, shipping and storage will be found in the MOP.  
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
33 
 
8.  STATISTICAL CONSIDERATIONS 
 
8.1.  Study Hypothesis 
 
Elucidation of the natural history of BK viremia in renal transplant patients will identify those groups 
at high risk for developing BKVN who may potentially benefit from therapeutic interventions (when 
these become available). In particular, it is of interest to compare the change in the glomerular 
filtration rate (GFR) a year after transplant between the BKV viremic and non-viremic subjects. We 
hypothesize that BKV viremia will have a negative effect on renal function as measured by GFR.  
 
8.2.  Sample Size Considerations 
 
8.2.1.  Sample Size 
 
We propose to enroll approximately 450 (up to a maximum of 518) patients in this study. The 
sample size justification is based on observing a target number of BKV viremia patients from the 
patients enrolled in the screening group. Table 1 below shows varying values of proportion of 
patients with BKV viremia. Figure 1 summarizes the probability of observing K number of BKV 
patients (K=30, 35, 40, 45, and 50) assuming varying values of true proportion of BKV viremia 
patients (3% to 17%) out of 450 enrolled patients. To interpret this graph, assume that the true 
proportion of BKV viremia patients is 10%. Then the probabilities of observing at least 30, 35, 40, 
45, and 50 BKV viremia patients out of the 450 enrolled are about 0.99, 0.94, 0.76, 0.46, and 0.19, 
respectively. 
 
In this study, we would like to target approximately 40 BKV viremia patients (up to a maximum of 
60). From Figure 1, enrolling 450 subjects give us at least 90% probability of identifying at least 40 
BKV viremia patients, if the true percent of BKV viremia patients is at least 11%. 
 
Table 1 
Location 
Study Type 
Sample size 
(N) 
% with BKV 
viremia 
Reference 
USA3 
Prospective 
200 
11.5% 
Brennan 2005 
Spain5 
Prospective 
156 
12.2% 
Munoz 2005 
USA23 
Prospective 
  66 
16.6% 
Petrov 2009 
Czech Republic24 
Prospective 
120 
     6% 
Girmanova 2011 
USA25 
Retrospective 
134 
   16% 
Koleilat 2011 
  
  
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
34 
 
Figure 1: Probability of Observing a Given Number of BKV Subjects or More as a function of True 
Percent with BKV viremia 
 
 
We are also interested in comparing the change in GFR between those with and without BKV 
viremia. In this power analysis, we will only be concerned about the change from baseline (time of 
enrollment) to Month 12 (time post-transplant). Assuming the standard deviation of the change in 
GFR is assumed to be the same for those with and without BKV viremia and equals 10.9 
ml/min/1.73 m2 (Ref: Srinivas TR, Flechner SM, Poggio ED, et al. Glomerular filtration rate slopes 
have significantly improved among renal transplants in the United States. Transplantation 2010; 
90:1499-505.). With 40 BKV viremia subjects and 410 non-BKV viremia subjects, we will detect a 
mean difference in the change in GFR of at least 5.9 ml/min/1.73 m2 with 90% power between 
these two groups of subjects at 5% level of significance based on a t-test. In the final analysis, we 
will be using all available GFR data for each subject which should increase the power as more 
information is used. This will enable us to still use data from subjects who dropped out before the 
end of the study. 
 
 8.2.2.  Estimated Annual Accrual 
 
We anticipate enrolling approximately 250 subjects per year into prospective screening  
 
8.3.  Demographic Analysis 
 
Demographics and clinical characteristics will be summarized using means and standard 
deviations for continuous variables and counts and proportions for categorical variables. ANOVA 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
35 
 
(or its nonparametric analog Krusall-Wallis) for continuous variables and Fisher’s exact test for 
categorical variables will be utilized to compare these characteristics.  Demographic characteristics 
will be summarized in tabular format.  
 
8.4.  Final Analysis Plan 
 
All statistical tests will be performed at 5% significance level and confidence interval at 95% level. 
There will be no adjustment on the levels for multiple testing. There will also be no imputation 
methods that will be used for missing data. Any viral load <100 (i.e., undetectable) will be replaced 
by viral load value of 10. Quantitative viral loads will be analyzed based on the log based 10 
transformation.  
 
  8.4.1.  Primary Outcome Analysis 
 
Incidence of BK viremia will be estimated using a 95% confidence interval for single proportion. 
Logistic regression will be used to investigate the risk factors for BKV viremia and BKVN. Factors 
will include: 
o Donor-derived factors:  
1. Deceased donor – Standard criteria donor (SCD), Donor after cardiac death 
(DCD), Expanded criteria donor (ECD) 
2. Living donor – related donor or unrelated donor 
3. ABO incompatibility  
4. Total HLA mismatches 
5. HLA C7 status  
6. Race/ethnicity 
7. Sex 
o Recipient-derived factors:  
1. Delayed graft function (DGF), defined as use of dialysis within 7 days of the 
transplant  
2. Cold ischemia time (CIT) 
3. Warm ischemia time (WIT)  
4. Use of stents  
5. HLA C7 status 
6. Type/intensity of immunosuppression, including corticosteroids 
7. Acute rejection  
8. Age 
9. Race/ethnicity  
10. Sex 
To compare the change in GFR over time between those with and without BKV viremia, we use all 
available GFR data from each subject.  We will use mixed model for repeated measures to analyze 
the GFR data over time. This analysis method will allow us to use any of the available GFR data 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
36 
 
even if they are not complete. We will determine the appropriate covariance structure to use as 
indicated by the Akaike Information Criterion.  
 
8.4.2.  Secondary Endpoints 
  
The distribution of the time to onset and duration of BKV viremia will be estimated using survival 
analysis methods such as Kaplan-Meier estimator for a single group. This will provide estimates of 
the median time to onset or median duration of BKV viremia. To compare different groups and/or 
determine risk factors, we will use Cox proportional hazard regression model if the proportional 
hazards assumption is found to be reasonable. Otherwise, we will consider using parametric 
survival regression models (in particular, accelerated failure time model). Parametric regression 
models are useful especially in cases where sample sizes are small or when the percent censored 
is high. This will also be the tool of preference if there will be left-censored subjects, i.e., subjects 
who at enrollment show evidence of BK viremia. Cox model cannot handle left-censored data. 
 
As with the BKV viremia, incidence of BKVN will be estimated using a 95% confidence interval for 
single proportion.  We will utilize logistic regression to compare groups, or adjust for covariates or 
determine risk factor. 
 
To investigate the change in the quantitative BK viremia over time and how it is associated with 
important factors such as the use of immunosuppressive therapy and recipient’s demographic and 
clinical characteristics, we will again use mixed regression modeling for repeated measures.  
 
8.4.3.  Exploratory Endpoints 
 
To investigate the association between the incidence between BK viremia and BK viruria, we will 
utilize the Fisher’s exact test or the large-sample chi-squared test for association whichever is 
applicable. Time to onset and duration of BK viremia and BK viruria will be analyzed using survival 
analyses. 
 
Logistic regression will be utilized to determine if other viruses such as CMV, adenovirus, etc. are 
risk factors for BK viremia. This tool will also be used to determine if selected urinary biomarkers of 
tubular injury are predictors of BKVN. 
 
To assess the relationship of the time to development of BKVN with the use of immunosuppressive 
therapy, we will use survival regression analysis with the length of use of immunosuppressive 
weighted by dose as a predictor variable of interest. 
 
Finally, to examine the reproducibility of the quantitative PCR assays at the participating sites and 
PCR assays at UAB, we compute the differences in the results and construct a 95% confidence 
interval for the mean difference. We will also create a Bland-Altman plot which will display the 
differences and their 95% confidence intervals as a function of the mean readings of the two PCR 
results. 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
37 
 
9.  SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/ 
DOCUMENTS 
 
Documentation of source data is necessary for the reconstruction, evaluation, and validation of 
clinical findings, observations, and other activities during a clinical trial.  Source documentation 
serves to substantiate the integrity of trial data, confirms observations that are recorded, and 
confirm the existence of study participants.  This standard also serves to ensure data quality by 
creating audit trails and enabling verification that data are present, complete, and accurate.  DMID 
studies will be monitored using these standards. 
 
Sites that are participating in this trial should consult the MOP, Central Unit website, and 
DMID/NIAID Source Document Standards (most current version) for specific instructions and 
forms. 
 
Local, state, institution, IRB/independent ethics committee (IEC) policies and procedures may be 
different from those stated in this standard.  The site should refer to local, state, institution, IRB/IEC 
policies and procedures and follow them if they are more stringent than the DMID Standards. 
 
According to the ICH E6 Guidelines 4.9, “The investigator should ensure the accuracy, 
completeness, legibility, and timeliness of the data reported to the sponsor in the CRFs 
and in all required reports.  Data reported on the CRFs, which are derived from source 
documents, should be consistent with the source documents or discrepancies should be 
explained.” 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
38 
 
10.  QUALITY CONTROL AND QUALITY ASSURANCE  
 
The study site will implement a quality management plan. The quality management procedures are 
described herein, as well as in the Manual of Procedures and the study site quality management 
plan (QMP). Per the QMP, data will be evaluated for compliance with the protocol and accuracy in 
relation to source documents. The study will be conducted in accordance with procedures 
identified in the protocol. Items to be reviewed include, but are not limited to: eligibility (including 
informed consent), any required AE reporting, study/clinical endpoints, follow-up visits, regulatory 
documents, missed calls, and review of clinical records. Data that will be reviewed, who is 
responsible for implementation, and the schedule for internal reviews will be specified or 
referenced in the quality management plan.  
 
The UAB Statistical and Data Coordinating Center will implement quality control procedures 
beginning with the data entry system, and will generate data quality control checks that will be run 
on the database within 24 hours of new data entered into the system. Full documentation of these 
checks will be provided to the UAB Central Unit so that any resulting queries can easily be 
understood and transmitted to the respective site for resolution within a short period of time. These 
processes are validated by a second programmer and also tested with faulty test data.  
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
39 
 
11.  ETHICS AND PROTECTION OF HUMAN SUBJECTS 
 
11.1.  Ethical Standard 
 
This trial will be conducted in compliance with the protocol, International Conference on 
Harmonization E6 Good Clinical Practice (ICH E6 GCP), and the applicable regulatory 
requirements, including: 
 
 
U.S. Code of Federal Regulations applicable to clinical studies (45 CFR 46 and 21 CFR 11 
including parts 50 and 56 concerning informed consent and IRB regulations). 
 
Completion of Human Subjects Protection Training.  Refer to 
http://grants.nih.gov/grants/guide/notice-files/NOT-OD-01-061.html; 
http://cme.cancer.gov/clinicaltrials/learning/humanparticipant-protections.asp  
 
11.2.  Institutional Review Board 
 
Reviewing IRBs must be registered with the OHRP to conduct FDA-regulated studies.  In the United 
States and in other countries, only institutions holding a current US Federalwide Assurance (FWA) 
issued by OHRP will be eligible to participate in this protocol. 
 
This protocol, informed consent documents, relevant supporting information, and all types of 
volunteer recruitment or advertisement information will be submitted to the Institutional Review 
Board (IRB) for review and must be approved before the study is initiated.  Any amendments to the 
protocol must also be approved by the IRB prior to implementing changes in the study.  
 
The investigator is responsible for keeping the IRB apprised of the progress of the study and of any 
changes made to the protocol as deemed appropriate, but in any case at least once per year.  The 
investigator must also keep the IRB informed of any significant AEs. 
 
All IRB approved documents as well as relevant study correspondence should be copied and sent 
to the UAB Central Unit. 
 
11.3.  Informed Consent Process 
 
The process of obtaining informed consent must be documented in the medical records, clinic 
chart, and/or research chart.  The consent form must be signed and dated by the study 
participant/study participant’s legal guardian before participation in the study.  Only in the case of 
an established legal guardian may the consent be signed by someone other than the subject.  A 
copy of the signed consent form must be provided to the study participant/study participant’s legal 
guardian.  Signed consent forms must remain in each study participants study file and must be 
available for verification by study monitors at any time.  
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
40 
 
The investigational nature and research objectives of this trial, the procedure, and its attendant 
risks and discomforts will be carefully explained to the study participant/study participant’s legal 
guardian.  A signed informed consent document will be obtained from each study participant/study 
participant’s legal guardian prior to entry into this study.  At any time during participation in the 
protocol, if new information becomes available relating to risks, AEs, or toxicities, this information 
will be provided orally or in writing to all enrolled or prospective study participant/study participants’ 
legal guardian. Documentation will be provided to the IRB and, if necessary, the informed consent 
will be amended to reflect any relevant information. 
 
An investigator shall seek such consent only under circumstances that provide the prospective 
subject or the representative sufficient opportunity to consider whether or not to participate and 
that minimize the possibility of coercion or undue influence. The information that is given to the 
subject or the representative shall be in language understandable to the subject or the 
representative. 
 
Subjects/subject’s legal guardian will sign the informed consent document prior to any procedures 
being done specifically for the study.  Subjects/subject’s legal guardian should have the 
opportunity to discuss the study with their family, friends or personal physician, or think about it 
prior to agreeing to participate.  Subjects/subject’s legal guardian may withdraw consent at any 
time throughout the course of the trial.  A copy of the informed consent document will be given to 
the subjects /subject’s legal guardian for their records.  The rights and welfare of the subjects will 
be protected by emphasizing to them that the quality of their medical care will not be adversely 
affected if they decline to participate in this study. 
 
If an investigator anticipates enrolling non-English subjects, he/she must provide an approved non-
English consent form.  The non-English consent form must be submitted to the Central Unit with an 
accompanying signed attestation that the non-English consent matches in content and meaning 
the IRB approved English consent.  If a subject presents him/herself for enrollment, the PI must 
identify personnel who will be conduct the consent procedures, discussion and communicate other 
information to the study subject.   Assurance must also be documented that the person proficient in 
the non-English language is available at all subject visits and at any time interaction is needed with 
the subject.  The Principle Investigator or designee will document the process. 
 
If a subject is unable to read or if a legally acceptable representative is unable to read, an impartial 
witness should be present during the entire informed consent discussion. After the written informed 
consent form and any other written information to be provided to subjects, is read and explained to 
the subject or the subject’s legally acceptable representative, and after the subject or the subject’s 
legally acceptable representative has orally consented to the subject’s participation in the trial and, 
if capable of doing so, has signed and personally dated the informed consent form, the witness 
should sign and personally date the consent form. By signing the consent form, the witness attests 
that the information in the consent form and any other written information was accurately explained 
to, and apparently understood by, the subject or the subject's legally acceptable representative, 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
41 
 
and that informed consent was freely given by the subject or the subject’s legally acceptable 
representative.  The Principle Investigator and or designee will document the consenting process. 
 
11.4.  Exclusion of Women, Minorities, and Children (Special Populations) 
 
All adult renal or renal-pancreas transplant patients with BKV viremia meeting protocol 
inclusion/exclusion criteria will be potentially eligible for participation in this study.  Subjects will not 
be excluded on the basis of gender or ethnicity. Since there is no known gender or ethnic 
predilection for BKV infection, it is expected that the percentage of women and minorities included 
in the study will reflect the local demographics of the renal or renal-pancreas transplant population 
at the participating sites. Children will not be enrolled. 
 
11.5  Subject Confidentiality 
 
The information obtained during the conduct of this clinical study is confidential, and disclosure to 
third parties other than those noted below is prohibited.  The results of the research study may be 
published, but study participant’s names or identities will not be revealed.  Records will remain 
confidential.  To maintain confidentiality, the principal investigators at each site will keep records in 
locked cabinets and the results of tests will be coded to prevent association with volunteers’ 
names.  Data entered into computerized files will be accessible only by authorized personnel 
directly involved with the study and will be encoded.  However, subject specific information will be 
available to the clinical monitors, to the FDA and to health authorities where provided by law.   
 
The study investigator is obliged to provide the NIAID/DMID and UAB Central Unit with complete 
test results and all data developed in this study.  The NIAID/DMID or UAB Central Unit may 
disclose this information to appropriate regulatory authorities as deemed necessary by the 
NIAID/DMID or UAB Central Unit   
  
Subject-specific information may be provided to other appropriate medical personnel only with the 
study participant’s parent/legal guardian permission.  To ensure compliance with current ICH E6 
Guidelines, data generated by this study must be available for inspection upon request by 
representatives of national and local health authorities, the NIAID/DMID, UAB Central Unit, and the 
IRB/IEC for each study site. 
 
11.6.  Recruitment and Compensation 
 
Study participants will be recruited using IRB-approved approaches.  The investigators will make 
every effort to recruit adult male and female volunteers from all ethnic backgrounds. 
 
Consented study participants/legal guardians may receive nominal payments to offset the cost of 
travel, parking, and meals for study visits in accordance with local site policies and local IRB 
policies, procedures, and approval. 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
42 
 
11.7  Future Use of Stored Specimens 
 
Some of the specimens obtained from study participants during this study (urine and plasma) will 
be stored indefinitely in the UAB Central Laboratory and may be used in future studies of viral 
infections in renal or renal-pancreas transplant patients.  These specimens will be labeled with a 
code number and not with the study participant’s name.  At the time of consent for study 
participation, study participants will have the opportunity to either agree or decline to have their 
specimens used in future research.  The study participant will indicate his/her preference by 
initialing the appropriate line or checking the appropriate box of the Consent Form in the section 
entitled, “Future Use of Specimens”.  Non-protocol designated, future testing of samples will be 
performed only on samples from study participants who have consented for future testing of 
samples.  These specimens will only be utilized to better understand the natural history of studies 
of viral infections in renal or renal-pancreas transplant patients or improve diagnosis. 
 
A repository for residual samples will be established according to OHRP guidelines ensuring that 
codes or other personally identifying links will not be distributed to future researchers. 
  
The specimens will be stored indefinitely in the UAB Central Laboratory.  Specimens from study 
participants will be labeled and coded without study participant’s identifiers.  If the study participant 
has indicated in the signed consent form that he/she does not agree to allow the future use of 
specimens for future studies of viral infections in renal or renal-pancreas transplant patients, then 
his/her specimens will be destroyed at the completion of this study. 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
43 
 
12.  DATA HANDLING AND RECORD KEEPING 
 
The investigator is responsible to ensure the accuracy, completeness, legibility, and timeliness of 
the data reported. 
Electronic case report forms (eCRFs) will be developed by the UAB Statistical and Data 
Coordinating Center.  The eCRFs will be provided electronically by the UAB Central Unit.  Original 
data will be recorded on source documents (e.g., medical records, research progress notes, or 
Source Document Worksheets documenting research related procedures).  The DMID 11-0071 
Data Management Plan provides a description of how the system will function.  Source Document 
Worksheets that mirror each data field on the eCRF will be available for use by sites as a tool to 
record and maintain data for each study participant enrolled in the study when other source 
documents are not used to collect original data.  All source documents should be completed in a 
neat, legible manner to ensure accurate interpretation of data.  When making a change or 
correction, cross out the original entry with a single line and initial and date the change.  DO NOT 
ERASE, OVERWRITE, OR USE CORRECTION FLUID OR TAPE ON THE ORIGINAL.  Specific 
guidance to investigators and study staff on making corrections to source documents and eCRFs 
will be provided in the MOP for this study. 
Data recorded on the eCRF that differ from source documents must be explained on the 
Comments eCRF and in the subject’s source documents.12.1 Data Management Responsibilities. 
All eCRFs must be reviewed by the investigator’s research team, under the supervision of the 
investigator, who will ensure that they are accurate and complete.  All data must be supported by 
source documents, which will remain available for review by regulatory personnel and monitors.  
Adverse events must be graded, assessed for intensity and causality, and reviewed by the site 
investigator or designee. 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site PI.  During the study, the investigator must maintain complete and accurate documentation for 
the study. 
The UAB Central Unit and Statistical and Data Coordinating will be responsible for data 
management, quality review, analysis of the study data, and writing of the clinical study report.  
These tasks are detailed in the DMID 11-0070 DMP. 
 
12.1  Data Capture Methods 
 
Clinical and laboratory data will be entered into a 21 CRF Part 11 compliant electronic Data Entry 
System (eDES)  provided by the UAB Statistical and Data Coordinating Center.  The data system 
includes password protection and internal quality checks, such as automated range checks, to 
identify data that appear to be inconsistent, incomplete, or inaccurate. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
44 
 
 
12.2  Types of Data 
 
Data for this study will include clinical laboratory and virologic results, and clinical and outcome 
measures. 
 
12.3  Timing/Reports 
 
There are no planned interim analyses or safety reviews for this trial.  There also are no stopping 
rules. 
 
12.4  Study Records Retention 
 
Records and documents pertaining to the conduct of this study, including source documents and 
consent forms, must be retained by the investigator for at least 2 years following completion of the 
study.  No study records shall be destroyed without prior authorization from the UAB Central Unit.   
These documents should be retained for a longer period, however, if required by local IRB or the 
site research office. 
 
12.5  Protocol Deviations 
 
Each investigator must adhere to the protocol as detailed in this document and agree that any 
changes to the protocol must be approved by the UAB Central Unit and NIAID/DMID prior to 
seeking approval from the IRB/IEC.  Each investigator will be responsible for enrolling only those 
study participants who have met protocol eligibility criteria. 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or Manual of 
Procedures requirements.  The noncompliance may be either on the part of the study participant, 
the investigator, or the study site staff.  As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly.  
These practices are consistent with ICH E6 GCP sections: 
4.5 
Compliance with Protocol, Sections 4.5.1, 4.5.2, and 4.5.3 
5.1 
Quality Assurance and Quality Control, Section 5.1.1 
5.20 
Noncompliance, Sections 5.20.1 and 5.20.2. 
It is the responsibility of the site to use continuous vigilance to identify and report deviations within 
1 business day of identification of the protocol deviation that increases subject risk.  Deviations that 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
45 
 
do not increase subject risk can be reported within 5 business days of knowledge of the event.  All 
deviations must be promptly reported to the UAB Central Unit.  UAB will report all deviations to 
DMID in accordance with DMID’s instructions. 
All deviations from the protocol must be addressed in the source documents.  A completed copy of 
the DMID protocol deviation form must be maintained in the regulatory file (Project Notebook or 
designated location) as well as in the subject’s source documents.  A log of protocol deviation will 
be maintained in the Project Notebook.  Protocol deviations must be sent to the local IRB per the 
IRB’s guidelines.  The site PI/study staff is responsible for knowing and adhering to their IRB/IEC 
requirements. 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
46 
 
13.  PUBLICATION POLICY 
Following completion of this study, the investigators are expected to publish the results in a 
scientific journal.  All research reports and other publications resulting from the work completed in 
this protocol shall: 
 
Acknowledge the support of the National Institutes of Health whenever publicizing the 
results from this clinical trial in any media. 
 
Be submitted to the Project Director in the form of advance copies for review and comment 
prior to the publication to ensure appropriate coordination of the research results. 
 
Be furnished in a list of publications resulting from the research as part of the annual 
progress report submitted to the principal investigator. 
The International Committee of Medical Journal Editors (ICMJE) member journals has adopted a 
trials-registration policy as a condition for publication.  This policy requires that all clinical trials be 
registered in a public trials registry such as ClinicalTrials.gov, which is sponsored by the National 
Library of Medicine.  Other biomedical journals are considering adopting similar policies.  
 
Unless exempted, this trial will be registered prior to enrollment of study subjects.  It is the 
responsibility of the study’s PI (i.e., Dr. Whitley) to register the non-exempted trials and post results 
in compliance with Public Law 110-85, the Food and Drug Administration Amendments Act of 2007 
(FDAAA). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
47 
 
14.  REFERENCES  
 
1. 
Egli A, Infanti L, Dumoulin A, et al. Prevalence of polyomavirus BK and JC infection and 
replication in 400 healthy blood donors. J Infect Dis 2009; 199:837-46. 
2. 
Bohl DL, Brennan DC, Ryschkewitsch C, Gaudreault-Keener M, Major EO, Storch GA. BK 
virus antibody titers and intensity of infections after renal transplantation. J Clin Virol 2008; 
43:184-9. 
3. 
Geddes CC, Gunson, R, Mazonakis E, Wan R, Thomson L, Clancy M, Carman WF, BK 
viremia surveillance after kidney transplant: sincle-center experience during a change from 
cyclosporine-based to lower-dose tacrolimus-based primary immunosuppresion regimen. 
Transpl Infect Dis 2011:13:109-116 
4. 
Mitui M, Leos NK, Lacey D, Doern C, Rogers BB, Park JY. Development and validation of a 
quantitative real time PCR assay for BK virus. Mol Cell Probes 2013 Oct-Dec(5-6) 230-6 
5. 
Brennan DC, Agha I, Bohl DL, et al. Incidence of BK with tacrolimus versus cyclosporine 
and impact of preemptive immunosuppression reduction. Am J Transplant 2005; 5:582-94. 
6. 
Helantera I, Egli A, Koskinen P, Lautenschlager I, Hirsch HH. Viral impact on long-term 
kidney graft function. Infect Dis Clin North Am 2010; 24:339-71. 
7. 
Munoz P, Fogeda M, Bouza E, Verde E, Palomo J, Banares R. Prevalence of BK virus 
replication among recipients of solid organ transplants. Clin Infect Dis 2005; 41:1720-5. 
8.   
Gillispie M, Yost SE, Meister E, Kaplan B. A cautionary tale of BK virus:Letter to the 
Editors. Transpl Int 2013 e99. 
9.   
Almeras C, Vetromile F, Garrigue V, Szwarc I, Foulongne V, Mourad G: Monthly screening 
for BK viremia is an effective strategy to prevent BK virus nephropathy in renal transplant 
recipients. Transpl Inf Dis 2011: 13:101-108. 
10  
Koukoulaki M, Grispou E, Pistolas D, Balaska K, Apostolou T, et al.  Prospective monitoring 
of BK virus replication in renal transplant recipients. Transpl Inf  Dis 2009: 11: 1-10.  
11. 
Hirsch HH, Randhawa P. BK virus in solid organ transplant recipients. Am J Transplant 
2009; 9 Suppl 4:S136-46. 
12. 
Bohl DL, Brennan DC. BK virus nephropathy and kidney transplantation. Clin J Am Soc 
Nephrol 2007; 2 Suppl 1:S36-46. 
13. 
Hirsch HH. BK virus: opportunity makes a pathogen. Clin Infect Dis 2005; 41:354-60. 
14. 
Nickeleit V, Mihatsch MJ. Polyomavirus nephropathy in native kidneys and renal allografts: 
an update on an escalating threat. Transpl Int 2006; 19:960-73. 
15. 
Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK 
replication and nephropathy in renal-transplant recipients. N Engl J Med 2002; 347:488-96. 
16. 
Mannon RB, Hoffmann SC, Kampen RL, Cheng OC, Kleiner DE, Rvschkewitsch C, et al. 
Molecular evaluation of BK polymaviru nephropathy.  Am J Transplant 2005; 5(12):2883-
93. 
17. 
Josephson MA, Williams JW, Chandraker A, Randhawa PS. Polyomavirus-associated 
nephropathy: update on antiviral strategies. Transpl Infect Dis 2006; 8:95-101. 
18. 
Smith F, Panek R, Kiberd BA. Screening to prevent polyoma virus nephropathy in kidney 
transplantation: a cost analysis. Am J Transplant 2009; 9:2177-9. 

 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
          
           DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
                   22 March 2016 
 
 
48 
 
19. 
Hirsch HH, Brennan DC, Drachenberg CB, et al. Polyomavirus-associated nephropathy in 
renal transplantation: interdisciplinary analyses and recommendations. Transplantation 
2005; 79:1277-86. 
20. 
Randhawa P, Brennan DC. BK virus infection in transplant recipients: an overview and 
update. Am J Transplant 2006; 6:2000-5. 
21. 
Petrov R, Elbahloul O, Gallichio MH, Stellrecht K, Conti DJ. Monthly screening for polyoma 
virus eliminates BK nephropathy and preserves renal function. Surg Infect (Larchmt) 2009; 
10:85-90.  
22 
Girmanova E, Brabcova I, Bandur S, Hribova P, Skibova J, Viklicky O. A prospective 
longitudinal study of BK virus infection in 120 Czech renal transplant recipients. J Med Virol 
2011; 83:1395-400.  
23. 
Koleilat I, Kushnir L, Gallichio M, Conti DJ. Initiation of a screening protocol for polyoma 
virus results in a decreased rate of opportunistic non-BK viral disease after renal 
transplantation. Transpl Infect Dis 2011; 13:1-8. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
      DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
 
 
 
 
 
 22 March 2016 
 
 
 
49 
 
APPENDIX A-1:  Table of Study Procedures -  Screening  Phase  
 
Procedures 
A 4 weeks 
to 100 
days 
Baseline  
Month 1 
Month 2 
Month 3 
Month 4 
Month 5 
Month 6 
Month 8 
Month 10 
Month 12 
1 Review informed consent 
 
X 
 
 
 
 
 
 
 
 
 
Assess eligibility criteria-inclusion/exclusion  
X 
 
 
 
 
 
 
 
 
 
1a Record medical/ surgical history 
X 
 
 
 
 
 
 
 
 
 
2 Record donor and recipient risk factor data   
X 
 
 
 
 
 
 
 
 
 
2a Record Specific Interval History Data 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
3 Record IS drug trough levels 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
4 Obtain >10 mL of blood for viral load by PCR  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
4 Obtain approximately 100 mL of urine for  PCR  
and  for biomarkers   
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
5 Record selected concomitant  medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
6 Serum Creatinine, estimated GFR  (local lab) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
7 Urinalysis - optional  (local lab) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
8Study Termination 
 
 
 
 
 
 
 
 
 
X 
 LEGEND 
A   The post‐transplant specimen collection and study procedures should not be implemented until 4 weeks (out to 100 days) post‐transplant  
1 The informed consent may be obtained during the peri‐transplant admission (as early as T‐7 days) out to T+100 days1a  The medical history 
includes assessment of the following: cardiovascular, respiratory, musculoskeletal, gastrointestinal, lymphatic, urinary, nervous, endocrine, skin, 
reproductive and EENT  Surgical history includes organ source, and date of surgery . 
2 Record donor/recipient risk factors data: donor= [deceased, living, ABO incompatibility, total HLA mismatches, HLA C7, age, race/ethnicity, sex] 
recipient= [delayed graft function(DGF), cold ischemia time (CIT), warm ischemia time (WIT), use of stents, HLA C7 status, type/intensity of 
immunosuppression, acute rejection, race/ethnicity, age, sex] 

 
 
 
 
 
 
 
 
 
 
 
     
 
      DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
 
 
 
              
  22 March 2016 
 
 
 
 
50 
 
2a Subject death, loss of graft function as defined by GFR <10 mL/min/1.73 m2, development of urinary outlet obstruction, development of gross 
hematuria, development of lymphocele  acute rejection, initiation of dialysis, re-transplantation, renal biopsies – Should renal biopsy be performed 
per standard-of 
3 Record lab results for immunosuppressive drug trough levels, if performed for standard of care 
4 Collect and process blood and urine samples according to instruction outlined in Manual of Procedure 
5 Record selected concomitant medication generic name dosage, start/stop date, and route of administration, failure to record, report as a 
protocol deviation. 
6 Record results of serum creatinine and estimated, if obtained for standard of care. 
7 Optional ‐ Record  urinalysis results performed at local lab for dipstick and microscopic for pH, bilirubin, blood, nitrate, protein, specific gravity, 
glucose, ketones, RBC/HPF,  WBC/HPF, urobilinogen, leukocyte esterase 
8 Screening and study participation will terminate for subjects who remain BKV negative at 12 months post‐transplantation. 
 
 

 
 
 
 
 
 
 
 
 
 
 
     
 
      DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
 
 
 
              
  22 March 2016 
 
 
 
 
51 
 
APPENDIX A-2:  Table of Study Procedures for BK Viremia Intensive Sampling Phase 
 
LEGEND: 
A When diagnosed with BK Viremia, perform procedures every 2 weeks until viremia has resolved.  
1  Review informed consent document with subject if consented during the surveillance period. 
1a The BK viremia criteria includes Central Unit Lab and Local plasma PCR BK viral load results, and dates of collection and dates of results 
2  Subject death, loss of graft function as defined by GFR <10 mL/min/1.73 m2, development of urinary outlet obstruction, development of gross 
hematuria, development of lymphocele  acute rejection, initiation of dialysis, re-transplantation, renal biopsies – Should renal biopsy be performed 
per standard-of care. 
3 Record lab results for immunosuppressive drug trough levels, if performed for standard of care 
Procedures 
BK Viremia 
diagnosis 
BK viremia   
monitoring  
A Every 2 weeks +/- 
7 days until resolved 
Post BK Viremia Follow-Up 
Baseline 
Month 1 
Month 2 
Month 3 
Month 4 
Month 5 
Month 6 
1  Review  informed consent process 
 
X 
 
 
 
 
 
 
 
 1a Assess BK Viremia criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2Record Specific Interval History Data  
 
X 
X 
X 
X 
X 
X 
X 
3 Record IS trough levels  
 
X 
X 
X 
X 
X 
X 
X 
4 Obtain >10 mL of blood for viral load by PCR  
 
X 
X 
X 
X 
X 
X 
X 
4 Obtain approximately 100 mL of urine for  
PCR  and  for biomarkers   
 
X 
X 
X 
X 
X 
X 
X 
5 Record selected concomitant  medications 
 
X 
X 
X 
X 
X 
X 
X 
6 Serum Creatinine, estimated GFR  (local lab) 
 
X 
X 
X 
X 
X 
X 
X 
7 Urinalysis - optional  (local lab) 
 
X 
X 
X 
X 
X 
X 
X 
Study Termination 
 
 
 
 
 
 
 
X 

 
 
 
 
 
 
 
 
 
 
 
     
 
      DMID Protocol 11-0071, Version 2.0 
BK Natural History 
 
 
 
 
 
 
 
 
 
 
 
              
  22 March 2016 
 
 
 
 
52 
 
4 Collect and process blood and urine samples according to instruction outlined in Manual of Procedure 
5 Record selected concomitant medication generic name dosage, start/stop date, and route of administration.6 Record results of serum creatinine 
and estimated, if obtained for standard of care. 
7 Record  urinalysis results performed at local lab, within 7 days of visit, for dipstick and microscopic for pH, bilirubin, blood, nitrate, protein, 
specific gravity, glucose, ketones, RBC/HPF,  WBC/HPF, urobilinogen, leukocyte esterase