A Pilot Study to Assess the Efficacy of Rituximab Therapy in Patients With Treatment Resistant Idiopathic Focal Segmental Glomerulosclerosis (FSGS): Integrating an Assessment of the Relevance of suPAR and Activation of Podocyte β3 Integrin
Phase: PHASE2
Conditions: Primary Focal Segmental Glomerulosclerosis
Sponsor: Mayo Clinic

A Pilot Study to Assess the Efficacy of 
Rituximab Therapy in Patients With 
Treatment Resistant Idiopathic Focal 
Segmental Glomerulosclerosis (FSGS): 
Integrating an Assessment of the 
Relevance of suPAR and Activation of 
Podocyte β3 Integrin   
 
 
NCT# 01573533 
 
May 30, 2017 

RDCRN Protocol # 
6803 
 
 
Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
Version 5 (30May17) 
 
 
1 
 
 
 
Rare Diseases Clinical Research Network 
 
 
 
Neptune Consortium 
 
A Pilot Study to Assess the Efficacy of Rituximab Therapy in Patients with 
Treatment Resistant Idiopathic Focal Segmental Glomerulosclerosis (FSGS): 
Integrating an Assessment of suPAR and Activation of Podocyte β3 Integrin 
. 
 
 
Study Chair 
Fernando C. Fervenza, MD 
Mayo Clinic College of Medicine 
200 First St., SW 
Rochester, MN 55905 
 
 
 
 
 
 
 
This protocol is for research purposes only, and should not be copied, 
redistributed or used for any other purpose.  The procedures in this 
protocol are intended only for use by Consortium investigators in carefully 
controlled settings.  The Chair of this study should be consulted before 
using or attempting any procedure in this protocol. 

RDCRN Protocol # 
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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
Version 5 (30May17) 
 
 
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Participating Institutions/Investigators Table  
 
Principal Investigator: Fernando C.  Fervenza  
Contact:  
Fernando C. Fervenza 
Institution: 
Mayo Clinic College of Medicine 
Address: 
200 First St., SW, Rochester, MN 55905 
Phone: 
 
Fax: 
 
Email: 
fervenza.fernando@mayo.edu  
 
 
 
Co-Investigator:  Michelle Hladunewich  
Contact:  
Michelle Hladunewich 
Institution: 
Sunnybrook Health Sciences Centre 
Address: 
A139 2075 Bayview Ave, Toronto, ON M4N 3M5 
Phone: 
 
Fax: 
 
Email: 
  
 
 
Co-Investigator: Daniel Cattran 
Contact: 
Daniel Cattran 
Institution: 
University Health Network (Toronto General Hospital) 
Address: 
585 University Avenue, NCSB 11C-1256, Toronto, ON M5G 2N2 
Phone: 
 
Fax: 
 
Email: 
  
Sub-
Investigators: 
Heather Reich 
 
 
 
Co-Investigator: Jochen Reiser 
Contact: 
Jochen Reiser  
Institution: 
Rush University Medical Center 
Address: 
1735 W. Harrison Street, Cohn Building, Suite 724 
Chicago, IL, 60612 
Phone: 
 
Fax: 
 
Email: 
 
Sub-
Investigator: 
Changli Wei  
Department of Internal Medicine 
Rush University Medical Center 

RDCRN Protocol # 
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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
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1735 W Harrison ST 
Cohn Bldg, 7th Floor, Suite 763 
Chicago, IL, 60612 
Tel: 
 
Email:  
 
 
 
 
Co-Investigator: Frederick Kaskel 
Contact: 
Frederick Kaskel 
Institution: 
Albert Einstein College of Medicine (The Children’s Hospital at 
Montefiore) 
Address: 
111 East 210th Street; Bronx, NY 10467 
Phone: 
  
Fax: 
  
Email: 
 
 
 
Co-Investigator: Howard Trachtman 
Contact:  
Howard Trachtman 
Institution: 
New York University Medical Center 
Address: 
160 E. 32nd St., 2nd Floor; New York, NY 10016 
Phone: 
 
Fax: 
 
Email: 
 
 
 
Data Management and Coordinating Center  
Principal Investigator: Jefferey Krischer, Ph.D. 
Contact:  
Carrie Light 
Institution/ 
Department: 
Data Management and Coordinating Center (DMCC); Pediatrics 
Epidemiology Center; University of South Florida 
Address: 
3650 Spectrum Blvd; Suite 100; Tampa, FL 33612 
Phone: 
 
Fax: 
 
Email: 
  
 
 
 
 
 
 
 

RDCRN Protocol # 
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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
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Table of Contents 
 
Participating Institutions/Investigators Table ........................................................................... 2 
1. Protocol Synopsis .............................................................................................................. 6 
1.1 Overview .......................................................................................................................... 9 
2. Objective and Research Questions .................................................................................... 9 
3. Background .......................................................................................................................10 
4. Study Design and Methods ...............................................................................................13 
4.1 Inclusion Criteria .............................................................................................................13 
4.2 Exclusion Criteria ............................................................................................................14 
4.3 Recruitment of Participants .............................................................................................15 
4.5 Retention strategies ........................................................................................................15 
4.6 Data Elements .................................................................................................................15 
4.7 Schedule of Events .........................................................................................................21 
5. Safety Monitoring ..............................................................................................................22 
5.1 Data and Safety Monitoring Plan .....................................................................................23 
5.2 Study Oversight ...............................................................................................................23 
5.3 Definitions and Standards ...............................................................................................24 
5.4 Expected/Known Risks/Discomforts/Adverse Events Associated with Study Intervention 
and Procedures: Definition of Expected Adverse Events .......................................................25 
5.5 Reporting Guidelines .......................................................................................................28 
5.6 RDCRN Adverse Event Data Management System (AEDAMS) ......................................30 
5.7 Study Discontinuation (Interventional) .............................................................................31 
5.8 Subject Discontinuation ...................................................................................................32 
5.9 Data Quality and Monitoring Measures............................................................................32 
6. Statistical Considerations ..................................................................................................32 
7. Data Management .............................................................................................................32 
7.1 Registration .....................................................................................................................33 
7.2 Data Entry .......................................................................................................................33 
7.3 Data Quality Control ........................................................................................................33 
8.Human Subjects …………………………………………………………………………………...34 
8.1 GCP Statement ...............................................................................................................34 
8.2 Risks ...............................................................................................................................34 

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8.3 Benefits ...........................................................................................................................34 
8.4 Recruitment .....................................................................................................................34 
8.5 Written Informed Consent ................................................................................................34 
8.6 Process of Consent: ........................................................................................................35 
8.7 Certificate of Confidentiality ................................................................................................  
9. References ........................................................................................................................36 
  
 
 

RDCRN Protocol # 
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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
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1. Protocol Synopsis 
Interventional Synopsis 
Protocol Number: 6803 
Protocol Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in 
Patients with Treatment Resistant Idiopathic Focal Segmental 
Glomerulosclerosis (FSGS): Integrating an Assessment of the 
Relevance of suPAR and Activation of Podocyte β3 Integrin 
Study Chair: Fernando C. Fervenza, MD 
Statistician: NA 
Consortium: Neptune 
Participating Sites: University Health Network, Sunnybrook Health Sciences 
Centre, Rush University Medical Center, Mayo Clinic College 
of Medicine, New York University Medical Center, Albert 
Einstein School of Medicine 
Activation Date: 06/29/16 
Current Status: Active  
Sample Size: 20 
Target Enrollment 
Period: 
2 years 
Study Design: Interventional Pilot 
Primary Study 
Objective: 
This is a pilot trial to assess the safety, feasibility and efficacy 
of Rituximab therapy in 20 adult and pediatric patients with 
either steroid and/or calcineurin inhibitor resistant focal 
segmental glomerulosclerosis (FSGS) or with a significant 
intolerance or contraindication to the use of these agents. In 
addition to clinical outcomes, levels of suPAR and β3 integrin 
activation will be assessed.  . 
Secondary Study 
Objective(s): 
Changes in the baseline levels of these potential biomarkers in 
response to treatment will be compared to clinical measures of 
efficacy. 
Study Population and 
Main Eligibility/ 
Exclusion Criteria: 
Inclusion Criteria: 
• 
FSGS involving native kidneys with a diagnostic biopsy.  
• 
Patients > 6 years of age and < 80 years of age 
• 
suPAR > 3500 pg/ ml 
• 
β3 integrin activation as indicated by relative AP5 
activity > 1 mean fluorescence intensity (MFI)  
• 
Treatment with an ACEI and/or ARB as tolerated for at 
least 3 months prior to enrollment with a target a 
systolic blood pressure ≤ 140 mmHg and a diastolic 

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pressure ≤ 90 mmHg in adults and blood pressure 
readings less than the 95th percentile for age, gender 
and height or less than 120/80 mmHg (whichever is 
lower) in children in at least 75% of readings  
• 
Proteinuria ≥ 3.0 grams as measured by 24-hour urine 
collection in adults or Urine Protein to creatinine ratio 
(Up/c) ≥ 1.0 in the first morning urine in children, 
despite ACE inhibitor / ARB treatment as tolerated and 
a minimum of 8 weeks of prednisone therapy at ≥ 1 
mg/kg/day, a trial of calcineurin inhibitor for ≥3 months 
or a contraindication/intolerance to such therapy  
• 
Patients must have a minimal washout period before 
initiating Rituximab to avoid over immunosuppression 
and consequent risk of morbidity. 
• 
Negative serum pregnancy test (for women of child 
bearing age) 
• 
Men and women of reproductive potential must agree 
to use an acceptable method of birth control during 
treatment and for twelve months (1 year) after 
completion of the trial 
• 
Able and willing to give written informed consent and 
comply with study requirements  
Exclusion Criteria: 
• 
Estimated GFR < 40 ml/min per 1.73m2. The rationale 
is that patients with advanced renal failure may 
progress rapidly towards ESRD. 
• 
Collapsing variant of FSGS, as it is rare and has been 
associated with an aggressive course 
• 
Patients with medical conditions that may cause FSGS 
(e.g. HIV, lymphoma, heroin use) or have a secondary 
form of FSGS due to hyperfiltration injury (eg. massive 
obesity, vesicoureteral reflux, or renal mass reduction) 
• 
Type 1 or type 2 diabetes mellitus as diabetic 
glomerulosclerosis may be contributing to proteinuria in 
these patients 
• 
History of serious recurrent or chronic infection 
• 
Presence or suspicion of active infection including HIV, 
Hepatitis B and HCV with positive tests for hepatitis B 
surface antigen (HBsAg), hepatitis B core antibody 
(HBcAb), hepatitis B virus (HBV), hepatitis C serology, 
or HIV serology. TB screening should be conducted on 
anyone who is at high risk for TB (i.e., clinical suspicion 
of TB, from country where TB common, or lives/works 
where TB more common).  Absolute neutrophil count 
< 1.5 x103/mL  
• 
Known active infection requiring hospitalization or 

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treatment with intravenous antibiotics within 4 weeks or 
oral antibiotics within 2 weeks of the study initiation 
• 
Patients in receipt of a live vaccine within 4 weeks of 
the study initiation 
• 
Concomitant malignancies or previous malignancies 
within the last five years, with the exception of 
adequately treated basal or squamous cell carcinoma 
of the skin or carcinoma in situ of the cervix 
• 
Previous Treatment with a B-cell depleting antibody 
• 
History of severe allergic reactions to humanized or 
murine monoclonal antibodies 
• 
Treatment with any investigational agent within 4 weeks 
of the study initiation 
• 
History of major psychiatric disorder, drug or alcohol 
abuse within the previous 6 months 
• 
Any other disease, metabolic dysfunction, physical 
examination finding or clinical laboratory that provides a 
reasonable suspicion of a disease or condition that 
contraindicates the use of an investigational drug or 
that may affect the interpretation of the results or render 
the patient at high risk from treatment complications 
Treatment  
Agent: Rituximab 
Dosage, schedule, route 
of administration: 
Rituximab will be infused intravenously on days one and fifteen 
at a dose of 375 mg/m2 up to a maximum of 1 gram per dose in 
children and at a dose of 1000 mg on days 1 and 15 in adults. 
Safety Issues: Participants will be monitored for infusion-related reactions. 
Primary Outcome 
Measures: 
The major outcomes (given the short duration of the study) will 
be categorized by changes in proteinuria (with stable renal 
function) The primary endpoint will be determined by patient 
status at 12 months of follow-up defined as 
In Adults: 
• 
Complete Remission – Proteinuria < 0.3 g/d daily 
• 
Partial Remission – Improvement in proteinuria by > 
50% and to a level between 0.3-3.5g/d   
• 
Incomplete Remission – Improvement in proteinuria 
equal to or >50%, but residual proteinuria still >3.5g/d 
In Children: 
• 
Complete Remission – Up/c < 0.2  
• 
Partial Remission – Improvement in proteinuria by > 
50% and to a Up/c value of 0.2-1  
• 
Incomplete Remission – Improvement in proteinuria 
equal to or >50%, but residual Up/c >1 
• 
 No Response: 

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• 
Worsening of renal function (serum creatinine > 30% 
above baseline) without significant improvement in 
proteinuria (<50% improvement) or no improvement or 
worsening in proteinuria  
 
Secondary Outcome 
Measures: 
• 
Change from baseline in suPAR level and in podocyte 
β3 integrin activity as indicated by relative AP5 after 1, 
3, 6 and 12 months activity 
• 
Duration of complete or partial remission following 
treatment 
 
Statistical 
Considerations (sample 
size and analysis plan): 
NA 
Sponsors (federal, state, 
foundation and industry  
Neptune Pilot Study Program - National Institutes of Health  
Genentech Pharmaceuticals  
 
1.1 Overview 
 
The incidence of focal segmental glomerulosclerosis (FSGS) is increasing. Novel insights into 
the pathogenesis of disease suggest the presence of a circulating factor (suPAR) that ultimately 
could damage renal podocytes.  This factor may distinguish idiopathic FSGS from secondary 
causes of glomerular damage. Currently available treatment options for idiopathic FSGS are 
often ineffective and/or associated with significant toxicity. Rituximab may be a potential therapy 
as beyond its potential for immunomodulation, it may also have a direct effect at the level of the 
renal podocyte.  
 
This is a pilot trial to assess the safety, feasibility and efficacy of Rituximab therapy in 20 adult 
and pediatric patients with either steroid and/or calcineurin inhibitor resistant focal segmental 
glomerulosclerosis (FSGS) or with a significant intolerance or contraindication to the use of 
these agents. In addition to clinical criteria, elevated levels of suPAR and β3 integrin activity as 
will define inclusion in an effort to establish a more homogeneous patient population and to 
understand the relationship of this permeability factor to response to treatment. Changes in the 
baseline levels of potential biomarkers in response to treatment will be compared to clinical 
measures of efficacy. 
2. Objective and Research Questions 
 
This is pilot trial (Phase 2). The overall objective of this study is to assess the safety, feasibility 
and efficacy of Rituximab therapy in 20 adult and pediatric patients with either steroid and/or 
calcineurin inhibitor resistant focal segmental glomerulosclerosis (FSGS) or with a significant 

RDCRN Protocol # 
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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
Version 5 (30May17) 
 
 
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intolerance or contraindication to the use of these agents. In addition to clinical criteria, elevated 
levels of suPAR and β3 integrin activity will define inclusion. We hypothesize that Rituximab will 
be effective at lowering proteinuria in this patient population and changes in these biomarkers 
will mirror response or lack thereof.  
 
The major outcomes (given the short duration of the study) will be categorized by changes in 
proteinuria (with stable renal function). The primary endpoint will be determined by patient 
status at 12 months of follow-up defined as: 
In Adults: 
• 
Complete Remission – Proteinuria < 0.3 g/d daily 
• 
Partial Remission – Improvement in proteinuria by > 50% and to a level between 0.3-
3.5g/d   
• 
Incomplete Remission – Improvement in proteinuria equal to or >50%, but residual 
proteinuria still >3.5g/d 
In Children: 
• 
Complete Remission – Up/c < 0.2  
• 
Partial Remission – Improvement in proteinuria by > 50% and to a Up/c value of 0.2-1  
• 
Incomplete Remission – Improvement in proteinuria equal to or >50%, but residual Up/c 
>1 
 
Or in Both Groups: 
• 
Worsening of renal function (serum creatinine > 30% above baseline) without significant 
improvement in proteinuria (<50% improvement) or no improvement in proteinuria 
(<50%) or worsening of proteinuria ie. No response 
 
Secondary outcomes will include: 
• 
Change from baseline suPAR level and activation of podocyte β3 integrin as indicated 
by relative AP5 activity (MFI > 1) after 1, 3, 6 and 12 months  
• 
Duration of complete or partial remission following treatment 
3. Background 
 
Focal Segmental Glomerulosclerosis (FSGS) 
The incidence of FSGS has increased and it is now the most common cause of nephrotic 
syndrome in North American adults and children 1. In a recent study, FSGS accounted for 17% 
of all renal biopsies representing a 13-fold increase in the incidence of this renal lesion over the 
past two-three decades 2. Spontaneous remissions are rare in patients with nephrotic range 
proteinuria (<5%), and if untreated and/or unresponsive, the disease typically progresses to end 
stage renal disease (ESRD) over 6-8 years in 50% of patients 3-5. Those with severe nephrotic 
syndrome (proteinuria > 10 grams) have a much worse prognosis and can expect to progress to 
ESRD over approximately 3 years 
3-5. Further, FSGS recurs after transplantation in 
approximately 30% of patients contributing significantly to loss of graft function.  Thus, FSGS 
poses a significant strain on patient health and well-being as well as health care resources.   
The pathophysiology of FSGS is unclear. It is a disease that primarily targets the glomerular 
epithelial cell or podocyte and the presence of a circulating factor that results in podocyte 

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effacement and disruption of the glomerular filtration barrier has been suggested by indirect 
evidence for over 3 decades. Evidence supporting the presence of a circulating factor is derived 
from clinical cases that have reported virtual immediate recurrence of massive proteinuria 
following anastamosis of the donor artery to the recipient vessels at the time of renal 
transplantation. There have also been studies using animal models that have been able to 
demonstrate that serum from patients with FSGS can increase glomerular permeability to 
albumin 6-8. Utilizing an in vitro assay, Savin and colleagues demonstrated significantly 
increased albumin permeability [P(alb)] of isolated glomeruli when exposed to plasma from 
patients with FSGS 8, yet  the specific  molecular characteristics and mechanism of action  of  
this permeability factor has remained elusive.   
 
Recent insights into podocyte biology have identified a urokinase receptor (uPar) integral to the 
maintenance of the slit diaphragm through its ability to form signalling complexes with other 
transmembrane proteins including lipid-dependent activation of αvβ3 integrin 9. Activation of this 
receptor and its downstream pathways result in hypermotility of podocyte foot processes, 
podocyte effacement, proteinuria, glomerular damage and loss of renal function. uPAR is a 
glycosyl-phosphatidylinisotol (GPI)-anchored three-domain (DI, DII and DIII, as numbered from 
the N terminus) protein, which can be released from the plasma membrane as a soluble 
molecule (suPAR) by cleavage of the GPI anchor 10. suPAR has been demonstrated to be 
elevated in patients with FSGS and is highest in patients with recurrent disease post-
transplantation. Further, this 20-50 kDa circulating protein can be partially removed by 
plasmapheresis, and beneficial responses in proteinuria can be observed in cases where 
suPAR levels drop below a certain threshold where there is reduced activation of the podocyte 
β3 integrin.   
 
Immunosuppressive treatments have been shown to improve proteinuria and slow progression 
to ESRD, but side effects of the current options including high dose prolonged corticosteroids, 
cytotoxic agents and calcineurin inhibitors are significant and rates of treatment failure and 
relapses are common. Steroid resistance even to prolonged treatment is present in up to 50% of 
patients 11-14, and such courses of high dose steroids can result is significant side-effects 
including, but not limited to, cataracts, skin thinning, acne, diabetes, osteoporosis/osteonecrosis 
and weight gain. Cytotoxic agents can result in increased rates of infections, propensity to late 
onset malignancy and infertility. Calcineurin inhibitors have been utilized successfully as either 
first line therapy in those at high risk of developing steroid-related side effects, or as second line 
therapy in corticosteroid resistant cases 14, 15.  However, treatment trials with these agents have 
shown a significant relapse rate (as high as 50%) and longer term or maintenance therapy with 
these drugs raises concerns with respect to nephrotoxicity and hypertension among other 
adverse effects 16.  
 
In summary, our current therapeutic options, although often at least partially successful, have 
significant adverse effects that limit their long-term utilization. Further, this broad-based, non-
specific approach also suffers from the lack of any early indicator that success in either 
controlling or terminating the disease process is being achieved. To date only response in 
proteinuria is available to guide therapy and an improved understanding in podocyte specific 
pathobiology would allow for an earlier assessment preventing unnecessary exposure to 
potentially toxic immunosuppression. 

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Rituximab 
 
Rituximab is a genetically engineered, chimeric, murine/human monoclonal antibody directed 
against the CD20 antigen found on the surface of normal and malignant pre-B and mature B 
cells. The CD20 antigen is not expressed on hematopoietic stem cells, pro-B cells, normal 
plasma cells or other normal tissues. Thus, it has an impressive safety record when compared 
to classic cytotoxic agents.  In vitro studies have demonstrated that the Fc portion of Rituximab 
binds human complement and can lead to cell lysis of the targeted cell through complement-
dependent 
cytotoxicity 
and 
it 
has 
been 
demonstrated 
that 
Rituximab 
mediates 
antibody-dependent cellular cytotoxicity. Most recently, Rituximab been shown to be effective in 
the treatment of idiopathic membranous nephropathy and may work at least in part by depletion 
of the autoantibody  to the podocyte located antigen PLA2R 17. Further, Rituximab may have a 
direct podocyte modulating effect via cross reactivity with sphingomyelin phosphodiesterase 
acid-like 3b (SMPDL-3b) protein and regulation of acid sphingomyelinase (ASMase) essential 
for the lipid-raft compartmentalization of the podocyte plasma membrane as well as for the 
organization and signaling of podocytes in general 18.  This potential direct effect on podocytes 
independent of its known effect on selective depletion of the B cell clone may make it a very 
effective option to consider for the treatment of idiopathic FSGS. 
 
To date, only case reports and a small open-label trial exist to suggest that Rituximab might 
prove effective in patients with FSGS and these reports included primarily children and renal 
transplant recipients19-25. In one study, the safety and efficacy of Rituximab was assessed in a 
multicenter series of 22 patients, aged 6 –22 years with severe steroid-dependent nephrotic 
syndrome or steroid-resistant, but cyclosporin-sensitive idiopathic nephrotic syndrome. Patient 
were treated with two to four infusions of Rituximab. Remission was induced in three of the 
seven proteinuric patients, and one or more immunosuppressive treatments could be withdrawn 
in 19 patients (85%), with no relapse of proteinuria26. More recently 54 children with idiopathic 
nephrotic syndrome dependent on either steroids or calcineurin inhibitors were randomized to 
receive either Rituximab or ongoing standard immunosuppression 27  The experimental arm  
had a relapse rate of 18% compared to 48% in the control arm at 3 months and had a 
significantly higher probability of being free of long-term immunosuppression. Although success 
has been noted in the pediatric literature, results have been mixed in adult patients with either 
idiopathic or recurrent disease post transplantation19-25.   
 
Integration of New Basic and Clinical Information into an Intervention Study of Patients 
with Idiopathic FSGS 
 
Treatment options and the assessment of efficacy have been limited by the complex 
pathogenesis of the disease including the inability to identify and measure in a precise manner 
these unknown serum factors. We have recently noted that suPAR is elevated in two-thirds of 
subjects with primary FSGS, but not in individuals with other glomerular diseases. Part of the 
foundation of this work was based on mouse models wherein we explored the effects of suPAR 
on kidney function and morphology. We determined that circulating suPAR activates podocyte 
β3 integrin in both native and grafted kidneys, which results in foot process effacement, 
proteinuria and FSGS-like glomerulopathy. These morphologic changes and subsequent 

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laboratory findings of renal disease only develop when suPAR activates podocyte β3 integrin. 
Our work suggests that suPAR is produced by neutrophils, monocytes and perhaps other cells, 
such as T cells, (although the precise source of suPAR is still unknown) and released into the 
circulation. It then enters the kidney glomeruli, binds and activates β3 integrin via a moiety on 
domain 2, one of the major proteins anchoring podocytes to the underlying glomerular 
basement membrane (GBM). Increased plasma levels of suPAR lead to increased β3 integrin 
activation, thus leading to the podocyte dysfunction, effacement and proteinuria characteristic of 
FSGS. We found increased integrin β3 activity in podocytes from failing kidney allografts due to 
recurrent FSGS. In addition, we determined that a higher concentration of suPAR before 
transplantation results in an increased risk for recurrence of FSGS after transplantation. We 
also found that suPAR-rich FSGS serum activates integrin β3 in human podocytes, and that co-
incubation with uPAR antibody or cycloRGDfV reduces integrin activity. We have demonstrated 
in preliminary data that Rituximab may affect integrin β3 activity in a SMPDL-3b dependent 
manner and preservation of podocyte expression of SMPDL-3b by Rituximab is likely to 
correlate to the activation of integrin β3. Thus, it appears that the disease can be abrogated by 
lowering serum suPAR concentrations through plasmapheresis, or by interfering with the 
suPAR–β3 integrin interaction through antibodies and small molecules targeting either uPAR, 
SMPDL-3b or β3 integrin.  
 
The SuPAR and renal function relationship was recently examined longitudinally in over 3500 
patients recruited from the Emory Cardiovascular Biobank.  SuPAR levels were found to be 
correlated with both baseline eGFR (r=-0.45, p<0.0001) and urine protein (r=0.22, p<0.0001), 
further those patients with normal renal function and the highest quartile of suPAR level had a 
three-fold increased incidence of CKD.  SuPAR levels were independently correlated with renal 
function, decrease in eGFR and incident kidney disease28.   
 
All of this data suggests that serum suPAR is a circulating factor that may cause FSGS 10. This 
variation in suPAR and activation of podocyte β3 integrin may also help explain the variation in 
the responses that have been seen with the various therapeutics options employed to date in 
the treatment of idiopathic FSGS treatment and can now be tested at the clinical level.  Further, 
this pathogenic mechanism is particularly intriguing due to the recent description of the action of 
Rituximab’s direct podocyte modulating effect via cross reactivity with SMPDL-3b protein and 
regulation of ASMase essential for the organization and signaling of podocytes 18. 
 
Thus we propose integrating a pilot project testing the efficacy of Rituximab in steroid resistant 
or intolerant patients with idiopathic FSGS patients and the newly described permeability factor 
by restricting trial entry to patients with elevated levels of suPAR. 
4. Study Design and Methods 
4.1 Inclusion Criteria 
Inclusion Criteria 
• 
FSGS involving native kidneys with a diagnostic biopsy.  
• 
Patients must be > 6 years of age and < 80 years of age 
• 
suPAR > 3500 pg ml-1    

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Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
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• 
β3 integrin activation as indicated by mean fluorescence intensity of AP5 (MFI > 1)  
corrected by paxillin FMI, followed by correction from normal controls. Activation of integrin 
in comparison to healthy controls is a measure to assess for a podocyte damaging effect of 
suPAR in the FSGS patients’ blood samples.   
• 
Treatment with an ACEI and/or ARB as tolerated for at least 3 months prior to enrollment to 
with a target a systolic blood pressure ≤ 140 mmHg and a diastolic pressure ≤ 90 mmHg in 
adults and blood pressure readings less than the 95th percentile for age, gender and height 
or less than 120/80 mmHg (whichever is lower) in children in at least 75% of readings  
•     Proteinuria ≥ 3.0 grams in adults, or urine protein to creatinine ratio ≥ 1.0 in the first morning 
urine in children, despite ACE inhibitor / ARB treatment as tolerated and a minimum of 8 
weeks of prednisone therapy, a trial of calcineurin inhibitor for ≥ 3 months  and/ or 
contraindication/intolerance to such therapy (diabetes, osteoporosis/osteonecrosis, age >60, 
BMI ≥35) 
•     Patients with treatment resistant FSGS, patients exhibiting partial response to 
immunosuppressive treatment but remaining nephrotic  
•     Patients must have a minimal washout period before initiating Rituximab to avoid over 
immunosuppression and consequent risk of morbidity.  However, to avoid risk of worsening 
of their underlying FSGS disease in those with partial response these patients are to 
discontinued or reduced other immunosuppressive therapies as follows: 
o   Cytotoxic therapy discontinued at least 6 months prior to initiation of Rituximab 
o   ACTH and/or MMF discontinued at least 30 days prior to initiation of Rituximab 
o   CNI tapered and discontinued beginning 60 days after the first Rituximab dose 
o   Prednisone reduced to ≤ 10 mg/day 30 days prior to Rituximab 
• 
Negative serum pregnancy test (for women of child bearing age) 
• 
Men and women of reproductive potential must agree to use an acceptable method of birth 
control during treatment and for twelve months (1 year) after completion of the trial 
• 
Able and willing to give written informed consent and comply with study requirements  
4.2 Exclusion Criteria 
Exclusion Criteria 
• 
Estimated GFR < 40 ml/min per1.73m2. The rationale is that patients with advanced renal 
failure may progress rapidly towards ESRD. 
• 
Collapsing variant of FSGS, as it is rare and has been associated with an aggressive course 
• 
Patients with medical conditions that may cause FSGS (e.g. HIV, lymphoma, heroin use) or 
have a secondary form of FSGS due to hyperfiltration injury (massive obesity, vesicoureteral 
reflux, or renal mass reduction) 
• 
Type 1 or type 2 diabetes mellitus as diabetic glomerulosclerosis may be contributing to 
proteinuria in these patients 
• 
History of serious recurrent or chronic infection  
• 
Presence or suspicion of active infection including HIV, Hepatitis B and HCV Positive tests 
for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), hepatitis B virus 
(HBV), hepatitis C serology, or HIV serology.  Testing for HIV, Hepatitis B and C should 
have occurred <2 years prior to enrollment into the study.  Potential participants who are at 
high risk for TB should be tested.  TB disease screening should be conducted on any 
potential study patient 1) for whom there is any clinical suspicion of TB, 2) who comes from 

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a country where TB disease is common (most countries in Latin America, the Caribbean, 
Africa, Asia, Eastern Europe and Russia) or 3) who lives or works where TB disease is more 
common (homeless shelters, prisons or jails or some nursing homes). 
• 
 
• 
Absolute neutrophil count < 1.5 x103/mL  
• 
Known active infection requiring hospitalization or treatment with intravenous antibiotics 
within 4 weeks or oral antibiotics within 2 weeks of the study initiation 
• 
Patients in receipt of a live vaccine within 4 weeks of the study initiation 
• 
Concomitant malignancies or previous malignancies within the last five years, with the 
exception of adequately treated basal or squamous cell carcinoma of the skin or carcinoma 
in situ of the cervix 
• 
Previous Treatment with a B-cell depleting antibody 
• 
History of severe allergic reactions to humanized or murine monoclonal antibodies 
• 
Treatment with any investigational agent within 4 weeks of the study initiation 
• 
History of major psychiatric disorder, drug or alcohol abuse within the previous 6 months 
• 
Any other disease, metabolic dysfunction, physical examination finding or clinical laboratory 
that provides a reasonable suspicion of a disease or condition that contraindicates the use 
of an investigational drug or that may affect the interpretation of the results or render the 
patient at high risk from treatment complications  
4.3 Recruitment of Participants 
 
Participants will be identified and enrolled from the 6801 NEPTUNE study, the contact registry 
already in place as well as from prevalent patients at the involved sites.  Coordinators from sites 
already involved in the NEPTUNE consortium will review these potential patient populations to 
find eligible candidates and ensure a seamless transition to this active therapeutic program. 
Both children and adult sites with participate. Involved centers have large, diverse patient 
populations. 
4.5 Retention strategies 
 
Given the small size of the trial and the fact that participants have resistant disease we do not 
expect any issues with respect to retention, as all participants will be followed closely by their 
care team. 
4.6 Data Elements 
Therapeutic Intervention 
Rituximab will be infused intravenously on days one and fifteen at a dose of 375 mg/m2 up to a 
maximum of 1 gram per dose in children and at a dose of 1000 mg on days 1 and 15 in adults. 
Clinical and Laboratory Evaluations 
 
Pre-Treatment Baseline Evaluation: 
• 
Hematology: complete blood count (CBC) with differential and platelet count (within 6 weeks 
of treatment). 

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• 
Serum Chemistries: BUN, creatinine, total bilirubin, alkaline phosphatase, total protein, 
albumin, AST, ALT, calcium, cholesterol profile, glucose, sodium, potassium, uric acid, 
bicarbonate and fasting cholesterol (total cholesterol, LDH, HDL, triglycerides) (within 6 
weeks of treatment). 
o Urine Chemistries:   
 
24 hour measurement of urinary sodium, protein and creatinine or protein to creatinine 
ratio in children if unable to complete a 24 hours urine collection. For patients who would 
like to begin urine collection prior to the pre-treatment baseline evaluation visit, oral 
consent will be obtained over the phone and a urine collection kit will be provided.  Oral 
will be documented by signing and dating the oral consent script.   
 
Random urine (UA) for study research laboratory measurement of suPAR, AP5, 
creatinine and albumin. 
• 
Flow Cytometry for CD 19 and 20 (Day 1)  
• 
Immunoglobulins (IgG, IgM and IgA) (Day 1) 
• 
Serology Testing: Hepatitis B, Hepatitis C, HIV (< 2 years prior to enrollment in the study) 
• 
Serum pregnancy test for women of childbearing potential at baseline (within 2 weeks of 
treatment) 
• 
Serum and urine suPAR concentration and activation of podocyte β3 integrin 
 
Pediatric patients will have blood drawn limited to 3 mL/kg as per recommended NIH 
guidelines. As necessary, cholesterol profile may be omitted in pediatric patients. Further, 
determination of infectious status can occur at a separate blood draw.  
 
If any of the above mentioned tests, procedures or evaluations were completed as standard 
of care within 6 weeks of baseline, participants need not repeat the investigations. Site 
investigator will review and consider completed evaluations to determine if appropriate to 
use for baseline evaluation and if repeat evaluations are necessary.  
 
Rituximab Infusion (Day 1 and Day 15) 
See below procedure for Rituximab infusion in adult patients or follow your site’s SOP as 
required. Pediatric sites will follow locally established protocols 
 
Dose Day 1  
 
At the Day 1 visit, the site coordinator should do the following: 
• 
Ask the participant if he/she has any questions or concerns. 
• 
Clinical Assessments- use source documents to collect information for each of the clinical 
assessments.  
a. Collect subject’s medical history (any changes since last visit) 
b. Ask the subject about his/her concomitant medications (changes since last visit) 
c. Ask the participant if they have experienced any adverse events since last visit 
d. Urine pregnancy test for women unless participant has had tubal ligation, hysterectomy 
or is post-menopausal for 2 years. 
• 
Ensure that PCM/charge nurse has confirmed that adequate resources are available to 
monitor patient during and following infusion. 
• 
Confirm that pre-treatment screening has been completed. 

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• 
Hold all antihypertensive medications 12 hours before and on day of infusion. 
 
Monitoring: 
• 
Vital signs at baseline, then every 30 minutes during infusion, and 1 hour following 
completion of infusion. 
• 
Monitor during infusion, and for up to 2 hours after completion of infusion for adverse 
effects: fever (temperature ≥ 38°C), chills, rigors, rash, urticaria, flushing, hypotension, 
bronchospasm, dyspnea, angioedema, acute pain in chest, back or extremities, rhinitis, 
nausea, weakness, headache. 
• 
Stop infusion and notify on-call physician and investigator, if any of the following are 
observed: 
o Any allergic or other adverse effects (see above). 
o Systolic BP falls below 100 mm Hg or decreases by 20% from baseline. 
o Respiration rate greater than 20. 
 
See section below for Management of Infusion Reactions.  
 
 
Pre-Medications: Give prior to Rituximab infusion 
• 
acetaminophen 1000 mg po (give 30-60 min prior to rituximab). 
• 
diphenhydramine (Benadryl®) 50 mg oral (give 30-60 minutes prior to rituximab). 
• 
Methylprednisolone 100 mg (SoluMedrol®) in 0.9% NaCL to total 50 mL (200mL/hr 
completed 30 minutes prior to the start of Rituximab infusion).   
 
Following Rituximab infusion, patients will be started on double strength Bactrim three times a 
week (or its equivalent) for pneumocystis pneumonia prophylaxis.  This treatment will continue 
until the B cells (CD19/20+) have been repleted (>15 cells/microliter on peripheral blood flow 
cytometry).  In the rare event that B cells (CD19/20+) are not replete by the 6 Month visit, flow 
cytometry should be repeated at Month 9 and Bactrim (or its equivalent) continued until point of 
repletion.   
 
FIRST of two Rituximab infusions: 
• 
Infuse rituximab through a dedicated IV line after pre-medications administered. 
• 
1,000 mg of Rituximab in 0.9% NaCL to total of 1000mL. 
• 
Start infusion at 50 mL/hr for the first hour. 
• 
If infusion tolerated, increase rate by 50 mL/hr every 30 minutes to a maximum of 400 
mL/hr as tolerated, until completed. 
• 
0.9% NaCL , 20mL flush after infusion.  Use same rate as Rituximab infusion. 
 
• 
Enter data collected on source documents into the e-CRF’s online. 
 
• 
Retain all informed consent documents, materials from visit, and source documents in 
 
an organized fashion in a secured, double-locked room.  
 
Dose Day 15 
 

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At the Day 15 visit, the site coordinator should do the following: 
• 
Ask the participant if he/she has any questions or concerns. 
 
• 
Clinical Assessments- use source documents to collect information for each of the clinical 
assessments.  
a.  Collect subject’s medical history (any changes since last visit) 
b.  Ask the subject about his/her concomitant medications (changes since last visit) 
c.  Ask the participant if they have experienced any adverse events since last visit 
d.  Urine pregnancy test for women unless participant has had tubal ligation, hysterectomy 
or is post-menopausal for 2 years. 
 
Use the following procedure for Rituximab infusion (or as per your site’s SOP as required): 
• 
Ensure that PCM/charge nurse has confirmed that adequate resources are available to 
 
monitor patient during and following infusion. 
• 
Confirm that pre-treatment screening has been completed. 
• 
Hold all antihypertensive medications 12 hours before and on day of infusion. 
 
Monitoring: 
• 
Vital signs at baseline, then every 30 minutes during infusion, and 1 hour following 
completion of infusion. 
• 
Monitor during infusion, and for up to 2 hours after completion of infusion for adverse 
effects: fever (temperature ≥ 38°C), chills, rigors, rash, urticaria, flushing, hypotension, 
bronchospasm, dyspnea, angioedema, acute pain in chest, back or extremities, rhinitis, 
nausea, weakness, headache. 
• 
Stop infusion and notify on-call physician and investigator, if any of the following are 
observed: 
o Any allergic or other adverse effects (see above). 
o Systolic BP falls below 100 mm Hg or decreases by 20% from baseline. 
o Respiration rate greater than 20. 
 
See section below for Management of Infusion Reactions.  
 
 
Pre-Medications: Give prior to rituximab infusion 
• 
acetaminophen 1000 mg po (give 30 min prior to rituximab). 
• 
diphenhydramine (Benadryl®) 50 mg oral (give 30-60 minutes prior to rituximab). 
• 
Methylprednisolone 100 mg (SoluMedrol®) in 0.9% NaCL to total 50 mL (200mL/hr 
completed 30-60 minutes prior to the start of Rituximab infusion).   
 
SECOND of 2 rituximab infusions to be given 2 weeks following first infusion: 
• 
Infuse rituximab through a dedicated IV line after pre-medications administered. 
• 
1,000 mg of Rituximab in 0.9% NaCL to total of 1000mL. 
 
If first infusion was tolerated without allergic reactions: 
• 
Start infusion at 100 mL/hr  
• 
If tolerated, increase rate by 100 mL/hr every 30 minutes to a maximum of 

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400 mL/hr until completed. 
• 
0.9% NaCL , 20mL flush after infusion.  Use same rate as Rituximab infusion. 
 
If first infusion was NOT tolerated: 
• 
Start infusion at 50 mL/hr . 
• 
If tolerated, increase rate by 50 mL/hr every 30 minutes to a maximum of 
• 
400 mL/h until completed. 
• 
0.9% NaCL , 20mL flush after infusion.  Use same rate as Rituximab infusion. 
 
 
• 
Enter data collected on source documents into the e-CRF’s online. 
 
• 
Retain all informed consent documents, materials from visit, and source documents in 
 
an organized fashion in a secured, double-locked room.  
 
Management of Infusion-Related Reactions to Rituximab 
Signs & Symptoms 
• 
Fever (temp ≥ 38°C), chills, rigors 
• 
Flushing, hypotension 
• 
Bronchospasm, dyspnea, angioedema 
• 
Rash, urticaria, angioedema, rhinitis 
• 
Pain in chest, back or extremities 
• 
Nausea, headache, weakness 
 
Management 
Stop infusion and notify on-call physician and PI if the above symptoms are observed, if systolic 
BP falls below 100 mmHg or decreases by 20% from baseline, or if respirations are greater than 
20.  If hypersensitivity or infusion-related reaction develops, the infusion may be slowed or 
interrupted.  Symptoms may be treated with diphenhydramine, acetaminophen, or IV saline or 
bronchodilators, if warranted.   
 
If patient experiences a mild reaction that is deemed by the investigator to be clinically 
significant, the infusion rate should be reduced to half the rate that was used at the time of the 
reaction.  Once the reaction has resolved, the infusion should be kept at the reduced rate for an 
additional 30 minutes.  If the reduced rate is tolerated, then the infusion rate may be increased 
to the next closest rate on the infusion schedule.   
 
Patients who experience a moderate to severe reaction should have their infusion interrupted 
immediately and should receive aggressive symptomatic treatment.  The infusion should not be 
restarted before all the symptoms have disappeared, and then at half the rate.  If the reduced 
rate is tolerated for 30 minutes, then the infusion rate may be increased to the next closest rate 
on the infusion schedule.   
 
Post –Treatment Evaluation (at 1, 3, 6 12 months and possible unscheduled visit): 
• 
Hematology: complete blood count (CBC) with differential and platelet count. 
• 
Serum Chemistries:  

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• 
BUN, creatinine, total bilirubin, alkaline phosphatase, total protein, albumin, AST, ALT, 
calcium, glucose, sodium, potassium, uric acid, bicarbonate and fasting cholesterol (total 
cholesterol, LDH, HDL, triglycerides) 
• 
Urine Chemistries: 24 hour measurement of urinary sodium, protein and creatinine or 
protein to creatinine ratio in children if unable to complete a 24 hours urine collection.  
• 
Random urine (UA) for study research laboratory measurement of suPAR, AP5, creatinine 
and albumin.Flow Cytometry for CD 19 and 20 
• 
Immunoglobulins (IgG, IgM and IgA) 
 
Post-treatment evaluation may occur at a visit not specified in the test and procedure schedule 
in the event that a patient contacts the physician with symptoms of relapse.  Upon such event, 
the patient would come in for an “unscheduled visit” and complete the evaluation above.   
 
As with the pre-treatment evaluation, pediatric patients will have blood drawn limited to 3 mL/kg 
as per recommended NIH guidelines. As necessary, the cholesterol profile may be omitted in 
pediatric patients.  
 
Treatment Failure and Criteria for Early Study Withdrawal 
Patients demonstrating a significant worsening of renal function (serum creatinine > 30% above 
baseline) or a significant worsening of urine protein that results in worsening symptoms of the 
nephrotic syndrome can exit the trial at their physicians discretion after review with the lead 
investigators (Drs Fervenza, Cattran and/or Hladunewich).  
 
Serum and Urine suPAR Measurement 
SuPAR concentration will be determined by quantitative sandwich enzyme immunoassay 
technique (Quantikine® ELISA Human uPAR Immunoassay, R&D Systems) specified by 
manufacturer’s protocol.  These samples will be assessed in a blinded manner and repeated on 
the same aliquot in an independent laboratory at the end of the trial. Further an additional 20 
samples from patients with nephrotic syndrome secondary to other histologic causes (eg 
membranous, MPGN) than FSGS with serve as an additional “control” group.  Although the 
baseline sample will be run in real time as it defines inclusion, subsequent samples will be 
batched and run at the end of the study.  
 
Determination of Podocyte β3 Integrin Activity  
To quantitatively examine the effect of FSGS patient sera on podocyte β3 integrin activity, a 
human podocyte cell line is cultured at 37 °C for 14 days for complete differentiation. The cells 
are then incubated in 5-10% of FSGS patient serum for 24 hours with recombinant suPAR 
protein as a positive control. Next, the cells are fixed with 4% paraformaldehyde (PFA) and 
proceeded for immunofluorescence staining for AP5 (Blood Center of Wisconsin) and paxillin 
(Millipore).  After immunostaining, confocal (Leica) images are taken to quantify the AP5 and 
paxillin intensity for each sample treatment.  Paxillin signal is used to correct AP5 signal.  The 
relative AP5 signal (AP5/paxillin ratio) from each patient serum is then normalized against that 
of normal blood donor included in each assay for final report.  To control for suPAR specificity, 
the cells will be co-incubated with both FSGS sera and suPAR blocking antibody.  
 
Aliquots of the baseline research blood and urine samples will be sent to Dr. Reiser’s laboratory 

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immediately.  All research blood and urine collected subsequent to baseline will be sent to Dr. 
Reiser’s and an independent laboratory at the end of the study. Research blood and urine tests, 
subsequent to test run on baseline collection will be performed as a batch, after study 
completion, as dictated by budgetary constraints. All suPAR and AP5 measurements will be 
performed in Dr. Reiser’s laboratory and confirmed in an independent laboratory.  
 
Research Sample Procedures 
Research blood and urine samples will be collected at baseline, 1, 3, 6 and 12 months.  Blood 
samples will be collected in red top serum tubes, centrifuged at 2,000 x g for 10 minutes at 4°C 
and sera immediately harvested.  Fresh urine samples will be drawn from a random urine 
collection, centrifuged at 2,000 x g for 10 min and supernatant harvested.  To eliminate and 
minimize freeze thaw, both serum and urine samples will be divided into 500uL aliquots.  
Aliquots will be stored at minus 80°. 
 
Samples will be labeled in a manner so as to blind laboratory assessment investigators to both 
patient and time-point.   Aliquots of the baseline research blood and urine samples will be sent 
to Dr. Reiser’s laboratory immediately, as suPAR and β3 integrin activation results determine 
eligibility.  All research blood and urine collected subsequent to baseline will be sent to Dr. 
Reiser’s and an independent laboratory at the end of the study. In addition, a  site stored aliquot 
of the baseline sample will be shipped along with these other samples to assess replication at 
the end of the study.  These assessments will be performed as a batch after study completion 
as dictated by budgetary constraints.  Baseline and subsequent samples will be sent to Dr. 
Changli Wei at Rush University.   
 
4.7 Schedule of Events 
 
Tests 
Baseline 
Day 1 
Day 15 
1 
month 
3 
months 
6 
months 
12 
months 
Unscheduled 
visit5 
Informed Consent 
X* 
 
 
 
 
 
 
 
History and Exam 
√* 
 
 
√ 
√ 
√ 
√ 
√ 
Complete blood count (CBC) 
with differential1 
√* 
 
 
√ 
√ 
√ 
√ 
√ 
Serum Chemistries2: 
BUN, Creatinine, Total 
bilirubin, Alkaline 
phosphatase,Total protein, 
Albumin, AST, ALT, Calcium, 
Glucose, Sodium, Potassium, 
√* 
 
 
√ 
√ 
√ 
√ 
√ 

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Uric acid, Bicarbonate, Total 
Cholesterol (LDH, HDL, 
Triglycerides) 
Serum pregnancy 
X 
 
 
 
 
 
 
 
Urine Pregnancy3 
 
 
X 
X 
 
 
 
 
 
Hold 
all 
antihypertensive 
medications 12 hours before 
and on day of infusion 
 
X 
X 
 
 
 
 
 
Pre-infusion Medication: 
• 
Acetaminophen 
• 
Diphenhydramine 
• 
Methylprednisolone 
 
X 
X 
 
 
 
 
 
Rituximab Infusion 
 
X 
X 
 
 
 
 
 
Double strength Bactrim three 
times 
a 
week 
(or 
its 
equivalent) for pneumocystis 
pneumonia prophylaxis.   
 
X 
X 
X 
X 
X 
X 
X 
CD 19 and 20 
 
 
X 
 
X 
X 
X 
X 
X 
Immunoglobulins (IgG, IgM 
and IgA) 
 
X 
 
X 
X 
X 
X 
X 
24 hour creatinine for CrCl  
√* 
 
 
√ 
√ 
√ 
√ 
√ 
24 hour urine protein OR 24 
hour Uprot/Ucreat 
√* 
 
 
√ 
√ 
√ 
√ 
√ 
24 hour urinary Na+ 
√* 
 
 
√ 
√ 
√ 
√ 
√ 
Research Labs (blood and 
random urine) 4 
X* 
 
 
X 
X 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
*within 6 weeks of infusion  
√ Standard of Care 
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study specific labs drawn clinically at Mayo within 30 days, those values may be appropriate to use upon the 
investigator’s review.  The exception to this is serum pregnancy test which must be completed within 2 weeks of Time 
0.   
3  Urine pregnancy test for women unless participant has had tubal ligation, hysterectomy or is post-menopausal for 2 
years. 
4  Blood and urine to be used for research purposes, see Appendix A. Research Sample Procedures. 
5 Post-treatment evaluation may occur at a visit not specified in the test and procedure schedule in the event that a patient contacts 
the physician with symptoms of relapse.   
5. Safety Monitoring 
All adverse events will be reported centrally and reviewed by the Study Chair. Either Dr. 
Hladunewich 
 or Dr. Cattran 
 will be available 24 hours a day, 
seven days a week to study investigators. If a significant reaction or serious adverse event 
occurs during or following the first Rituximab infusion, the second infusion may be modified or 
may not proceed at the direction of the study chair. All adverse events will be reported back to 
the study investigators and to the DSMB who would subsequently make recommendations with 
respect to discontinuation of the trial and disclosure to study participants.  
 
5.1 Data and Safety Monitoring Plan 
 
The study protocol will be reviewed and approved by the National Institutes of Health (NIH) 
before submission to individual center IRB’s for approval.  Participant enrollment may only begin 
with IRB approved consent forms.  
 
This is an interventional pilot study that meets the federal definition of moderate risk. 
5.2 Study Oversight 
 
The Study Chair has primary oversight responsibility of this clinical trial. The appointed Data 
(Observational) Safety Monitoring Board (D/OSMB) has oversight responsibility of the Data 
Safety Monitoring Plan (DSMP) for this clinical trial. The D/OSMB will review accrual, patterns 
and frequencies of all adverse events, protocol compliance every interventional “6 months”. The 
D/OSMB makes recommendations to the NIH regarding the continuation status of the protocol. 
 
Each site’s Primary Investigator and their research team (co-Investigators, research nurses, 
clinical trial coordinators, and data managers) are responsible for identifying adverse events. 
Aggregate report- detailed by severity, attribution (expected or unexpected), and relationship to 
the study drug/study procedures – will be available from the DMCC for site review.  Adverse 
events will be reviewed immediately by the research team and reported as detailed below (see 
section 5.5).   A separate report detailing protocol compliance will also be available from the 
DMCC for site review on a monthly basis. The research team will then evaluate whether the 
protocol or informed consent document requires revision based on the reports. 

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5.3 Definitions and Standards 
 
The Rare Diseases Clinical Research Network defines an adverse event as:  “…an unfavorable 
and unintended sign, symptom or disease associated with a participant’s participation in a Rare 
Diseases Clinical Research Network study.”  
 
This includes the following: 
• 
AEs not previously observed in the subject that emerge during the protocol-specified AE 
reporting period, including signs or symptoms associated with Idiopathic Focal 
Segmental Glomerulosclerosis (FSGS) that were not present prior to the AE reporting 
period. 
• 
Complications that occur as a result of protocol-mandated interventions  
• 
If applicable, AEs that occur prior to assignment of study treatment associated with 
medication washout, no treatment run-in, or other protocol-mandated intervention. 
• 
Preexisting medical conditions (other than the condition being studied) judged by the 
investigator to have worsened in severity or frequency or changed in character during 
the protocol-specified AE reporting period.  
Serious Adverse Events 
An AE should be classified as an SAE if the following criteria are met: 
• 
It results in death (i.e., the AE actually causes or leads to death). 
• 
It is life threatening (i.e., the AE, in the view of the investigator, places the subject at 
immediate risk of death. It does not include an AE that, had it occurred in a more severe 
form, might have caused death.). 
• 
It requires or prolongs inpatient hospitalization. 
• 
It results in persistent or significant disability/incapacity (i.e., the AE results in substantial 
disruption of the subject’s ability to conduct normal life functions). 
• 
It results in a congenital anomaly/birth defect in a neonate/infant born to a mother 
exposed to the IMP. 
• 
It is considered a significant medical event by the investigator based on medical 
judgment (e.g., may jeopardize the subject or may require medical/surgical intervention 
to prevent one of the outcomes listed above). 
Assessment of Adverse Events 
All AEs and SAEs whether volunteered by the subject, discovered by study personnel during 
questioning, or detected through physical examination, laboratory test, or other means will be 
reported appropriately. Each reported AE or SAE will be described by its duration (i.e., start and 
end dates), regulatory seriousness criteria if applicable, suspected relationship to Rituximab 
(see following guidance), and actions taken. 
 
To ensure consistency of AE and SAE causality assessments, investigators should apply the 
following general guideline: 
Yes - There is a plausible temporal relationship between the onset of the AE and administration 
of the study drug, and the AE cannot be readily explained by the subject’s clinical state, 
intercurrent illness, or concomitant therapies; and/or the AE follows a known pattern of response 

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to the study drug; and/or the AE abates or resolves upon discontinuation of the study drug or 
dose reduction and, if applicable, reappears upon re-challenge. 
No - Evidence exists that the AE has an etiology other than the study drug (e.g., preexisting 
medical condition, underlying disease, intercurrent illness, or concomitant medication); and/or 
the AE has no plausible temporal relationship to study drug administration (e.g., cancer 
diagnosed 2 days after first dose of study drug). 
 
Expected adverse events are those that are identified in the research protocol as having been 
previously associated with or having the potential to arise as a consequence of participation in 
the study.  Expected adverse events are also listed or characterized in the Product Monograph 
or current Investigator Brochure.  
 
An unexpected adverse event is defined as any adverse experience…the specificity or severity 
of which is not consistent with the risks of information described in the protocol. Unexpected 
adverse events are those not listed in the Product Monograph (P.M) or current Investigator 
Brochure (I.B.) or not identified. This includes adverse events for which the specificity or severity 
is not consistent with the description in the P.M. or I.B. For example, under this definition, 
hepatic necrosis would be unexpected if the P.M. or I.B. only referred to elevated hepatic 
enzymes or hepatitis. 
 
All reported adverse events will be classified using the Common Terminology Criteria for 
Adverse Events (CTCAE), developed and maintained by CTEP at National Cancer Institute. 
5.4 Expected/Known Risks/Discomforts/Adverse Events Associated with 
Study Intervention and Procedures: Definition of Expected Adverse Events 
 
Study Drug/Intervention: Drug Information for Rituximab: 
Rituximab has been associated with infusion-related reactions, which may be related to the 
release of cytokines and/or other chemical mediators.  These reactions may involve fever and 
chills; skin rash and itching; flushing; nausea and vomiting; fatigue; headache; cold-like 
symptoms; sensation of tongue or throat swelling; and difficulty breathing.  These conditions 
usually manifest from 30 minutes to 2 hours after the start of a Rituximab infusion.  These 
symptoms are more commonly seen during the first infusion of Rituximab.  Infusion related side 
effects have occurred in 77% of patients during the first infusion when the drug was given to 
treat Non-Hodgkin’s Lymphoma, but only 7% were considered to be severe reactions.  A mild to 
moderate change in blood pressure may also occur during the infusion.  In a previous study in 
patients with rheumatoid arthritis, 18-30% of the patients had a decrease in blood pressure with 
the first infusion of Rituximab, whereas a mild to moderate increase in blood pressure occurred 
in up to a quarter of patients (8-25%).   
In about 1 in 1000 patients, serious side effects may occur. These serious side effects include:  
• 
Chest pain (approximately 1 in 1,000) 
• 
Abnormal heart beat (approximately 1 in 1,000) 
• 
Severe shortness of breath (approximately 1 in 10,000) 
• 
Severe skin rash (approximately 1 in 10,000) 
• 
Lung inflammation (swelling and redness inside the lungs; approximately 1 in 10,000) 

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• 
Heart failure (approximately 1 in 10,000) 
• 
Kidney failure from rapid killing of tumor cells (approximately 1 in 10,000; seen only in 
cancer patients) 
 
In the most rare circumstances (1 in 10,000) death can result, related to the infusion.  
 
Other side effects, not necessarily occurring during the Rituximab infusion, may include the 
following: 
 
• 
Anemia or low blood count 
• 
Low platelet count (uncommon) 
• 
Joint pain 
• 
Infection 
• 
Flu-like symptoms 
• 
Decreased appetite (uncommon) 
• 
Fatigue  
• 
Sleep problems (uncommon) 
• 
High blood pressure (uncommon)  
• 
Bowel Perforation (development of a hole in the small or large intestine) or Bowel 
Obstruction (blockage of the small or large intestine). To date, 4 cases have occurred in 
Canada following the use of Rituximab for the treatment of either Lymphoma or Arthritis 
 
Cardiovascular Events  
Because hypotension may occur during a Rituximab infusion, consideration should be given to 
withholding anti-hypertensive medications 12 hours prior to the Rituximab infusion. Angina 
pectoris, cardiac arrhythmias such as atrial flutter and fibrillation, heart failure, and myocardial 
infarction have occurred in patients treated with Rituximab.  Therefore, patients with a history of 
cardiac disease should be monitored closely.  
 
Infections  
Given the mechanism of action of Rituximab and the knowledge that B cells play an important 
role in maintaining normal immune response, patients may have an increased risk of infection 
following Rituximab therapy.  Rituximab should not be administered to patients with an active 
infection or to severely immunocompromised patients (e.g., those in whom levels of CD4 or 
CD8 are very low).  Physicians should exercise caution when considering the use of Rituximab 
in patients with a history of recurring or chronic infections or with underlying conditions that may 
further predispose patients to serious infection.  Patients who develop infection following 
Rituximab therapy should be promptly evaluated and treated appropriately.  If a patient 
experiences a new infection during the intervening time between any of the four Rituximab 
infusions, the subsequent infusion should be delayed (up to a maximum of 14 days) until the 
infection has completely resolved and treatment with any anti-infective medications has been 
completed.  
Receipt 
of 
further 
Rituximab 
infusions 
is 
at 
the 
discretion 
of 
the 
investigator.  Remaining infusions should be scheduled so that they are given 1 week apart.  
 
Hepatitis B Infections  
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patients with RA, GPA, and MPA treated with Rituximab. Screening for HBsAg, HBcAb, HBV, 
and hepatitis C serology must be performed in all patients before initiation of treatment with 
Rituximab.  Patients with positive hepatitis serology will be excluded from the study.  Any patient 
who experiences a de novo hepatitis infection during the study will be immediately withdrawn 
from Rituximab study therapy and will be followed until the common closeout date or, if required, 
for longer in Extended Follow-Up (see Section 3.1.4). 
 
Progressive Multifocal Leukoencephalopathy  
Cases of fatal PML have been reported following use of Rituximab for the treatment of 
autoimmune diseases, including RA.  Several, but not all, of the reported cases had potential 
risk factors for PML, including the underlying disease, long-term immunosuppressive therapy, or 
chemotherapy.  PML has also been reported in patients with autoimmune disease not treated 
with Rituximab.  Physicians treating patients with autoimmune diseases should consider PML in 
the differential diagnosis of patients reporting neurological symptoms which may include 
clumsiness, progressive weakness, visual, speech, and sometimes, personality changes, If PML 
is considered then a neurological consultation should be obtained. If PML is diagnosed in a 
patient receiving Rituximab, no further infusions of rituximab should be administered; reductions 
in concomitant immunosuppressive therapy and appropriate treatment including antiviral 
therapy should be considered. There are no known interventions that can reliably prevent PML 
or adequately treat PML should it occur.  
 
Neutropenia  
Decreases in neutrophils have been observed in adult patients with GPA and MPA following 
treatment with Rituximab.  Neutropenia was not associated with an observed increase in serious 
infection in such patients.  Patients with an ANC < 1.5 ´ 103/mL at screening will not be enrolled 
in the study.  The risk mitigation strategies for neutropenia occurring during the study are 
summarized below.  
 
 
Risk Mitigation for Neutropenia 
 
ANC 
(cells x 
103/µL) 
Action 
0.5 – <1.5 
Interrupt dosing. 
When ANC increases to ≥ 1.5 x 103/µL, resume dosing as 
clinically appropriate. 
< 0.5 
Permanently discontinue study drug and follow patient with safety 
visits to look for signs of infection until ANC ≥ 1.5 x 103/µL.  If 
count does not return to ≥ 1.5 x 103/µL within 2 months (or sooner 
if deemed necessary by the investigator), a hematologic consult 
should be requested and the patient followed until resolution or 

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stabilization. 
ANC = absolute neutrophil count. 
Hypogammaglobulinaemia  
Decreases in IgA, IgG, and IgM have been observed in adult patients with GPA and MPA 
following treatment with rituximab.  No increased rate in overall infections or serious infections 
was observed after the development of low IgA, IgG, or IgM levels.  Assessment of the Roche 
safety database and published literature reveals that development of hypogammaglobulinemia 
after rituximab treatment in pediatric patients with various underlying disease has been 
observed, and, in some cases, this has been reported as severe and long term requiring long-
term IVIg treatment.  However, attribution of these events to rituximab is limited by potential 
alternate etiologies, such as common variable immunodeficiency disease, severity of underlying 
diseases, use of rituximab as a last resort after exposure to other immunosuppressive agents, 
and limited clinical data including lack of randomized clinical trials, retrospective data collection, 
and lack of detailed safety data reporting.  Importantly, the majority of these cases were not 
reported to have been associated with serious infections. The investigator should closely 
monitor the patient’s immunoglobulin levels during the study.  If immunoglobulin levels decrease 
below the LLN, dosing should be interrupted or discontinued, as clinically appropriate.  IVIg 
(restricted to replacement dosing for hypogammaglobulinemia) should be given at the discretion 
of the investigator.  
The safety of immunization with any vaccine, particularly live viral vaccines, following Rituximab 
therapy has not been studied and it is not recommended that any live viral vaccines be given 
within 4 weeks of Rituximab infusion.  
It is also unknown what affect Rituximab will have on a developing fetus, sperm, or a breast-fed 
infant. For this reason, study participants are advised to use adequate contraception and avoid 
pregnancy during participation in the study and for a period of 12 months after receiving 
Rituximab 
 
Study Procedures:  
Venipuncture:   The risks of drawing blood include temporary pain, bruising, or rarely infection at 
the site of the needle stick. Participants may experience similar discomfort from the needle used 
for the infusions of Rituximab.  
5.5 Reporting Guidelines 
Adverse Event Reporting Period 
The study period during which all AEs and SAEs must be reported begins after informed 
consent is obtained and ends 30 days after study discontinuation/termination. After this period, 
investigators should only report SAEs that are attributed to prior study treatment. 
 
Procedures for Eliciting, Recording, and Reporting Adverse Events 
Eliciting Adverse Events 
A consistent methodology for eliciting AEs at all subject evaluation time points should be 
adopted. Examples of non-directive questions include:  
• 
“How have you felt since your last clinical visit?” 

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• 
“Have you had any new or changed health problems since you were last here?”  
Specific Instructions for Recording Adverse Events 
Investigators should use correct medical terminology/concepts when reporting AEs or SAEs. 
Avoid colloquialisms and abbreviations. 
a. 
Diagnosis vs. Signs and Symptoms 
If known at the time of reporting, a diagnosis should be reported rather than individual signs and 
symptoms (e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and elevated 
transaminases). However, if a constellation of signs and/or symptoms cannot be medically 
characterized as a single diagnosis or syndrome at the time of reporting, it is ok to report the 
information that is currently available. If a diagnosis is subsequently established, it should be 
reported as follow-up information. 
b. 
Deaths 
All deaths that occur during the protocol-specified AE reporting period (see Section 5.1.2), 
regardless of attribution, will be reported to the appropriate parties. When recording a death, the 
event or condition that caused or contributed to the fatal outcome should be reported as the 
single medical concept. If the cause of death is unknown and cannot be ascertained at the time 
of reporting, report “Unexplained Death”. 
c. 
Preexisting Medical Conditions 
A preexisting medical condition is one that is present at the start of the study. Such conditions 
should be reported as medical and surgical history. A preexisting medical condition should be 
re-assessed throughout the trial and reported as an AE or SAE only if the frequency, severity, or 
character of the condition worsens during the study. When reporting such events, it is important 
to convey the concept that the preexisting condition has changed by including applicable 
descriptors (e.g., “more frequent headaches”). 
d. 
Hospitalizations for Medical or Surgical Procedures 
Any AE that results in hospitalization or prolonged hospitalization should be documented and 
reported as an SAE. If a subject is hospitalized to undergo a medical or surgical procedure as a 
result of an AE, the event responsible for the procedure, not the procedure itself, should be 
reported as the SAE. For example, if a subject is hospitalized to undergo coronary bypass 
surgery, record the heart condition that necessitated the bypass as the SAE. 
 
Hospitalizations for the following reasons do not require reporting: 
• 
Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures 
for preexisting conditions 
• 
Hospitalization or prolonged hospitalization required to allow efficacy measurement for 
the study or 
• 
Hospitalization or prolonged hospitalization for scheduled therapy of the target disease 
of the study. 
e. 
Pregnancy 
If a female subject becomes pregnant while receiving investigational therapy or within 12 
months after the last dose of study drug, a report should be completed and expeditiously 

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submitted to the sponsor who will report this information to Genentech, Inc. Follow-up to obtain 
the outcome of the pregnancy should also occur. Abortion, whether accidental, therapeutic, or 
spontaneous, should always be classified as serious, and expeditiously reported as an SAE. 
Similarly, any congenital anomaly/birth defect in a child born to a female subject exposed to the 
study drug should be reported as an SAE. 
f. 
Post-Study Adverse Events 
The investigator should expeditiously report any SAE occurring after a subject has completed or 
discontinued study participation if attributed to prior study drug exposure. If the investigator 
should become aware of the development of cancer or a congenital anomaly in a subsequently 
conceived offspring of a female subject who participated in the study, this should be reported as 
an SAE.  
 
g. 
AEs of Special Interest are defined as a potential safety problem, identified as a 
result of safety monitoring of the Product  
• 
Progressive Multifocal Leukoencephalopathy (John Cunningham Virus) 
• 
Malignancy Events 
• 
Posterior Reversible Encephalopathy Syndrome 
• 
Hepatobiliary Events 
These events should be reported to the sponsor as soon as site is aware, as they must be 
further communicated to Genentech by the sponsor within a 15 day time period. 
 
Serious Adverse Events 
• Within 24 hours (of learning of the event), investigators must report to the sponsor any 
reportable Serious Adverse Event (SAE) that: 
o 
Is considered life-threatening/disabling or results in death of subject 
-OR- 
o 
Is Unexpected/Unanticipated  
• Investigators must report all other reportable SAEs within 5 working days (of learning of the 
event). 
• All other (suspected) reportable AEs must be reported to the RDCRN within 20 working days 
of the notification of the event or of the site becoming aware of the event. 
 
Local institutional reporting requirements to IRBs, any GCRC oversight committee and the 
country specific regulatory authorities, if appropriate, remain the responsibility of the treating 
physician and the Study Chair. 
5.6 RDCRN Adverse Event Data Management System (AEDAMS) 
 
Upon entry of a serious adverse event, the DMCC created Adverse Event Data Management 
System (AEDAMS) will immediately notify the Study Chair, site PIs, the  Medical Review Officer, 
and any additional agencies (if applicable- industry sponsor, CTEP, etc) of any reported adverse 
events via email.  
 
Serious adverse events: The NIH appointed Medical Review Officer (MRO) determines 
causality (definitely not related, probably not related, possibly related, probably related,  

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definitely related) of the adverse event. The MRO may request further information if necessary 
and possibly request changes to the protocol or consent form as a consequence of the adverse 
event. A back-up notification system is in place so that any delays in review by the MRO beyond 
a specified period of time are forwarded to a secondary reviewer. The Adverse Event Data 
Management System (AEDAMS) maintains audit trails and stores data (and data updated) and 
communication related to any adverse event in the study.  
 
Non-serious expected adverse events: Except those listed above as immediately reportable, 
non-serious expected adverse events that are reported to or observed by the investigator or a 
member of his research team will be submitted to the DMCC in a timely fashion (within 20 
working days). The events will be presented in tabular form and given to the MRO and RDCRN 
DSMB on a “bi-annual” basis. Local site investigators are also required to fulfill all reporting 
requirements of their local institutions. 
 
The DMCC will post aggregate reports of all adverse events (serious/not serious and expected, 
unexpected) for site investigators, IRBs, and country specific regulatory authorities. This 
information will also be communicated directly to Genetech. 
 
The sponsor is responsible for ensuring that all AEs and SAEs that are observed or reported 
during the study are collected and reported to the appropriate regulatory authority (FDA or 
Health Canada), appropriate IRB(s), and Genentech, Inc. in accordance with GCP and 
regulatory guidelines. 
5.7 Study Discontinuation (Interventional) 
 
The NIH, DSMB and local IRB's (at their local site) have the authority to stop or suspend this 
trial at any time. This study may be suspended or closed if: 
• 
Early stopping rules have been met 
 
Cessation of Trial 
Patients with a documented reaction to rituximab or a serious infection secondary to 
immunosuppression will be allowed to exit the trial. Patients with greater than 30% increase in 
serum creatinine without improvement in proteinuria and without alternative reasons beyond the 
their natives kidney disease progression eg NSAID, infection, volume depletion  etc that occurs 
beyond the first three months post rituximab will also be allowed to exit the study in order that 
alternative therapy can be considered. 
 
• 
Accrual has been met 
• 
The study objectives have been met 
• 
The Study Chair / Study Investigators believe it is not safe for the study to continue 
• 
The DSMB suspends or closes the trial 
• 
The NIH suspends or closes the trial 
• 
The FDA or Health Canada suspends or closes the trial 

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5.8 Subject Discontinuation 
 
An intent to treat approach will be used. All data acquired prior to termination for the reasons 
outlined below will be included in the primary analysis unless patient withdraws consent. Every 
effort will be made to conduct a final study visit with the participant and participants will be 
followed clinically until, if applicable, all adverse events resolve.  
 
• 
Withdrawal of consent 
• 
Withdrawal by the participant 
• 
Withdrawal by the investigator 
• 
Intercurrent illness or event that precludes further visits to the study site or ability to 
evaluate disease (e.g..severe infusion related reaction)  
5.9 Data Quality and Monitoring Measures 
 
As much as possible data quality is assessed at the data entry point using intelligent on-line 
data entry via visual basic designed screen forms. Data element constraints, whether 
independent range and/or format limitations or ‘relative’ referential integrity limitations, can be 
enforced by all methods employed for data input. QA reports assess data quality post-data 
entry. As we note, data quality begins with the design of the data collection forms and 
procedures and incorporates reasonable checks to minimize transcription and omission errors.  
Of the more important quality assurance measures are the internal validity checks for 
reasonableness and consistency.  
 
• 
Data Monitoring: The RDCRN DMCC identifies missing or unclear data and generates a 
data query to the consortium administrator contact.  
• 
Data Delinquency Tracking: The Data Management and Coordinating Center will monitor 
data delinquency on an ongoing basis.   
6. Statistical Considerations 
 
This is a small pilot study to primarily assess safety for the use of Rituximab in idiopathic FSGS. 
There is no preliminary data available to perform a power calculation, thereforethe number of 
participants was chosen based on available drug and funding. However, paired parametric or 
non-parametric testing, where appropriate, will be utilized to assess for any meaningful 
differences from the baseline values for all variables of interest (serum creatinine, urine protein, 
serum albumin, cholesterol profiles as well as serum and urine suPAR values. The results of 
this pilot trial are expected to assist in the design of larger future randomized trials.  
 
7. Data Management 
 
As much as possible data quality is assessed at the data entry point using intelligent on-line 
forms. QA reports assess data quality post-data entry. As we note, data quality begins with the 
design of the data collection forms and procedures and incorporates reasonable checks to 
minimize transcription and omission errors.  Of the more important quality assurance measures 

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are the internal validity checks for reasonableness and consistency.  In addition to those  
described above, we propose to build these checks into the initial tables and cross tabulations 
that should reveal any remaining data quality issues. 
 
All study data will be collected via systems created in collaboration with the RDCRN Data 
Management and Coordinating Center and will comply with all applicable guidelines regarding 
patient confidentiality and data integrity.   
7.1 Registration 
 
Registration of participants on this protocol will employ an interactive data system in which the 
clinical site will attest to the participant’s eligibility as per protocol criteria and obtain appropriate 
informed consent. IRB approval for the protocol must be on file at the DMCC before accrual can 
occur from the clinical site. 
 
The DMCC will use a system of coded identifiers to protect participant confidentiality and 
safety.  Each participant enrolled will be assigned a local identifier by the enrollment site.  This 
number can be a combination of the site identifier (location code) and a serial accession 
number.  Only the registering site will have access to the linkage between this number and the 
personal identifier of the subject.  When the participant is registered to participate in the study, 
using the DMCC provided web-based registration system, the system will assign a participant ID 
number.  Thus each participant will have two codes: the local one that can be used by the 
registering site to obtain personal identifiers and a second code assigned by the DMCC.  For all 
data transfers to the DMCC both numbers will be required to uniquely identify the subject.  In 
this fashion, it is possible to protect against data keying errors, digit transposition or other 
mistakes when identifying a participant for data entry since the numbers should match to 
properly identify the participant.  In this fashion, no personal identifiers would be accessible to 
the DMCC.  
 
7.2 Data Entry 
 
Data collection for this study will be accomplished with online electronic case report 
forms.  Using encrypted communication links, on-line forms will be developed that contain the 
requisite data fields.  
7.3 Data Quality Control 
 
As much as possible data quality is assessed at the data entry point. QA reports assess data 
quality post-data entry. As we note, data quality begins with the design of the data collection 
forms and procedures and incorporates reasonable checks to minimize transcription and 
omission errors.  Of the more important quality assurance measures are the internal validity 
checks for reasonableness and consistency.  In addition to those described above, we propose 
to build these checks into the initial tables and cross tabulations that should reveal any 
remaining data quality issues. 
 

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8. Human Subjects 
8.1 GCP Statement 
 
This clinical trial will be conducted in accordance with the ethical principles that have their origin 
in the Declaration of Helsinki, and that are consistent with Good Clinical Practice and all 
applicable regulatory requirements. 
 
8.2 Risks  
 
The potential risks of this study are: 
In addition to the risks related to Rituximab administration and venipuncture listed in Section 
5.4, participants may have risks related to the disclosure of personal health information 
collected during this study. In order to minimize the possibility of a breach of confidentiality, all 
data and samples will be de-identified and stored in a secure manner.  
 
8.3 Benefits  
 
The potential benefits of this study are: 
Participants may or may not receive any direct medical benefit from participation in this study. 
However, it is possible that Rituximab may result in a remission of kidney disease. Further, any 
abnormalities detected during the study will be communicated directly to participants and their 
physicians to aid in their treatment plan. Information learned from this study may benefit other 
patients with FSGS in the future.  
 
8.4 Recruitment   
 
Potentially eligible patients will be approached by an individual within their circle of care (nurse, 
physician, etc).  For patients interested in participating, the Investigator or designate will then 
obtain written informed consent.  The informed consent process will be conducted in 
accordance with ICH/GCP guidelines. 
8.5 Written Informed Consent 
 
Written informed consent will be obtained from each participant before any study-specific 
procedures or assessments are done and after the aims, methods, anticipated benefits, and 
potential hazards are explained.  The participant’s willingness to participate in the study will be 
documented in writing in a consent form, which will be signed by the participant with the date of 
that signature indicated.  The investigator will keep the original consent forms and signed copies 
will be given to the participants.  It will also be explained to the participants that they are free to 
refuse entry into the study and free to withdraw from the study at any time without prejudice to 
future treatment.  Written and/or oral information about the study in a language understandable 
by the participant will be given to all participants. 

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8.6 Process of Consent:   
 
The informed consent process will begin when a potentially eligible patient is approached by an 
appropriately trained and delegated member of the study staff to discuss participation in this 
study.  After reviewing the Informed Consent form, the potential participant must be given ample 
time to ask questions and decide upon participation. The study staff must ensure 
comprehension of the material reviewed and then ascertain the potential participant’s 
willingness to participate.  The informed consent process is ongoing, and it is the responsibility 
of the investigator to ensure that participants continue to consent throughout the course of the 
study.  New information that is relevant to the participant’s ongoing consent will be 
communicated to study participants throughout the study.  The informed consent form will be 
revised, as appropriate, and ongoing participants re-consented or given the opportunity to 
decline further participation.   
 
 
 

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9. References 
1. 
Haas M, Meehan SM, Karrison TG, et al. Changing etiologies of unexplained adult 
nephrotic syndrome: a comparison of renal biopsy findings from 1976-1979 and 1995-
1997. Am J Kidney Dis 1997; 30: 621-631. 
 
2. 
Swaminathan S, Leung N, Lager DJ, et al. Changing incidence of glomerular disease in 
Olmsted County, Minnesota: a 30-year renal biopsy study. Clin J Am Soc Nephrol 2006; 
1: 483-487. 
 
3. 
Korbet SM. Clinical picture and outcome of primary focal segmental glomerulosclerosis. 
Nephrol Dial Transplant 1999; 14 Suppl 3: 68-73. 
 
4. 
Chun MJ, Korbet SM, Schwartz MM, et al. Focal segmental glomerulosclerosis in 
nephrotic adults: presentation, prognosis, and response to therapy of the histologic 
variants. J Am Soc Nephrol 2004; 15: 2169-2177. 
 
5. 
Velosa JA, Holley KE, Torres VE, et al. Significance of proteinuria on the outcome of 
renal function in patients with focal segmental glomerulosclerosis. Mayo Clin Proc 1983; 
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6. 
Suthar K, Vanikar AV, Trivedi HL. Renal transplantation in primary focal segmental 
glomerulosclerosis using a tolerance induction protocol. Transplant Proc 2008; 40: 1108-
1110. 
 
7. 
Gohh RY, Yango AF, Morrissey PE, et al. Preemptive plasmapheresis and recurrence of 
FSGS in high-risk renal transplant recipients. Am J Transplant 2005; 5: 2907-2912. 
 
8. 
Sharma M, Sharma R, McCarthy ET, et al. The focal segmental glomerulosclerosis 
permeability factor: biochemical characteristics and biological effects. Exp Biol Med 
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Wei C, Moller CC, Altintas MM, et al. Modification of kidney barrier function by the 

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urokinase receptor. Nat Med 2008; 14: 55-63. 
 
10. 
Wei C, El Hindi S, Li J, et al. Circulating urokinase receptor as a cause of focal 
segmental glomerulosclerosis. Nat Med 2011; 17: 952-960. 
 
11. 
Ponticelli C, Villa M, Banfi G, et al. Can prolonged treatment improve the prognosis in 
adults with focal segmental glomerulosclerosis? Am J Kidney Dis 1999; 34: 618-625. 
 
12. 
Alexopoulos E, Stangou M, Papagianni A, et al. Factors influencing the course and the 
response to treatment in primary focal segmental glomerulosclerosis. Nephrol Dial 
Transplant 2000; 15: 1348-1356. 
 
13. 
Rydel JJ, Korbet SM, Borok RZ, et al. Focal segmental glomerular sclerosis in adults: 
presentation, course, and response to treatment. Am J Kidney Dis 1995; 25: 534-542. 
 
14. 
Goumenos DS, Tsagalis G, El Nahas AM, et al. Immunosuppressive treatment of 
idiopathic focal segmental glomerulosclerosis: a five-year follow-up study. Nephron Clin 
Pract 2006; 104: c75-82. 
 
15. 
Cattran DC, Alexopoulos E, Heering P, et al. Cyclosporin in idiopathic glomerular 
disease associated with the nephrotic syndrome : workshop recommendations. Kidney 
Int 2007; 72: 1429-1447. 
 
16. 
Cattran DC, Appel GB, Hebert LA, et al. A randomized trial of cyclosporine in patients 
with steroid-resistant focal segmental glomerulosclerosis. North America Nephrotic 
Syndrome Study Group. Kidney Int 1999; 56: 2220-2226. 
 
17. 
Beck LH, Fervenza FC, Beck DM, et al. Rituximab-Induced Depletion of Anti-PLA2R 
Autoantibodies Predicts Response in Membranous Nephropathy. Journal of the 
American Society of Nephrology 2011; 22: 1543-1550. 
 
18. 
Fornoni A, Sageshima J, Wei C, et al. Rituximab Targets Podocytes in Recurrent Focal 
Segmental Glomerulosclerosis. Science Translational Medicine 2011; 3: 85ra46. 

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19. 
Suri M, Tran K, Sharma AP, et al. Remission of steroid-resistant nephrotic syndrome 
due to focal and segmental glomerulosclerosis using rituximab. Int Urol Nephrol 2008; 
40: 807-810. 
 
20. 
Nakayama M, Kamei K, Nozu K, et al. Rituximab for refractory focal segmental 
glomerulosclerosis. Pediatr Nephrol 2008; 23: 481-485. 
 
21. 
Yabu JM, Ho B, Scandling JD, et al. Rituximab failed to improve nephrotic syndrome in 
renal transplant patients with recurrent focal segmental glomerulosclerosis. Am J 
Transplant 2008; 8: 222-227. 
 
22. 
Kamar N, Faguer S, Esposito L, et al. Treatment of focal segmental glomerular sclerosis 
with rituximab: 2 case reports. Clin Nephrol 2007; 67: 250-254. 
 
23. 
Meyer TN, Thaiss F, Stahl RA. Immunoadsorbtion and rituximab therapy in a second 
living-related kidney transplant patient with recurrent focal segmental glomerulosclerosis. 
Transpl Int 2007; 20: 1066-1071. 
 
24. 
Gossmann J, Scheuermann EH, Porubsky S, et al. Abrogation of nephrotic proteinuria 
by rituximab treatment in a renal transplant patient with relapsed focal segmental 
glomerulosclerosis. Transpl Int 2007; 20: 558-562. 
 
25. 
Hristea D, Hadaya K, Marangon N, et al. Successful treatment of recurrent focal 
segmental glomerulosclerosis after kidney transplantation by plasmapheresis and 
rituximab. Transpl Int 2007; 20: 102-105. 
 
26. 
Guigonis V, Dallocchio A, Baudouin V, et al. Rituximab treatment for severe steroid- or 
cyclosporine-dependent nephrotic syndrome: a multicentric series of 22 cases. Pediatr 
Nephrol 2008; 23: 1269-1279. 
 
27. 
Ravani P, Magnasco A, Edefonti A, et al. Short-Term Effects of Rituximab in Children 
with Steroid- and Calcineurin-Dependent Nephrotic Syndrome: A Randomized 

RDCRN Protocol # 
6803 
 
 
Running Title: A Pilot Study to Assess the Efficacy of Rituximab Therapy in Treatment Resistant FSGS 
 
Version 5 (30May17) 
 
 
39 
 
Controlled Trial. Clinical Journal of the American Society of Nephrology 2011; 6: 1308-
1315. 
 
28.   
Hayek S, Sever S, Ko Y, Lerakis S, Sperling L, Quyyumi A, Reiser J.  25-LB - Elevated 
Soluable Urokinase-type Plasminogen Activator is a Predictor of Incident Renal Disease.  
Poster session presented at: American Diabetes Association 75th Scientific Sessions; 
2015 June 5-9; Boston, MA.