Contrast-enhanced Ultrasound for Complex Kidney Lesion Diagnosis in Patients With CKD (CEUS CKD)
Phase: PHASE2
Conditions: Chronic Kidney Disease, Cystic Kidney Disease
Sponsor: University of North Carolina, Chapel Hill

 
Contrast-enhanced Ultrasound for Complex Kidney Lesion Diagnosis 
(CEUS CKD) 
 
 
NCT number NCT02684435 
Document Date July 29, 2016 
 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
1 
Contrast-enhanced Ultrasound for Complex Kidney Lesion Diagnosis in 
Patients with CKD (CEUS CKD) 
 
Principal Investigators  
Emily H. Chang, MD 
UNC Kidney Center, CB #7155 
919-445-2621 (Phone) 
919-966-4251 (Fax) 
919-216-0932 (Pager) 
Email: emily_chang@med.unc.edu 
 
Wui K. Chong, MD, MBBS, FRCR  
Radiology, CB# 7510  
919-966-2854 (Phone) 
919-843-8740 (Fax)  
919-216-9128 (Pager)   
Email: WK_Chong@med.unc.edu  
 
Paul A. Dayton, PhD 
Biomedical Engineering, CB #7575 
919-843-9521 (Phone) 
919-843 -9520 (Fax) 
Email: padayton@email.unc.edu 
 
Vanderbilt Co-Principal Investigator 
W. Kimryn Rathmell, MD, PhD 
Department of Medicine, Division of Hematology and Oncology 
777 Preston Research Building 
Vanderbilt University 
Nashville, TN 37232 
615-875-9744 (Phone) 
615-343-7200 (Fax) 
Email: kim.rathmell@vanderbilt.edu 
 
Co-Investigators  
Ersan Altun, MD 
 
Biostatistician  
Dr. Jason Fine, ScD 
Department of Biostatistics  
3103 Mcgavran-Greenberg, CB 7420  
919-966-7259 (Phone) 
Email: jfine@email.unc.edu 
  

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
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Sponsor: NC TraCS 
Version Date: July 14, 2015 
 
Signature Page  
The signature below constitutes the approval of this protocol and the attachments, 
and provides the necessary assurances that this trial will be conducted according to 
all stipulations of the protocol, including all statements regarding confidentiality, 
and according to local legal and regulatory requirements and applicable U.S. federal 
regulations and ICH guidelines.  
 
Principal Investigator (PI) Name:_______________________  
 
PI Signature: ___________________  
 
Date:____________________  
 
 
 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
3 
 
TABLE OF CONTENTS  
1.0 BACKGROUND AND RATIONALE .................................................................... 5  
1.1 Study Synopsis ...................................................................................................... 5  
1.2 Background ............................................................................................................ 5  
1.3 Perflutren Lipid Background and Associated Known Toxicities..... 8  
1.4 Rationale.................................................................................................................. 10  
 
2.0 STUDY OBJECTIVES............................................................................................. 11  
2.1 Primary Objective ................................................................................................11  
2.2 Secondary Objectives.......................................................................................... 11 
 
3.0 PATIENT ELIGIBILITY ....................................................................................... 11  
3.1 Inclusion Criteria.................................................................................................. 11  
3.2 Exclusion Criteria................................................................................................. 11  
 
4.0 STUDY PLAN ......................................................................................................... 13  
4.1 Schema ..................................................................................................................... 13 
4.2 Study Design .......................................................................................................... 13  
4.3 Follow-up ……………............................................................................................. 16  
4.4 Duration of Study Intervention ..................................................................... 16  
4.5 Duration of Follow Up ....................................................................................... 16  
4.6 Removal of Patients from Protocol .............................................................. 16  
 
5.0 DRUG INFORMATION ......................................................................................... 16  
5.1 Perflutren Lipid Microspheres (Lantheus Medical Imaging)............ 16  
5.2 Supplier/How Supplied .................................................................................... 17  
5.3 Handling and Dispensing of Perflutren.......................................................17  
5.4 Storage Requirements/Stability ................................................................... 17  
5.5 Preparation ............................................................................................................ 17  
5.6 Dosage and Administration ............................................................................ 17  
5.7 Clinical Safety Summary ................................................................................... 17  
5.8 Return and Retention of Study Drug............................................................ 19  
 
6.0 EVALUATIONS AND ASSESSMENTS................................................................ 19  
6.1 Pre-Study Assessments ..................................................................................... 19  
6.2 Treatment Assessments ................................................................................... 19  
6.3 Follow-up Assessments..................................................................................... 20  
6.4 Assessment of Safety ......................................................................................... 20  
6.5 Tissue Collection and Optional Storage..................................................... 20  
 
7.0 ADVERSE EVENTS ............................................................................................... 20  
7.1 Definitions .............................................................................................................. 20  
7.2 Documentation of non-serious AEs or SARs............................................ 22  

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
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7.3 SAEs or Serious SARs ......................................................................................... 22  
7.4 Data and Safety Monitoring Plan .................................................................. 23  
 
8.0 STATISTICAL CONSIDERATIONS .................................................................... 25  
8.1 Study Design/ Study Endpoints .................................................................... 25  
8.2 Sample Size and Accrual.................................................................................... 25  
8.3 Data Analysis Plans.............................................................................................. 25  
 
9.0 STUDY MANAGEMENT ....................................................................................... 26  
9.1 Institutional Review Board (IRB) Approval and Consent................... 26  
9.2 Required Documentation.................................................................................. 27  
9.3 Data Management and Monitoring/Auditing .......................................... 27  
9.4 Adherence to the Protocol ............................................................................... 28  
9.5 Amendments to the Protocol ......................................................................... 29  
9.6 Record Retention ................................................................................................. 29  
9.7 Obligations of Investigators ............................................................................ 29  
 
10.0 REFERENCES....................................................................................................... 30  
 
11.0 APPENDICES ....................................................................................................... 33  
 
 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
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1.0  BACKGROUND AND RATIONALE   
1.1  Study Synopsis    
This is an investigator-initiated, prospective study designed to evaluate the accuracy 
of contrast-enhanced ultrasound (CEUS) with microbubble contrast agent 
(perflutren lipid; Definity®) to identify malignancy in patients with kidney disease, 
a known risk factor for kidney malignancy, in whom a conventional ultrasound (US) 
shows an indeterminate cystic kidney lesion.    
The primary objective of the study is to estimate the sensitivity of CEUS in 
diagnosing kidney malignancy in patients with a risk factor for kidney malignancy 
and compare it to the current gold standard test in this patient population. 
Secondary analysis will include more optimal contrast-enhanced imaging with 
computed tomography (CT) or magnetic resonance imaging (MRI) in a subset of 
patients who can receive these studies. The study outcome will lead to immediate 
clinical application in patients with chronic kidney disease. Given the cost-
effectiveness and adverse event profile, it has excellent potential to become 
established as first line diagnostics in the general patient population as well. 
1.2  Background    
Introduction   
According to the US Renal Data System 2014 report, there are over 600,000 people 
in the US living with end stage kidney disease (ESKD) with almost 450,000 receiving 
dialysis. In a large collaborative international study, kidney cancers have a 
standardized incidence ratio of 3.6 in patients receiving dialysis1 meaning that for 
the nearly 500,000 patients receiving dialysis, there are an additional 50,000 cases 
of kidney cancer that occur above that of the general population. More recent 
findings show that patients with chronic kidney disease (CKD) are also at increased 
risk of kidney cancer, with hazard ratios increasing with CKD stage2. For this reason, 
patients on the waiting list for renal transplant and those receiving dialysis have 
been advised to have annual screenings for kidney malignancy.  
 
Currently, contrast-enhanced CT and MRI are the gold standard imaging studies for 
kidney lesion characterization. However iodinated contrast agents are nephrotoxic 
in patients with renal insufficiency3 and therefore contraindicated in patients with a 
serum creatinine > 2.0 as they can lead to permanent deterioration of kidney 
function. Until recently, contrast MRI was a suitable alternative. However, 
Nephrogenic Systemic Fibrosis (NSF) is now regarded as a serious, potentially lethal 
complication of the gadolinium contrast agents used in MRI if administered to 
patients with impaired renal function. Inadequate preoperative imaging can lead to 
unnecessary nephrectomy, which would further limit already compromised renal 
function4. There is therefore a need for an imaging method for evaluating renal 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
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masses that does not use iodinated or gadolinium contrast agents. CEUS represents 
one potential alternative.  
Contrast-Enhanced US Diagnostic Imaging of the Kidney   
For CKD patients screened annually for kidney malignancy, US imaging of the kidney 
is performed in the United States without contrast as no US contrast agent is 
approved for this indication. Without contrast, malignant tumors cannot be 
differentiated from benign tumors or pseudotumors. Typically, following the 
identification of a kidney lesion via US without contrast, contrasted-CT or MRI may 
then be performed to stage and grade the lesion, depending on a risk/benefit 
analysis performed by the patient’s physician. If a contrasted-CT or MRI is deemed 
too risky, the patient may proceed directly to surgery, or more likely, will be 
followed closely with repeated non-contrast imaging, typically anywhere from 1-5 
years.  
US contrast agents are gas-filled microbubbles which are intravenously 
administered in very small volume boluses or slow infusions. These microbubbles 
typically have mean diameters between 1 to 6 μm5, remain intravascular for several 
minutes, and do not diffuse into the interstitium (pure blood-pool agents)5. The first 
generation of microbubbles was air encapsulated in albumin (Albunex®) or in 
lipid/galactose polymers (Levovist®). These microbubbles were hampered by the 
relatively fast outward diffusion of air, decreasing the gas volume and thereby 
reducing the contrast enhancement. The following generation used inert high 
molecular weight gases with low diffusion coefficients and low solubility in water 
such as perfluorocarbon gases or sulfur hexafluoride encapsulated in lipid, protein 
or polymer shells.  
Early microbubble studies were performed with Doppler-based imaging methods 
which rely on the detection and quantification of shifts in the frequency of the 
received US signals6-8. This method was hampered by an inability to assess 
microvascular blood flow. Later, advances in US imaging utilized the detection of 
harmonic frequencies produced by microbubbles, thereby allowing for more 
sensitive detection of microbubbles and improving imaging of tissue 
microvasculature9-11. Further improvements in harmonic imaging and the discovery 
of the nonlinear properties of microbubbles have spurred the development of 
contrast-specific US techniques such as CPS (Contrast Pulse Sequencing). Such 
imaging techniques provide high-resolution images of tissue vasculature and allow 
the assessment of the microcirculation patterns in real-time12-18. Outside of the 
United States, or in the context of clinical trials, US contrast agents have been used 
in kidney imaging7-11, 14-17, 19-21. Levovist® (lipid and galactose microparticle 
suspension) and Sonovue® (lyophilized sulfur hexafluoride microbubbles), two 
non-FDA approved similar US contrast agents approved for use in countries outside 
of the United States, have been used in the general population to identify and 
diagnose renal pseudotumors6, 16, 19, cystic renal lesions8, 10, 16, 19, 22 and solid renal 
lesions7, 9, 11, 16-20. See a descriptive table of these studies below. To date, no study 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
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has evaluated the effectiveness of any US contrast agents in patients with renal 
insufficiency who are at an increased risk for both cystic and solid renal lesions. 
Author 
(year) 
Contrast 
Agent 
Imaging 
Method 
# 
lesions  
Lesion 
Type 
Results 
Kim 
(1999)8 
Levovist
®  
Power 
Doppler  
13  
Cystic  
PPV: 100% NPV: 57% DxA: 77%  
Ascenti 
(2001)7 
Levovist
®  
Power 
Doppler  
41  
Solid  
DxA: 78%  
Ascenti 
(2004)9 
SonoVue
®  2
nd 
Harmonic  40  
Solid  
Se: 85.7%  
Park 
(2005)11 
Levovist
®  
2
nd 
Harmonic  30  
Solid  
Se: 97%  
Sp: 93% DxA: 95%  
Tamai 
(2005)20 
Levovist
®  
SieFlow  
29  
Solid  
Se: 94.4%  
Sp: 45.4% PPV: 100%  
Wink 
(2007)14 
SonoVue
®  CPS  
20  
Solid & 
Cystic  
Se: 95%  
Quaia 
(2008)15 
SonoVue
®  CPS  
40  
Cystic  
Se: 89% Sp: 73.6% PPV: 79.3% 
NPV: 86% DxA: 82%  
Fan 
(2008)18 
SonoVue
®  CPS  
72  
Solid 
Sp: 96.4% Se: 77.3%  
Meloni 
(2008)17  
SonoVue
®  CPS  
30  
Solid  
Se: 96.6% Sp: 100% PPV: 100% 
NPV: 95.8% DxA: 98.1%  
Roy 
(2008)19 
SonoVue
®  CPS  
86  
Solid & 
Cystic  
Sp: 92.9% - Papillary carcinoma 
57.1% - Clear Cell carcinoma 100% - 
Oncocytoma 100% - Benign  
Abbreviations: PPV – Positive Predictive Value, NPV – Negative Predictive Value, DxA – 
Diagnostic Accuracy, Se – Sensitivity, Sp – Specificity  
 
In the United States, where there has been significantly less research on using US 
contrast in humans, the US contrast agent, Definity®, has recently been used in one 
study to measure renal blood flow in a healthy population21, effectively reproducing 
previous animal studies in the human population. Only two US contrast agents are 
FDA approved for human use: perflutren lipid microspheres (Definity®) and 
perflutren protein-type A microspheres (Optison®). These agents differ in that 
perflutren lipid (Definity®) has a lipid coat and Optison® an albumin coat. Both are 
FDA indicated only for use in cardiac studies.  
1.3 Perflutren Lipid Background and Associated Known Toxicities  
See http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ for full prescribing 
information on perflutren when used according to its FDA-approved indication. Also 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
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see section 5.7.  
1.3.1 Background  
Definity® (perflutren lipid) is an FDA-approved US contrast agent indicated to 
opacify the left ventricular chamber and to improve the delineation of the left 
ventricular endocardial border in patients with sub-optimal echocardiograms. It is 
activated by mechanical agitation with a Vialmix® which produces a milky white 
injectable suspension of perflutren lipid microspheres composed of 
octafluoropropane. Activated perflutren may be injected by either an intravenous 
bolus or infusion. See http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ for 
full prescribing information when used in this indication. When used in this setting, 
the maximum dose of perflutren is administered as either two bolus doses or one 
single intravenous infusion.  
 
1.3.2 Associated Toxicities  
In pre-market clinical trials, 1716 subjects were evaluated with activated perflutren 
lipid. Of the 1716 subjects, 144 (8.4%) had at least one treatment-related adverse 
reaction. There were 26 serious adverse events and 15 (0.9%) subjects discontinued 
because of an adverse event. Nineteen subjects (1.1%) suffered serious 
cardiopulmonary adverse events including 8 deaths. The deaths occurred several 
days after activated perflutren lipid administration and appear to be related to the 
course of underlying disease. Of the 11 other serious adverse events, which 
appeared within 2-15 days of the drug administration, all appeared to be a 
progression of underlying cardiac and non-cardiac disease. However, a role for 
perflutren lipid in the initiation or course of these adverse events cannot be ruled 
out.  
There were 15 discontinuations reported. Nine of these patients were discontinued 
after the first injection. One patient experienced a hypersensitivity reaction with 
urticaria and pruritus and all the other patients experienced dizziness, chest pain, 
dyspnea or back pain. Adverse events (AEs) appeared within 1 – 15 minutes of the 
drug administration and were of moderate intensity resolving usually without 
treatment within minutes or hours after onset.  
For all AEs, there were no differences in the overall incidence based on age, gender, 
or route of administration. The most common events were (% of patients 
experiencing): headache (2.3%), back and renal pain (1.2%), flushing (1.1%) and 
nausea (1.0%).  
Cardiopulmonary Reactions   
In 2007, in response to post-marketing reports of 4 deaths and 190 serious 
cardiopulmonary reactions, the FDA issued a black box warning for both Definity® 
and Optison® adding disease state contraindications and a mandatory 30 minute 
monitoring period following administration in all patients. Following this there have 
been several large-scale safety studies looking into the records of a total of more 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
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than 200,000 patients who received one of these contrast agents. In all those studies 
a composite rate of serious adverse events was calculated to be 1 – 3 in 10,000,23 
compared to gadolinium-based MRI contrast which has an incidence of NSF of 2 – 5 
in 100 patients with chronic kidney disease.24  
 
Following a meeting of the FDA Cardio-renal Advisory Committee in 2008, the black 
box warning was revised. The revisions shortened the contraindications to include 
cardiac shunts and hypersensitivity to perflutren and mandated the 30-minute 
monitoring period be limited to patients with pulmonary hypertension or unstable 
cardiopulmonary conditions. The black box warning was further revised in 2011, 
removing the mandatory 30-minute monitoring period, but stating that most 
serious cardiopulmonary reactions occur within 30 minutes of administration. For 
this reason, the label states that cardiopulmonary resuscitation personnel and 
equipment be readily available prior to perflutren administration, and that all 
patients be monitored for acute reactions.  
 
Patients with a history of cardiac shunts, pulmonary hypertension or unstable 
cardiopulmonary conditions will be excluded from our study. In addition, all 
patients will be monitored for 30-minute post-perflutren administration by the 
research or clinical nurse or research physician.  
Hypersensitivity Reactions   
The real risk of perflutren in our study is to the small number of potential patients 
with an undiagnosed allergy to perflutren. Post-marketing reports have included 
anaphylactoid events and other serious but non-fatal adverse reactions, typically 
within 30 minutes of drug administration (see the package insert, and section 5.7 
for additional information. In order to avoid a potentially fatal event, EpiPen® 
(epinephrine) injections will be kept near the US machine for all patients.  
High Ultrasound Mechanical Index (MI)   
High ultrasound MI values may cause microsphere cavitation or rupture and lead to 
ventricular arrhythmias. In addition, end-systolic triggering with high MI has been 
reported to cause ventricular arrhythmias. While the safety of perflutren at MIs >0.8 
has not been established by the manufacturer, real-time measurement of renal 
blood flow in 19 healthy subjects using perflutren was recently reported, using a 
flash replenishment high-MI (MI of 1.0) US technique. The contrast agent was well 
tolerated with no serious adverse events. One patient each had a 20 mmHg increase 
in systolic blood pressure, a very brief and mild episode of flushing, and mild back 
pain, but no cardiac arrhythmias were recorded during the study period.21   
 
A second study using the Sonovue® contrast agent with flash-replenishment high-
MI to detect changes in kidney perfusion via US in 10 normal volunteers reported 
the agent was well tolerated, and not associated with any adverse events.25 The 
safety of using a flash-replenishment high MI echocardiography with Sonovue®26 

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
July 29, 2016 
 
 UNIVERSITY OF NORTH CAROLINA 
 
 
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has been established in patients with chest pain of undetermined origin as well as in 
patients undergoing stress testing for detection of ischemia.27 
 
Use in Renal Insufficiency   
US contrast agents including perflutren should carry no additional risks in patients 
with renal insufficiency, as peflutren is cleared by the lungs. The phospholipid 
component of perflutren lipid microspheres is thought to be metabolized to free 
fatty acids, while the octafluoropropane (OFP), as a stable gas, is not metabolized. In 
a small (n=8) pharmacokinetic study in healthy subjects, OFP was undetectable after 
10 minutes in most subjects either in the blood or expired air, with a mean half-life 
of 1.3 minutes (Definity® Prescribing Information).  
 
The UNC Division of Cardiology routinely uses perflutren as an echocardiographic 
contrast agent, including in patients with renal insufficiency.  
 
1.4 Rationale  
At this time, contrast-enhanced CT and MRI are the standard imaging studies for 
evaluation of suspected renal tumors. However, there are serious adverse effects 
from iodinated CT contrast and gadolinium MRI contrast in patients with renal 
insufficiency. Currently, to reduce exposure of potentially nephrotoxic contrast 
agents in patients with renal insufficiency, use of iodinated CT and gadolinium MR is 
limited to those patients in whom US without contrast indicates a suspicious or 
indeterminate lesion, and for whom the risk/benefit ratio warrants this risk.  
 
Our primary objective is to compare the accuracy of perflutren enhanced US to the 
current clinical gold standard of follow-up non-contrasted imaging in patients with 
CKD. The accuracy of perflutren-enhanced US will be determined by comparing 
results of the perflutren-enhanced US with the Truth Standard (change in 1-year 
follow-up non-contrast US imaging). In patients where tissue diagnosis or 
contrasted imaging (CT or MRI) is available, these results will be incorporated into 
the Truth Standard in a secondary analysis. 
Unlike CT and MRI contrast agents, US contrast agents are not associated with 
complications in patients with impaired kidney function. We hope to show that 
contrast-enhanced US may provide a viable alternative to contrast-enhanced CT and 
MRI for identifying malignancy in kidney lesions in patients with impaired kidney 
function in view of the serious adverse effects associated with CT and MR contrast 
agents in this patient population.  
2.0  STUDY OBJECTIVES    
2.1  Primary Objective    
To estimate the sensitivity and specificity of qualitative interpretations of CEUS in 
diagnosing kidney malignancy in patients with CKD and a suspicious or 
indeterminate lesion on non-contrasted imaging compared to the truth standard 

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PI: Emily Chang 
 
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described in 1.4 and 4.2.6. 
    
2.2  Secondary Objectives    
To estimate the sensitivity and specificity of quantitative metrics generated from 
CEUS in diagnosing kidney malignancy in patients with CKD and a suspicious or 
indeterminate lesion on non-contrasted imaging compared to the truth standard 
described in 1.4 and 4.2.6. We will also compare sensitivity and specificity of 
quantitative metrics to the sensitivity and specificity of the qualitative 
interpretations. 
 
3.0  PATIENT ELIGIBILITY    
3.1  Inclusion Criteria    
To be eligible for the present study, patients must meet the following criteria:    
 
3.1.1  Able to provide written informed consent    
 
3.1.2  Willing to comply with protocol requirements    
 
3.1.3  At least 18 years of age    
 
3.1.4  Have kidney disease, defined as either CKD II-V, determined by estimated 
glomerular filtration rate (GFR) of <90 and derived from serum creatinine 
measurements, or albuminuria/proteinuria, determined by albumin to creatinine 
ratio or protein to creatinine ratio of >30mg/gm within 3 months of recruitment, or 
on dialysis or having received a kidney transplant or have biopsy proven kidney 
disease 
  
3.1.5  Have at least one kidney lesion identified but incompletely characterized on a 
non-contrasted US, CT, or MR exam for which the patient’s provider recommends 
follow-up studies or further evaluation with an additional imaging tests. 
 
3.2 Exclusion Criteria  
Patients who meet any of the following criteria will be excluded for enrollment:  
 
3.2.1  Critically ill or medically unstable and whose critical course during the 
observation period would be unpredictable (e.g., chronic obstructive pulmonary 
disease (COPD) requiring oxygen)    
 
3.2.2  Known hypersensitivity to sulfur hexafluoride or to any component of 
perflutren lipid (Definity®)    
 
3.2.3  Right to left shunt, severe pulmonary hypertension (Pulmonary artery 
pressure >90mmHg), or adult respiratory distress syndrome    

CEUS CKD 
PI: Emily Chang 
 
CONFIDENTIAL 
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3.2.4  Active cardiac disease including any of the following:  
• Severe congestive heart failure (class IV in accordance with the 
  classification of the New York Heart Association)    
• Unstable angina.    
• Severe arrhythmia (i.e. ventricular tachycardia, flutter fibrillation; 
  ventricular premature complexes occurring close to the preceding T- 
  wave, multifocal complexes).    
• Myocardial infarction within 14 days prior to the date of proposed Definity® 
administration.    
• Uncontrolled systemic hypertension (systolic blood pressure (BP)   >180 
mm Hg and/or diastolic BP >100 mm Hg despite optimal  medical 
management    
 
3.2.5  Is in an intensive care setting    
 
3.2.6  Has an unstable neurological disease (e.g cerebrovascular accident (including 
transient ischemic attacks (TIAs) within the 3 months before signing of informed 
consent  
 
3.2.7  Has undergone an invasive procedure on kidney lesion (e.g. tissue biopsy, 
surgery, nonsurgical cytoreductive procedure) since identification of lesion via US 
without contrast  
 
3.2.8  Has any other medical condition or other circumstances that would 
significantly decrease the chances of obtaining reliable data or of achieving the 
study objectives such as:    
• Mental illness  
• Drug abuse    
 
3.2.9  Female patient who is pregnant or lactating (the possibility of pregnancy has 
to be excluded by negative serum or urine Β-HCG results, obtained within 24 hours 
before the perflutren lipid administration, or on the basis of patient history, e.g.: 
tubal ligation, hysterectomy or a minimum of 1 year without menses)  
 
3.2.10 Obesity that limits obtainment of acceptable images 
 
 
 

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PI: Emily Chang 
 
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4.0  STUDY PLAN    
 
4.1  Schema  
 
 
Patients who meet study inclusion and exclusion criteria (see Sections 3.1 and 3.2) 
and provide informed consent will be subjected to a baseline conventional, non-
contrasted ultrasound on Day 1. Following the non-contrasted ultrasound, CEUS will 
be performed on the identified lesion of interest. One year after initial study, a 
follow-up non-contrasted ultrasound will be obtained. The results of any other 
additional studies obtained clinically, including histology, contrasted or non-
contrasted CT/MR, will be collected. Once all CEUS studies are completed, blinded 
radiologists will grade each lesion based on Bosniak criteria. Once all follow-up non-
contrasted ultrasounds are obtained, radiologists will grade each lesion as stable, 
progressed, or regressed. 
 
Please see the Time and Events Table in Appendix 2 for a full listing of evaluations 
and assessments throughout the course of the study.  
 
4.2  Study Design  
 
4.2.1 Patient Identification and Recruitment 
Patients will be identified through UNC’s nephrology, transplant and dialysis clinics. 
Additionally, community collaborators will be alerted to the study and asked for 
referrals. Patients who participated in the prior pilot study (LCCC 1219) with 
similar inclusion and exclusion criteria will be screened to determine if they still 

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PI: Emily Chang 
 
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meet criteria. The PI will communicate with the patient’s referring clinician and the 
patient to determine whether they fit the inclusion/exclusion criteria and would like 
to participate in the study. The study coordinator will then be notified of these 
patients and approach the patient to further explain the study and obtain their 
signature on the informed consent form if they wish to participate. If patients 
consents, they will undergo perflutren-enhanced US. We will make every attempt to 
perform the perflutren-enhanced US during a regularly scheduled clinic visit. We 
will provide $50 compensation and a parking voucher for completion of initial CEUS 
study. If two lesions are imaged, they will receive $100. We will offer an additional 
$50 for completion of all follow-up studies (6-month and 1-year urinalysis and 
serum creatinine and 1-year follow-up conventional ultrasound) and $75 if they are 
not cared for at UNC and need to make an additional trip to UNC to obtain the 
studies. We plan on enrolling a total of 75 patients that fit the above criteria over a 
6-month period.  
 
Healthy volunteers will also be recruited at study initiation to optimize the imaging 
technique. These volunteers will receive equivalent compensation. In the case of any 
abnormalities found during the study, the subject will be informed of the finding, 
and the finding will be communicated to the subject’s primary provider by study PI 
for further management. 
 
Patients that decline enrollment will be asked if they would be willing to participate 
as controls. This would involve no CEUS study and only collection of serum 
creatinine levels over a 1-year follow-up period from the patient’s primary provider. 
 
4.2.2 Multicenter sites.  
Vanderbilt University (VU) will be a partnering institution participating in 
enrollment and imaging of patients on this trial.  Affiliates will be subjected to the 
same protocol. Patients will be identified similarly through nephrology, transplant 
and dialysis clinics. 
 
4.2.3  Sonographic Evaluation  
Study subjects will be asked to lie on an examination table in the UNC Radiology 
Department of US or at VU for the patients at the affiliate site. Once the patient is 
positioned, US gel will be applied to the patient’s back or flank. The US imaging 
transducer will then be placed on top of the gel. Once the kidney lesion is located, 
the distance from the transducer to the nearest edge of the target lesion will be 
recorded. Pre-dose Doppler and B-mode investigations of the target lesion will be 
performed at baseline using commercially available US equipment and standard 
technique. Subsequent to this, either color or power Doppler imaging should be 
used to study the anatomy of the target lesion and surrounding vessels. Images 
(baseline and perflutren-enhanced) will be digitally recorded on a cine loop.  
 
4.2.4  Perflutren Administration    

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See http://www.definityimaging.com/pdf/VIALMIX%20Users%20Guide.pdf, and 
the package insert, for instructions on perflutren lipid preparation and activation. 
Peflutren lipid is intended for intravenous (IV) administration only after activation 
in the Vialmix® apparatus.  
 
Resuscitative carts and trained personnel will be immediately available during 
Perflutren administration and imaging. 
 
Perflutren will be administered in a continuous infusion using the dosing range and 
administration type within the perflutren prescribing information (see 
http://www.definityimaging.com/how-administration.html).  
If a subject has a central port 20 gauge or greater and does not have a filter then 
perflutren will be administered through the central port. If a subject does not have a 
central port then perflutren will be administered through the antecubital vein, 
preferably on their dominant hand. 
 
Once perflutren lipid has been administered, the transducer is maintained in a 
constant position over the area of interest to show the target lesion and include 
some normal kidney, in order to assess the enhancement pattern during the early, 
mid and late vascular phases. Using flash-replenishment imaging approach, the 
contrast agent needs to be fully cleared from the tissue of interest to achieve 
accurate flow measurements. Imaging with perflutren lipid will be performed with 
software (Siemens Medical Solutions USA, Inc) using the flash-replenishment high-
MI imaging technique. We will use sufficient MI to cause microbubble elimination, 
not to exceed 1.1.  
 
The contrast-enhanced US examination will consist of the complete dynamic real- 
time assessment of the contrast enhancement profile of the lesion in comparison to 
the surrounding renal parenchyma. The flash-replenishment technique will allow 
the area of interest to be captured with multiple image sequences until the infusion 
dose is complete (approximately 5 – 6 minutes).  If there are multiple lesions in one 
subject, the subject will have the option to undergo a 2nd contrast-enhanced study 
30-minutes after the initial contrast dose, per dosing instructions in the package 
insert. 
 
Upon completion of imaging study, the patient will be brought back to the radiology 
holding area and monitored by nursing staff for 30 minutes after study completion. 
Blood pressure and heart rate will be obtained 15 and 30 minutes post procedure 
and recorded on the flowsheet. 
 
4.2.5 Assessment of Imaged Lesions  
Two blinded radiologists at each institution (UNC and VU) will interpret the US 
images independently. Each interpreter will be asked to assess multiple lesion 
characteristics including echogenicity, size, septations, vascularity, and patterns of 

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enhancement which will be used to classify the lesion into a Bosniak category. A 
diagnostic conclusion (e.g. benign, malignant, or indeterminate lesion) will be 
derived based on the Bosniak category. Bosniak categories I, II and IIF will be 
classified as benign, and categories III and IV as malignant. The Bosniak 
classification system can be found in Appendix I.    
 
Results of the perflutren-enhanced scans will not be used to dictate treatment and 
will not be shared with patients.  
 
4.2.6 Truth Standard  
Because the majority of patients will not undergo surgery/biopsy or receive a 
contrasted CT or MRI, the truth standard will be the change from baseline non-
contrasted US at one year follow-up non-contrasted US, the most typical clinical 
approach to these lesions. Follow-up US will be categorized as either stable, 
regression or progression. Lesions that are stable or have regressed will be deemed 
a negative test. Lesions that have progressed will be positive. When clinically 
indicated, if tissue pathology/biopsy or other imaging studies including contrasted 
CT or MRI are available, these will be collected and used in secondary analyses.  
 
4.3  Follow-up  
For all patients, the treatment path will be decided by the subject’s primary 
physician. We will review the medical records from each patient for a minimum of 
12 months post CEUS and document results of 6-month and 1-year urinalysis and 
serum creatinine and follow-up non-contrasted US 12 months after CEUS. 
Additionally, any contrast-enhanced or non-contrast CT and/or MRI findings or 
surgical procedures performed as part of their routine standard of care will be 
collected and reviewed.  
   
4.4  Duration of Study Intervention    
The study intervention is complete once the patient receives perflutren-enhanced 
US (see Study Schema). We anticipate that CEUS imaging will last approximately 15 
minutes for each subject, including set-up, pre-scan, and image capture.  The patient 
may be withdrawn from the study prior to this point if any of the following apply:  
• Inter-current illness prevents completion of perflutren-enhanced US    
• Unacceptable adverse event(s) prevents completion of perflutren-enhanced 
US    
• Patient decides to withdraw from the study, OR    
• General or specific changes in the patient’s condition render the   patient 
unacceptable for completion of perflutren-enhanced US in the judgment of 
the investigator.  
 
4.5  Duration of Follow Up    
Patients will be followed up via review of their medical records and through receipt 
of 6-month and 1-year urinalysis and serum creatinine and a 1-year follow-up non-

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contrast US. Additional imaging studies and histopathological diagnoses will also be 
obtained for any scheduled biopsy and/or surgery as dictated by standard of care. 
Patients will also be followed indefinitely after the initial year for lesion 
changes/histologic diagnosis or changes in kidney function. 
  
4.6 Removal of Patients from Protocol  
Patients will be removed from study when any of the criteria listed in Section 4.4 
apply. The Principal Investigator will be notified, and the reason for study removal 
and the date the patient was removed documented in the study documentation 
sheets. The patient should be followed-up per protocol.  
 
5.0  DRUG INFORMATION    
5.1  Perflutren Lipid Microspheres (Lantheus Medical Imaging)    
The Definity® vial contains components that upon activation yield perflutren lipid 
microspheres composed of octafluoropropane. Perflutren is a diagnostic drug that is 
intended to be used for contrast enhancement. The vial contains a clear, colorless, 
sterile, non-pyrogenic, hypertonic solution which is activated by mechanical 
agitation with Vialmix®.    
 
Vialmix® is the activation device used in the preparation of US contrast imaging 
agents, including Definity®. Prior to activation, each Definity® vial contains 6.52 
mg/mL octafluoropropane in the headspace and 0.75 mg lipid blend (0.045 mg 
DPPA, 0.401 mg DPPC, and 0.304 mg MPEG5000 DPPE), 103.5 mg propylene glycol, 
126.2 mg glycerin, 2.34 mg sodium phosphate monobasic monohydrate, 2.16 mg 
sodium phosphate dibasic heptahydrate and 4.87 mg sodium chloride in water in 
the clear liquid. Upon activation, each mL of the milky white suspension contains a 
maximum of 1.2 x 1010 perflutren lipid microspheres with approximately 150 
μL/mL octafluoropropane.    
 
5.2  Supplier/How Supplied    
Perflutren (Definity®) will be provided to study subjects at no cost. Perflutren is 
supplied as a single use 2mL clear glass vial containing clear liquid. Each package 
contains 4 single-use vials. 
 
5.3  Handling and Dispensing of Perflutren    
Perflutren lipid must be dispensed only from official study sites by authorized 
personnel according to local regulations. Perflutren should be stored in a secure 
area according to local regulations. It is the responsibility of the Investigator to 
ensure that study drug is only dispensed to study patients.  
 
5.4  Storage Requirements/Stability    
The drug product should be stored in a secure location with limited access under 
controlled temperature conditions of 2-8° C (36° -46° F) in a refrigerator.    
 

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5.5  Preparation    
See http://www.definityimaging.com/pdf/VIALMIX%20Users%20Guide.pdf, and 
the package insert for instructions on the use of Vialmix®.    
 
5.6  Dosage and Administration    
See Section 4.2.4.    
 
5.7  Clinical Safety Summary    
See prescribing information on perflutren when used according to its FDA 
indication (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ and highlights 
for perflutren prescribing at 
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021064s011lbl.pdf), 
 
In addition, the following warnings and precautions are noted in the October 2011 
labeling:    
 
Serious Cardiopulmonary Reactions 
Serious cardiopulmonary reactions including fatalities have occurred uncommonly 
during or shortly following perflutren-containing microsphere administration, 
typically within 30 minutes of administration. The risk for these reactions may be 
increased among patients with unstable cardiopulmonary conditions (acute 
myocardial infarction, acute coronary artery syndromes, worsening or unstable 
congestive heart failure, or serious ventricular arrhythmias). Always have 
cardiopulmonary resuscitation personnel and equipment readily available prior to 
perflutren administration and monitor all patients for acute reactions.   The 
reported reactions include: fatal cardiac or respiratory arrest, shock, syncope, 
symptomatic arrhythmias (atrial fibrillation, tachycardia, bradycardia, 
supraventricular tachycardia, ventricular fibrillation, ventricular tachycardia), 
hypertension, hypotension, dyspnea, hypoxia, chest pain, respiratory distress, 
stridor, wheezing, loss of consciousness, and convulsions.    
 
Anaphylactoid Reactions   
In postmarketing use, uncommon but serious anaphylactoid reactions were 
observed during or shortly following perflutren-containing microsphere 
administration including: shock, hypersensitivity, bronchospasm, throat tightness, 
angioedema, edema (pharyngeal, palatal, mouth, peripheral, localized), swelling 
(face, eye, lip, tongue, upper airway), facial hypoesthesia, rash, urticaria, pruritus, 
flushing, and erythema. These have occurred in patients with no prior exposure to 
perflutren-containing microsphere products.    
 
Systemic Embolization of Perflutren in Patients with Cardiac Shunts   
In patients with right-to-left, bi-directional, or transient right-to-left cardiac shunts 
phospholipid-encapsulated microspheres can bypass the pulmonary particle-
filtering mechanisms and directly enter the arterial circulation resulting in 

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microvascular occlusion and ischemia. In an animal study utilizing intra-arterial 
administration of activated perflutren, microsphere trapping was seen in small 
arterioles <15 μm, especially at branch points and in capillaries at all doses tested, 
including doses directly applicable to those used in humans. An animal study 
utilizing intravenous  administration did not result in arterial microvascular 
obstruction presumably because of filtering by the lungs. Do not administer 
perflutren by intra-arterial injection.  
 
High Ultrasound Mechanical Index   
High ultrasound mechanical index values may cause microsphere cavitation or 
rupture and lead to ventricular arrhythmias. Additionally, end-systolic triggering 
with high mechanical indices has been reported to cause ventricular arrhythmias. 
The safety of activated perflutren at mechanical indices greater than 0.8 has not 
been evaluated.  
 
QTc Prolongation   
ECG parameters for doses up to10 μL/kg were monitored in 221 subjects at multiple 
time points from 1 hour to 72 hours after the first bolus injection. In the 221 
subjects, QTc prolongations of >30 msec were noted in 64 (29%) subjects. Forty-six 
out of 64 subjects with QTc prolongations were further evaluated and 39% (18/46) 
showed associated cardiac rhythm changes. The effects of concomitant drugs were 
not studied.  
 
5.8 Return and Retention of Study Drug  
Remaining reagent at the completion of the study or expired reagent will be 
destroyed by UNC IDS.  
 
6.0  EVALUATIONS AND ASSESSMENTS 
    
6.1  Pre-Study Assessments    
Written informed consent will be obtained from the subjects prior to the 
implementation of any study procedures. The subject will receive a signed and 
dated informed consent form.   A complete medical history will be taken at 
enrollment and reviewed on presentation for the study ultrasound. A serum or 
urine β-HCG test will be performed within 24 hours prior to perflutren 
administration if clinically appropriate.   All medications (prescription and over-
the-counter) taken within 24 hours prior to perflutren lipid administration will be 
recorded. 
    
6.2  Treatment Assessments    
Subjects will be monitored for any untoward medical occurrences or toxicities from 
the time of signed informed consent through 30 minutes after perflutren lipid 
administration.    
 

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6.3  Follow-up Assessments    
All post-CEUS clinical diagnoses based on 1-year follow-up non-contrasted US will 
be reviewed.   Any post-operative histopathological diagnoses for patients who 
undergo biopsy/surgery within the 12-month follow-up period post perflutren lipid 
administration will be reviewed. Any additional non-contrasted or contrasted 
imaging (CT or MRI) within the 12-month follow-up period post perflutren lipid 
administration will be reviewed.  
 
6.4  Assessment of Safety    
Any patient in whom perflutren administration is initiated will be evaluable for 
toxicity.  
 
Baseline creatinine (within 8 weeks prior to study) and urinalysis (on day of study, 
pre and post-CEUS) will be collected from each patient prior to CEUS. At 6-month 
and 1-year post-CEUS, serum creatinine levels and urinalysis will be obtained from 
primary providers. Serum creatinine from a comparison group drawn from patients 
who meet study inclusion and exclusion criteria but decline to participate in the 
study will be followed over the study period to detect potential adverse effects the 
study intervention may have on kidney function of the study subjects. Their serum 
creatinine values will be collected at 6-month and 1-year post initial recruitment 
with a minimum of 1 value at 1-year timepoint. 
 
6.5  Tissue Collection and Optional Storage    
If a patient undergoes nephrectomy, all nephrectomy specimens will be collected by 
the tissue procurement facility. Final diagnoses will be obtained by chart review.    
 
7.0  ADVERSE EVENTS  
 
7.1  Definitions    
 
7.1.1  Adverse Event (AE)    
An adverse event (AE) is any untoward medical occurrence (e.g., an abnormal 
laboratory finding, symptom, or disease temporally associated with the use of a 
drug) in a patient or clinical investigation subject administered a pharmaceutical 
product and which does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign (including 
an abnormal laboratory finding), symptom, or disease temporally associated with 
the use of a medicinal product, whether or not related to the medicinal product. 
Each AE will be graded on a mild-moderate-severe scale. 
 
Hospitalization for elective surgery or routine clinical procedures that are not the 
result of an AE (e.g., surgical insertion of central line) need not be considered AEs 
and should not be recorded as an AE. Disease progression should not be recorded as 
an AE, unless it is attributable by the investigator to the study therapy.  

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7.1.2  Suspected Adverse Reaction (SAR)    
A suspected adverse reaction (SAR) is any AE for which there is a reasonable 
possibility that the drug is the cause. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the drug and the AE. A suspected 
adverse reaction implies a lesser degree of certainty about causality than adverse 
reaction, which means any adverse event caused by a drug. Each SAR will be graded 
on a mild-moderate-severe scale. 
 
Causality assessment to a study drug is a medical judgment made in consideration of 
the following factors: temporal relationship of the AE to study drug exposure, 
known mechanism of action or side effect profile of study treatment, other recent or 
concomitant drug exposures, normal clinical course of the disease under 
investigation, and any other underlying or concurrent medical conditions. Other 
factors to consider in considering drug as the cause of the AE:  
• Single occurrence of an uncommon event known to be strongly associated 
with drug exposure (e.g., angioedema, hepatic injury, Stevens-Johnson 
Syndrome)    
• One or more occurrences of an event not commonly associated with drug 
exposure, but otherwise uncommon in the population (e.g., tendon rupture); 
often more than one occurrence from one or multiple studies would be 
needed before the sponsor could determine that there is reasonable 
possibility that the drug caused the event.    
• An aggregate analysis of specific events observed in a clinical trial that 
indicates the events occur more frequently in the drug treatment group than 
in a concurrent or historical control group 
 
7.1.3  Unexpected AE or SAR    
An AE or SAR is considered unexpected if the specificity or severity of it is not 
consistent with the applicable product information (e.g., Investigator’s Brochure 
(IB) for an unapproved investigational product or package insert/summary of 
product characteristics for an approved product). Unexpected also refers to AEs or 
SARs that are mentioned in the IB as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug, but are not specifically 
mentioned as occurring with the particular drug under investigation.  
 
7.1.4  Serious AE or SAR    
An AE or SAR is considered serious if, in the view of either the investigator or 
sponsor, it results in any of the following outcomes:    
• Death 
• Is life-threatening (places the subject at immediate risk of death from the 
event as it occurred) 
• Requires inpatient hospitalization (>24 hours) or prolongation of existing 
hospitalization 

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• Results in congenital anomaly/birth defect 
• Results in a persistent or significant incapacity or substantial disruption of 
the ability to conduct normal life functions 
• Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered a serious adverse drug experience 
when, based upon appropriate medical judgment, they may jeopardize the 
patient or subject and may require medical or surgical intervention to 
prevent one of the outcomes listed in the definition. For reporting purposes, 
also consider the occurrences of pregnancy as an event which must be 
reported as an important medical event.  
 
*Hospitalization for anticipated or protocol specified procedures such as 
administration of chemotherapy, central line insertion, metastasis interventional 
therapy, resection of primary tumor, or elective surgery, will not be considered 
serious adverse events.  
 
Pregnancy that occurs during the study must also be reported as an SAE.  
 
7.2  Documentation of non-serious AEs or SARs    
For non-serious AEs or SARs, documentation must begin from day 1 of study 
treatment and continue through 24 hours after treatment is discontinued. 
  Collected information should be recorded in the Case Report Forms (CRF) for that 
patient. A description of the event, its severity or toxicity grade, onset and resolved 
dates (if applicable), and the relationship to the study drug will be documented.  
 
7.3  SAEs or Serious SARs  
 
7.3.1  Timing    
For any experience or condition that meets the definition of an SAE or a serious SAR, 
recording of the event must begin from day 1 of study treatment and continue 
through the 30-day follow-up period after treatment is discontinued.  
 
7.3.2  Documentation and Notification    
These events (SAEs or Serious SARs) must be recorded within 24 hours of learning 
of its occurrence.  
 
7.3.3  Reporting   
IRB Reporting Requirements:  
• UNC will submit an aggregated list of all SAEs to the UNC IRB annually at the 
time of study renewal according to the UNC IRB policies and procedures.    
• The UNC-IRB will be notified of all SAEs that qualify as an Unanticipated 
Problem as per the UNC IRB Policies using the IRB’s web-based reporting 
system (see section 9.4.3) within 7 days of the Investigator becoming aware 
of the problem.  

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Pregnancy   
Pregnancies and suspected pregnancies (including a positive pregnancy test 
regardless of age or disease state) of a female subject occurring while the subject is 
on study should be recorded as SAEs. The patient is to be discontinued immediately 
from the study. The female subject should be referred to an obstetrician-
gynecologist, preferably one experienced in reproductive toxicity for further 
evaluation and counseling.  
 
The Investigator will follow the female subject until completion of the pregnancy, 
and must document the outcome of the pregnancy (either normal or abnormal 
outcome). If the outcome of the pregnancy was abnormal (e.g., spontaneous or 
therapeutic abortion), the Investigator should report the abnormal outcome as an 
AE. If the abnormal outcome meets any of the serious criteria, it must be reported as 
an SAE.  
 
FDA Expedited Reporting requirements for studies conducted under an IND:  
If an investigator deems that an event is both a serious SAR AND unexpected, it must 
also be recorded on the MedWatch Form 3500A as per 21 CFR 312.32. The 
MedWatch 3500a form can be accessed at: 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/default.ht
m. (Please be sure and access form 3500a, and not form 3500). For Affiliate 
Investigators, the MedWatch form should be faxed to the UNC Study Coordinator at 
919-966-0817 along with supporting documentation defining the event and 
causality. UNC, as the Sponsor of the study, will make the final determination 
regarding FDA submission. 
  
Once the UNC Principal Investigator determines an event is a serious SAR AND 
unexpected, the MedWatch 3500A form will be submitted to the FDA.  
 
The UNC Study Coordinator will also be responsible for informing each Affiliate site 
of all serious and unexpected SARs reported to the FDA via fax as soon as possible.   
 
7.4 Data and Safety Monitoring Plan  
The Principal Investigator will provide continuous monitoring of patient safety in 
this trial.  
 
Every 2 weeks or more often as necessary, the UNC research team (including a 
minimum of PI and study coordinator) will meet to discuss enrollment, study-wide 
safety data, and logistical issues related to the study. Formal study meetings will 
happen every 6 months, during accrual, and include PI, study coordinator, nursing 
staff, sonographers, and any other relevant personnel. In addition, 
meetings/teleconferences will be held at a frequency dependent on accrual, at a 
minimum of every month, which will include the UNC and Affiliate investigators as 

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well as protocol nurses, study coordinators, regulatory associates, data managers, 
biostatisticians, and any other relevant personnel the principal investigators may 
deem appropriate.  At these meetings, the research team will discuss all issues 
relevant to study progress, including enrollment, safety, regulatory, data 
collection, etc. 
 
The Study Coordinator will produce summaries or minutes of the UNC and Affiliate 
meetings. These summaries will be available for inspection when requested by any 
of the regulatory bodies charged with the safety of human subjects and the integrity 
of data including, but not limited to, the oversight (Office of Human Research Ethics 
(OHRE) Biomedical, or the North Carolina TraCS Institute Data and Safety 
Monitoring Board (DSMB).  
 
Since this is not a randomized, blinded trial, enrollment with the Data Safety 
Monitoring Board would not provide added benefit to the patients. If during the 
course of the trial any of the Investigators feel the participation of the Data Safety 
Monitory Board (DSMB) would be of value, their assistance will be solicited. 
 
7.4.1 Monitoring Safety of Participants 
Blood and urine test results within 8 weeks of study recruitment will be obtained 
from the subject’s clinical provider at the time of enrollment, as a part of the 
standard of care disease management and for determination of inclusion. In 
particular, serum creatinine and any evidence of hematuria will be noted. Urinalyses 
will be obtained just prior and post-CEUS to detect any evidence of hematuria. 
Serum creatinine measurements and urinalyses will be followed during the duration 
of study follow-up with intervals at the discretion of the primary provider. This 
information will be compiled by study coordinators by review of the medical chart 
and when necessary, obtaining records directly from the clinical provider.  
 
Multi-center safety issues and protocol changes will be communicated directly from 
Affiliate PI to the UNC PI and the research coordinators and recorded as in 7.2 and 
7.3.3. 
 
7.4.2 Individual Subject Stopping 
Patient safety will be considered during the study intervention with individual 
patient withdrawal for criteria outlined in 4.4 and managed as described in 4.6. 
There are no subsequent interventions after the initial contrast-enhanced 
ultrasound.  
 
7.4.3 Study-wide Stopping 
If there is a severe SAR or a severe AE suspected to be related to the study 
intervention, CEUS, the study will be put on hold and re-evaluated as this would not 
be an expected event. 
 

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7.4.4 Ensuring data accuracy and protocol compliance 
The PI will monitor the accruing data and make decisions about the ongoing safety 
of the trial. A Medical Monitor outside the study will be asked to provide an 
independent review of the study and data. The UNC PI will be responsible for 
providing the following information for such a review: 1) safety and accrual data 
including the number of patients treated; 2) significant developments reported in 
the literature that may affect the safety of participants or the ethics of the study; 3) 
preliminary diagnostic data; and 4) summaries of team meetings that have occurred 
since the last report.  
 
8.0  STATISTICAL CONSIDERATIONS    
 
8.1  Study Design/Study Endpoints    
This is an investigator-initiated, prospective pilot study evaluating the sensitivity of 
contrast enhanced ultrasound using microbubble contrast agent (perflutren lipid; 
Definity®) in diagnosing renal malignancy in patients with kidney disease and an 
indeterminate or possibly malignant kidney mass on a screening CT/MR/US. The 
study is designed to estimate the sensitivity of CEUS as a surrogate for conventional 
imaging.  
 
8.2  Sample Size and Accrual    
This study will recruit to a target goal of 75 patients total between the primary site 
(UNC) and Affiliate (VU). We expect to complete the enrollment in about 6 months. 
Based on available literature regarding incidence of malignancy in indeterminate 
(Bosniak IIF and III) lesions28, 29 and accuracy of CEUS for cystic kidney lesion 
characterization in a general, non-CKD population10, 15, 22, 30, 31 and our experience 
from a pilot study including 27 patients with kidney disease and an indeterminate 
lesion, we approximate a true positive rate of 10%, false positive rate of 8%, true 
negative rate of 80% and false negative rate of 2%. Given the sample size of 75 
(allowing for 10 to be lost to follow-up/death) and these approximated rates, we 
project an achievable sensitivity of 83%, specificity of 91%, PPV of 56% and NPV of 
98%. The 95% confidence interval for this sensitivity estimate is 74.5-91.5% with a 
width of 17%. 
 
8.3 Data Analysis Plans  
Primary analyses will include 1) estimating the sensitivity of CEUS qualitative 
interpretations using the gold standard of findings on 1-yr follow-up non-contrasted 
US compared to baseline non-contrasted US and 2) estimating the sensitivity of 
various quantitative metrics derived from CEUS images using the gold standard of 
findings on 1-yr follow-up non-contrasted US compared to baseline non-contrasted 
US. 
 
Descriptive summary statistics such as mean, median and standard deviation of 
tumor measurement will be provided to quantify and characterize kidney lesions.  

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Similarly, other patient clinical and demographic characteristics will be 
summarized, using frequencies in the case of categorical variables.  
 
For Aim 1, sensitivity and specificity and their 95% confidence intervals will be 
computed for CEUS qualitative interpretations compared to change in baseline non-
contrasted US. Based on the gold standard diagnosis of lesion progression at one 
year follow-up, a 95% confidence interval for the Mantel-Haenszel odds ratio will be 
constructed to quantify the odds that a subject with a diagnosis of a malignant lesion 
by non-contrasted US will be diagnosed with a malignant lesion by CEUS relative to 
the odds for a subject without a malignant lesion diagnosis by non-contrasted US.  A 
similar odds ratio and 95% confidence interval will be constructed for subjects with 
a gold standard diagnosis of stable or lesion regression.  Sensitivities, specificities 
are based on diagnoses made using CEUS-based risk classification (class I, II, and IIF 
considered negative, class III and IV as positive, using modified Bosniak criteria).  
Estimation of sensitivity and specificity will be carried out for each reader, two per 
site.  Agreement between readers will be based on kappa statistics for the 
dichotomous diagnosis and using weighted kappas based on the ordinal Bosniak 
scale. Inter-institutional agreement will be assessed using kappa statistics by 
sending all decoded images from UNC to Vanderbilt and vice versa.   
   
For Aim 2, the prediction performance of quantitative CEUS metrics (including but 
not limited to wash-in rate, time-to-peak intensity, and wash-out rate) will be 
assessed with ROC analysis based on area-under-the-curve (AUC) for each metric.  
Meaningful cutoff points will be determined for the metrics such that sensitivity is at 
least 80%, the lower end of sensitivity of contrast-enhanced CT in a general 
population) without decreasing specificity to below 60%.  Confidence intervals for 
sensitivities and specificities based upon these cutoffs will be calculated to 
determine if one is better than the others.  Additionally, multiple logistic regression 
analysis will be performed with the gold standard diagnosis of lesion progression as 
outcome to determine whether multiple metrics improves AUC.  The ROC in this 
case is determined by applying different cutoffs to the model-predicted probability 
of lesion progression where the multiple metrics serve as the independent variables 
in the model.  We will also determine if the predictive model can be improved by 
inclusion of patient demographic and clinical variables. 
 
As part of a secondary sensitivity analysis, the sensitivity of CEUS, both qualitative 
interpretations and quantitative metrics, will be compared to the sensitivity when 
other standards are incorporated when available, including pathology and 
additional imaging with contrasted or non-contrasted CT or MR. 
 
9.0  STUDY MANAGEMENT 
 
9.1  Institutional Review Board (IRB) Approval and Consent    
It is expected that the IRB will have the proper representation and function in 

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accordance with federally mandated regulations. The IRB should approve the 
consent form and protocol.   In obtaining and documenting informed consent, the 
investigator should comply with the applicable regulatory requirement(s), and 
should adhere to Good Clinical Practice (GCP) Good Laboratory Practice (GLP) and 
to ethical principles that have their origin in the Declaration of Helsinki.   Before 
recruitment and enrollment into this study, the patient will be given a full 
explanation of the study and will be given the opportunity to review the consent 
form. Each consent form must include all the relevant elements currently required 
by the FDA Regulations and local or state regulations. Once this essential 
information has been provided to the patient and the investigator is assured that the 
patient understands the implications of participating in the study, the patient will be 
asked to give consent to participate in the study by signing an IRB-approved consent 
form.   Prior to a patient’s participation in the trial, the written informed consent 
form should be signed and personally dated by the patient and by the person who 
conducted the informed consent discussion.  
 
9.2  Required Documentation    
Before the study can be initiated at any site, the following documentation must be 
provided to the Study Sponsor, NC TraCS at the University of North Carolina.  
• A copy of the official IRB approval letter for the protocol and informed 
consent    
• IRB membership list    
• CVs and medical licensure for the principal investigator and any co-
investigators who will be involved in the study 
• Form FDA 1572 appropriately filled out and signed with appropriate 
  documentation (NOTE: this is required if UNC holds the IND. Otherwise, the 
Investigator’s signature documenting understanding of the protocol and 
providing commitment that this trial will be conducted according to all 
stipulations of the protocol is sufficient to ensure compliance)    
• Executed clinical research contract  
   
9.3  Data Management and Monitoring/Auditing    
The Radiology Research Department will serve as the coordinating center for this 
trial. Data will be collected on paper charts, translated into Excel flowsheets and 
housed in the Radiology Research Department. UNC personnel will coordinate and 
manage data for quality control assurance and integrity. There will be three 
components of data collection: 1) CEUS data, stored in the Dayton lab under the 
unique identifier; 2) general patient data, stored in the radiology study coordinator 
database; 3) study specific patient clinical information including blood and urine 
tests and “gold standard” conventional US results and any additional imaging tests 
or histology, stored in the study coordinator and PI’s office on a password-
protected, secured network drive.  
 
All data will be collected and stored by Study Coordinators from the Radiology 

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Research Department. All electronic data will be stored on a password-protected, 
secured computer. The study files will be password-protected. Paper records will be 
housed in a secured lockbox in a locked office. The investigators will allow monitors 
to review all source documents supporting stored data.   
 
The data management plan includes assigning a unique identifier to each patient. 
For example, 101, 102, 103, etc. for each UNC patient, 201, 202, 203 for each 
Vanderbilt patient. If a patient has multiple lesions, these lesions will be designated 
A, B, etc. These will be the unique de-identified codes for each lesion with the master 
code held in the radiology study coordinator’s office in a separate, password-
protected database. Prior to statistical analysis, a general quality control will be 
performed to look for invalid entries/out of range findings/outliers. Only principal 
investigators, research coordinators and members of Dr. Dayton’s lab performing 
image and data analysis will have access to study data. The study biostatistician will 
only have access to de-identified data (with the possible exception of dates that are 
clinically meaningful, e.g., study visit dates). 
   
9.4  Adherence to the Protocol    
Except for an emergency situation in which proper care for the protection, safety, 
and well-being of the study patient requires alternative treatment, the study shall be 
conducted exactly as described in the approved protocol.  
 
9.4.1  Emergency Modifications    
UNC and Affiliate investigators may implement a deviation from, or a change of, the 
protocol to eliminate an immediate hazard(s) to trial subjects without prior UNC or 
their respective institution’s IRB/IEC approval/favorable opinion.   For any such 
emergency modification implemented, a UNC IRB modification form must be 
completed by UNC Research Personnel within five (5) business days of making the 
change.  
 
9.4.2  Single Patient/Subject Exceptions    
Any request to enroll a single subject who does not meet all the eligibility criteria of 
this study requires the approval of the UNC Principal Investigator and the UNC IRB. 
   
 
9.4.3  Other Protocol Deviations/Violations    
According to UNC’s IRB, a protocol deviation is any unplanned variance from an IRB 
approved protocol that:    
• Is generally noted or recognized after it occurs   
• Has no substantive effect on the risks to research participants    
• Has no substantive effect on the scientific integrity of the research plan or the 
value of the data collected    
• Did not result from willful or knowing misconduct on the part of the 
investigator(s).  

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An unplanned protocol variance is considered a violation if the variance meets any 
of the following criteria:    
• Has harmed or increased the risk of harm to one or more research 
participants    
• Has damaged the scientific integrity of the data collected for the study 
• Results from willful or knowing misconduct on the part of the 
  investigator(s)   
• Demonstrates serious or continuing noncompliance with federal regulations, 
State laws, or University policies.   
 
If a deviation or violation occurs please follow the guidelines below:    
 
Protocol Deviations: UNC or Affiliate personnel will record the deviation in XXX 
and report to any sponsor or data and safety monitoring committee in accordance 
with their policies. Deviations should be summarized and reported to the IRB at the 
time of continuing review.    
 
Protocol Violations: Violations should be reported by UNC personnel within one 
(1) week of the investigator becoming aware of the event using the same IRB online 
mechanism used to report Unanticipated Problems.    
 
Unanticipated Problems:   Any events that meet the criteria for “Unanticipated 
Problems” as defined by UNC’s IRB must be reported by the Study Coordinator using 
the IRB’s web- based reporting system.  
 
9.5  Amendments to the Protocol    
Should amendments to the protocol be required, the amendments will be originated 
and documented by the Principal Investigator at UNC. It should also be noted that 
when an amendment to the protocol substantially alters the study design or the 
potential risk to the patient, a revised consent form might be required.   The written 
amendment, and if required the amended consent form, must be sent to UNC’s IRB 
for approval prior to implementation.  
 
9.6  Record Retention    
Study documentation includes all CRFs, data correction forms or queries, source 
documents, Sponsor-Investigator correspondence, monitoring logs/letters, and 
regulatory documents (e.g., protocol and amendments, IRB correspondence and 
approval, signed patient consent forms).  
 
Source documents include all recordings of observations or notations of clinical 
activities and all reports and records necessary for the evaluation and 
reconstruction of the clinical research study.  
 

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Government agency regulations and directives require that all study documentation 
pertaining to the conduct of a clinical trial must be retained by the study 
investigator. In the case of a study with a drug seeking regulatory approval and 
marketing, these documents shall be retained for at least two years after the last 
approval of marketing application in an International Conference on Harmonization 
(ICH) region. In all other cases, study documents should be kept on file until three 
years after the completion and final study report of this investigational study.  
 
9.7 Obligations of Investigators  
The Principal Investigator is responsible for the conduct of the clinical trial at the 
site in accordance with Title 21 of the Code of Federal Regulations and/or the 
Declaration of Helsinki. The Principal Investigator is responsible for personally 
overseeing the treatment of all study patients. The Principal Investigator must 
assure that all study site personnel, including sub-investigators and other study staff 
members, adhere to the study protocol and all FDA/GCP/GLP/NCI regulations and 
guidelines regarding clinical trials both during and after study completion.  
 
The Principal Investigator at each institution or site will be responsible for assuring 
that all the required data will be collected and entered into the eCRFs. Periodically, 
monitoring visits will be conducted and the Principal Investigator will provide 
access to his/her original records to permit verification of proper entry of data. At 
the completion of the study, all eCRFs will be reviewed by the Principal Investigator 
and will require his/her final signature to verify the accuracy of the data.  
 
10.0 REFERENCES  
 
1. 
Maisonneuve, P., Agodoa, L., Gellert, R. et al.: Cancer in patients on dialysis for 
end-stage renal disease: an international collaborative study. Lancet, 354: 
93, 1999 
2. 
Lowrance, W. T., Ordonez, J., Udaltsova, N. et al.: CKD and the Risk of Incident 
Cancer. J Am Soc Nephrol, 2014 
3. 
Lind Ramskov, K., Thomsen, H. S.: Nephrogenic systemic fibrosis and contrast 
medium-induced nephropathy: a choice between the devil and the deep blue 
sea for patients with reduced renal function? Acta Radiol, 50: 965, 2009 
4. 
Huang, W. C., Levey, A. S., Serio, A. M. et al.: Chronic kidney disease after 
nephrectomy in patients with renal cortical tumours: a retrospective cohort 
study. Lancet Oncol, 7: 735, 2006 
5. 
Lindner, J. R.: Microbubbles in medical imaging: current applications and 
future directions. Nat Rev Drug Discov, 3: 527, 2004 
6. 
Ascenti, G., Zimbaro, G., Mazziotti, S. et al.: Contrast-enhanced power Doppler 
US in the diagnosis of renal pseudotumors. Eur Radiol, 11: 2496, 2001 
7. 
Ascenti, G., Zimbaro, G., Mazziotti, S. et al.: Usefulness of power Doppler and 
contrast-enhanced sonography in the differentiation of hyperechoic renal 
masses. Abdom Imaging, 26: 654, 2001 

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8. 
Kim, A. Y., Kim, S. H., Kim, Y. J. et al.: Contrast-enhanced power Doppler 
sonography for the differentiation of cystic renal lesions: preliminary study. J 
Ultrasound Med, 18: 581, 1999 
9. 
Ascenti, G., Gaeta, M., Magno, C. et al.: Contrast-enhanced second-harmonic 
sonography in the detection of pseudocapsule in renal cell carcinoma. AJR 
Am J Roentgenol, 182: 1525, 2004 
10. 
Ascenti, G., Mazziotti, S., Zimbaro, G. et al.: Complex cystic renal masses: 
characterization with contrast-enhanced US. Radiology, 243: 158, 2007 
11. 
Park, B. K., Kim, S. H., Choi, H. J.: Characterization of renal cell carcinoma 
using agent detection imaging: comparison with gray-scale US. Korean J 
Radiol, 6: 173, 2005 
12. 
von Herbay, A., Vogt, C., Willers, R. et al.: Real-time imaging with the 
sonographic contrast agent SonoVue: differentiation between benign and 
malignant hepatic lesions. J Ultrasound Med, 23: 1557, 2004 
13. 
Celli, N., Gaiani, S., Piscaglia, F. et al.: Characterization of liver lesions by real-
time contrast-enhanced ultrasonography. Eur J Gastroenterol Hepatol, 19: 3, 
2007 
14. 
Wink, M. H., de la Rosette, J. J., Laguna, P. et al.: Ultrasonography of renal 
masses using contrast pulse sequence imaging: a pilot study. J Endourol, 21: 
466, 2007 
15. 
Quaia, E., Bertolotto, M., Cioffi, V. et al.: Comparison of contrast-enhanced 
sonography with unenhanced sonography and contrast-enhanced CT in the 
diagnosis of malignancy in complex cystic renal masses. AJR Am J Roentgenol, 
191: 1239, 2008 
16. 
Setola, S. V., Catalano, O., Sandomenico, F. et al.: Contrast-enhanced 
sonography of the kidney. Abdom Imaging, 32: 21, 2007 
17. 
Meloni, M. F., Bertolotto, M., Alberzoni, C. et al.: Follow-up after percutaneous 
radiofrequency ablation of renal cell carcinoma: contrast-enhanced 
sonography versus contrast-enhanced CT or MRI. AJR Am J Roentgenol, 191: 
1233, 2008 
18. 
Fan, L., Lianfang, D., Jinfang, X. et al.: Diagnostic efficacy of contrast-enhanced 
ultrasonography in solid renal parenchymal lesions with maximum 
diameters of 5 cm. J Ultrasound Med, 27: 875, 2008 
19. 
Roy, C., Gengler, L., Sauer, B. et al.: [Role of contrast enhanced US in the 
evaluation of renal tumors]. J Radiol, 89: 1735, 2008 
20. 
Tamai, H., Takiguchi, Y., Oka, M. et al.: Contrast-enhanced ultrasonography in 
the diagnosis of solid renal tumors. J Ultrasound Med, 24: 1635, 2005 
21. 
Kalantarinia, K., Belcik, J. T., Patrie, J. T. et al.: Real-time measurement of renal 
blood flow in healthy subjects using contrast-enhanced ultrasound. Am J 
Physiol Renal Physiol, 297: F1129, 2009 
22. 
Clevert, D. A., Minaifar, N., Weckbach, S. et al.: Multislice computed 
tomography versus contrast-enhanced ultrasound in evaluation of complex 
cystic renal masses using the Bosniak classification system. Clin Hemorheol 
Microcirc, 39: 171, 2008 

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23. 
Main, M. L., Goldman, J. H., Grayburn, P. A.: Ultrasound contrast agents: 
balancing safety versus efficacy. Expert Opin Drug Saf, 8: 49, 2009 
24. 
Chrysochou, C., Buckley, D. L., Dark, P. et al.: Gadolinium-enhanced magnetic 
resonance imaging for renovascular disease and nephrogenic systemic 
fibrosis: critical review of the literature and UK experience. J Magn Reson 
Imaging, 29: 887, 2009 
25. 
Schneider, A. G., Hofmann, L., Wuerzner, G. et al.: Renal perfusion evaluation 
with contrast-enhanced ultrasonography. Nephrol Dial Transplant, 27: 674, 
2012 
26. 
Gaibazzi, N., Squeri, A., Ardissino, D. et al.: Safety of contrast flash-
replenishment stress echocardiography in 500 patients with a chest pain 
episode of undetermined origin within the last 5 days. Eur J Echocardiogr, 
10: 726, 2009 
27. 
Aggeli, C., Giannopoulos, G., Roussakis, G. et al.: Safety of myocardial flash-
contrast echocardiography in combination with dobutamine stress testing 
for the detection of ischaemia in 5250 studies. Heart, 94: 1571, 2008 
28. 
Hindman, N. M., Hecht, E. M., Bosniak, M. A.: Follow-up for Bosniak category 
2F cystic renal lesions. Radiology, 272: 757, 2014 
29. 
Smith, A. D., Remer, E. M., Cox, K. L. et al.: Bosniak category IIF and III cystic 
renal lesions: outcomes and associations. Radiology, 262: 152, 2012 
30. 
Barr, R. G., Peterson, C., Hindi, A.: Evaluation of indeterminate renal masses 
with contrast-enhanced US: a diagnostic performance study. Radiology, 271: 
133, 2014 
31. 
Chen, Y., Wu, N., Xue, T. et al.: Comparison of contrast-enhanced sonography 
with MRI in the diagnosis of complex cystic renal masses. J Clin Ultrasound, 
2014 
32. 
Israel, G. M., Bosniak, M. A.: An update of the Bosniak renal cyst classification 
system. Urology, 66: 484, 2005 
 
 
 

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11.0 APPENDICES  
 
Appendix I  
The Bosniak classification system is as follows32:  
 
 
Appendix 2 
Time and Events Table 
 
Screening 
Pre-CEUS 
Visit 
CEUS 
study 
Mo6 
(Wk 24) 
Mo12 
(Wk 48) 
Early  
Termination1 
Inclusion/ 
Exclusion Criteria 
X 
 
 
 
 
 
Comprehensive Medical 
History 
X2 
X2 
 
 
 
 
Informed Consent 
X3 
X3 
 
 
 
 
Education of potential 
side effects 
 
X 
 
 
 
 
Pregnancy test (urine), if 
applicable 
 
X4 
 
 
 
 
Serum creatinine 
X 
 
 
X5 
X5 
X5 
Urinalysis 
 
X6 
 
X6 
X6 
 
Contrast-Enhanced US 
(CEUS) 
 
 
X7 
 
 
 
AE Assessment 
 
 
X8 
 
 
 
Request tissue diagnosis 
 
 
 
X9 
X9 
 
Obtain follow-up 
conventional US and any 
other imaging studies 
obtained during the 
 
 
 
 
X 
X 

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follow-up period 
 
Patients declining CEUS 
but allowing creatinine 
follow-up10 
 
 
 
 
 
 
Serum creatinine 
X 
 
 
X 
X 
X 
 
1For any patients that do not complete the CEUS study, an ongoing adverse 
events/serious adverse events will be followed to the resolution of the event. For 
any patient that is deceased before the 1-year follow-up most recent creatinine 
levels and imaging studies will be collected and autopsy results documented, if 
available.  
 
2Comprehensive medical history obtained at time of enrollment; thereafter history 
focused on symptoms and assessments. 
 
3Consent can be obtained and signed at either screening visit or during the pre-
study visit. It will always be reviewed at pre-study visit, even if signed during 
screening visit. 
 
4Women of childbearing potential must have negative urine or serum pregnancy 
test on the day of CEUS study, prior to the study. 
 
5Serum creatinine levels will be obtained clinically at the discretion of the patient’s 
primary provider. We will obtain results of serum creatinine levels drawn by the 
primary provider. 
 
6Urinalysis will be obtained prior to and post CEUS study. This will be obtained by 
Radiology Nursing staff as per agreement. Results will be obtained and recorded by 
Study Coordinator. At approximate 6 and 12-month intervals, urinalysis will also be 
obtained. This can be done locally with results sent to UNC. 
 
7During the CEUS study, Study Coordinator will record time of injection. 
 
8Adverse event assessment will happen during the CEUS study and the 30-minute 
post-study monitoring period, where they will be monitored by the Radiology 
nursing staff with vital signs (blood pressure and heart rate) recorded in the 
hospital’s electronic monitoring system. These results will be collected by the Study 
Coordinator and documented in the Monitoring Logs/Flowsheets housed in the 
Radiology Research Coordinator Office. 
 
9For patients who undergo biopsy or nephrectomy, tissue diagnosis will be 
requested after the procedure. 
 

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10For patients who decline study enrollment with CEUS but meet all study 
inclusion/exclusion criteria but agree to allow us to collect creatinine values from 
their primary providers over the study period, serum creatinine will be collected, if 
available at the designated time periods with a minimum value at 1-year.