Exploratory Evaluation of the Potential for Long-term Retention of Gadolinium in the Bones of Patients Who Have Received Gadolinium Based Contrast Agents According to Their Medical History
Phase: NA
Conditions: Focus: Long-term Retention of Gadolinium-based Contrast Agent
Sponsor: Navitas Life Sciences GmbH

Study No.: ALS-Gd64/001 
 
Long-Term Retention of Gadolinium in Bone 
Version 4.0 Final, 29 April 2016 
Page 1 of 51 
 
 
 
This document is proprietary to the Sponsor (EAG) and for restricted circulation and access only. 
Study Protocol 
Exploratory evaluation of the potential for 
long-term retention of Gadolinium in the bones 
of patients who have received 
Gadolinium based Contrast Agents 
according to their medical history. 
 
A multicentre, retrospective and prospectively 
interventional, exploratory phase IV study 
EudraCT No.: 2012-001439-30 
Study No.: ALS-Gd64/001 
 
Version 4.0 Final, 29 April 2016 
 
 
Ecron Acunova GmbH 
Hahnstrasse 70 
D-60528 Frankfurt/Main 
Germany 
Confidentiality Statement 
The information in this document is confidential and proprietary to Ecron Acunova GmbH (EAG). It is 
understood that the information will not be disclosed to any person or institution other than investiga-
tors or consultants for review, their staff, applicable Ethics Committee(s)/Institutional Review Board(s), 
regulatory authorities and study patients without express authorisation by EAG. 

Study No.: ALS-Gd64/001 
 
Long-Term Retention of Gadolinium in Bone 
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PROTOCOL SYNOPSIS 
Title 
Exploratory evaluation of the potential for long-term retention 
of Gadolinium (Gd) in the bones of patients who have 
received Gadolinium based Contrast Agents (GdCAs) 
according to their medical history. 
Study no. 
ALS-Gd64/001 
EudraCT no. 
2012-001439-30 
Clinical phase 
Post Authorisation Study / Phase IV 
Active ingredients of  
products under evaluation 
Gadobutrol, Gadodiamide, Gadopentetic acid, Gadoteric 
acid, Gadoversetamide, and Gadoxetic acid 
Study objective(s) 
Primary objective 
To prospectively explore the potential for long-term retention 
of Gd in bones in patients who have received a single dose 
of GdCA or multiple doses of the same GdCA, with 
moderate or severe renal impairment or stable normal renal 
function 
(estimated 
glomerular 
filtration 
rate 
> 
60 
ml/min/1.73 m2) at the time of GdCA injection. 
Secondary objectives 
 
To evaluate skin samples for concentration of Gd 
 
To 
evaluate 
bone 
and 
skin 
samples 
for 
concentrations of calcium, phosphorus, sodium, iron, 
zinc and potassium 
 
To 
evaluate 
skin 
samples 
for 
any 
dermatopathological changes that may be associated 
with Nephrogenic Systemic Fibrosis (NSF) 
 
To 
describe 
potential 
co-factors 
for 
NSF, 
susceptibility factors and drug treatments with 
potential impact on bone metabolism 
Methods 
Gd concentration in bone (trabecular and cortical) and skin 
tissue will be analysed by inductively coupled plasma mass 
spectrometry 
(ICP-MS). 
Other 
analytes 
(calcium, 
phosphorus, sodium, iron, zinc and potassium) will be 
analysed also by ICP-MS or alternatively (if this method is 
not satisfactory during method set-up) by inductively coupled 
plasma atomic emission spectroscopy (ICP-AES). 
Histopathology of skin samples will be evaluated by routine 
light microscopy methods, including immunostaining for 
CD34, factor XIIIa and CD68.  
Design 
Multicentre, retrospective and prospectively interventional, 
exploratory. 
Previous treatment 
(test group only) 
Single doses: 0.025 mmol per kg body weight for Gadoxetic 
acid and 0.1 mmol per kg body weight for all other GdCAs. 
Multiple doses: each dose (volume) administered at each 
time point of dosing. 

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Population 
Study population consists of patients undergoing an 
orthopaedic procedure, provided that the required amount of 
trans-operatory collection of bone and skin as defined per-
protocol is feasible. All inclusion criteria and no exclusion 
criteria should be met (please refer to sections 5.1.3, 4.1 and 
4.2). Patients must have received GdCA at least 1 month 
prior to surgery (test group). Additionally, a group of patients 
undergoing hip or knee replacement surgery who have not 
received GdCA will be enrolled (control group).  
Number of patients 
At least 99 evaluable patients will be included. 
Number of centres 
At least 35 centres in America, Europe  and Asia. 
Statistics 
 
Sample Size:  
There are six groups for active GdCA ingredients 
Gadobutrol, Gadodiamide, Gadopentetic acid, Gadoteric 
acid, Gadoversetamide, and Gadoxetic acid.  
In each group, three categories of renal function (stable 
normal renal function (eGFR > 60 ml/min/1.73 m2), impaired 
renal function (eGFR <30 ml/min/1.73 m2 (severe) and ≥30 
to <=60 ml/min/1.73 m2 (moderate)) and two subgroups of 
dosing of GdCA (single / multiple) are to be evaluated.  
 
Per active GdCA ingredient the recruitment targets are 
defined as follows 
 
5 patients for stable normal renal function (eGFR > 
60 ml/min/1.73 m2) and single dose 
 
at least 3 patients and up to 5 patients for stable 
normal renal function and multiple doses  
 
5 patients for impaired renal function (eGFR <=60 
ml/min/1.73 m2) and single dose  
 
up to 5 patients for impaired renal function (eGFR 
<=60 ml/min/1.73 m2) and multiple doses. For 
Gadobutrol and Gadoteric acid, at least 3 patients 
are required. For Gadodiamide, Gadopentetic acid, 
Gadoversetamide, and Gadoxetic acid, there is no 
requirement to reach a specific number of patients to 
achieve study completion.  
 
The total number of patients enrolled in these groups will be 
at least 84.  
The number of subgroups in the GdCA-naïve population is 3 
according to renal function category (i.e. severe or moderate 
impairment, and stable normal renal function). Five patients 
will be enrolled per each sub-group. Therefore, the total 
number of GdCA-naïve patients enrolled will be at least 15.  
Consequently, a minimum of 99 patients in total shall be 
included in the study. 
 

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Statistical analysis 
Primary 
and 
secondary 
variables 
will 
be 
analysed 
descriptively. No formal hypothesis testing is planned. All 
statistical tables will compare all GdCA groups pooled as 
well as each GdCA group separately versus the control 
group. They will be further stratified according to renal 
function category (3 groups), single / multiple doses of all 
patients (2 groups), and the combination of “renal function” 
and “single / multiple doses”. The elapsed time from dosing 
of GdCA until surgery will be classified and used for 
stratification. Safety data will be tabulated. No further 
subgroup analyses are planned. 
 
Interim analysis 
 
An interim analysis will be carried out on all patients enrolled 
in the single dose subgroups for Gadobutrol, Gadoteric acid, 
Gadodiamide, and Gadopentetic acid once at least three 
patients have been recruited to the single-dose subgroups 
for the 4 agents. 
The descriptive  analysis encompasses the evaluation of Gd 
concentration in trabecular and cortical bone (primary 
analysis) and the Gd concentration in skin (secondary 
analysis) within in the subgroups defined for evaluation 
above.  
Planned time schedule 
First patient first visit (FPFV):  
March 2013 
Last patient last visit (LPLV) : 
October 2017. 

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RESPONSIBILITIES 
Co-ordinating Investigator: 
Professor Christoph Lohmann, MD 
(applicable in multicentre studies) 
Universitätsklinikum Magdeburg A. ö. R. 
 
Orthopädie - Operatives Zentrum 
 
Leipzigerstr. 44 
 
39120 Magdeburg, Germany 
 
Tel.: 
+49 (0) 391 67-14000 
 
Fax: 
+49 (0) 391-67 14006 
 
e-Mail: christoph.lohmann@med.ovgu. 
Sponsor's Responsible 
Representative: 
Anders Malm 
 
Managing Director Ecron Acunova GmbH 
 
Ecron Acunova GmbH 
 
Hahnstrasse 70 
 
60528 Frankfurt, Germany 
 
Tel.: 
+49 (0) 69-66 80 30-0 
 
Fax: 
+49 (0) 69-66 80 30-29 
  
e-Mail: anders.malm@ecronacunova.com 
Program Manager: 
Julia Flugel, MSc  
 
Senior Project Manager 
 
Ecron Acunova GmbH 
 
Hahnstrasse 70 
 
60528 Frankfurt, Germany 
 
Tel.: 
+49 (0) 69 66 80 30-0 
 
Fax.: 
+49 (0) 69 66 80 30-29 
 
e-Mail: julia.flugel@ecronacunova.com 
Biometrician: 
Ernst Blümner, MSc Math, MD 
 
Director Biometrics 
 
Ecron Acunova GmbH 
 
Hahnstrasse 70 
 
60528 Frankfurt, Germany 
 
Tel.: 
+49 (0) 69 66 80 30-0 
 
Fax.: 
+49 (0) 69 66 80 30-29 
 
e-Mail: ernst.bluemner@ecronacunova.com 
Medical Advisor & 
Safety Lead:  
Luis Mendoza Burgos, MD 
 
Head of Pharmacovigilance and 
 
Medical Services 
 
Ecron Acunova GmbH 
 
Hahnstrasse 70 
 
60528 Frankfurt, Germany 
 
Tel.: 
+49 (0) 69 66 80 30-0 
 
Fax.: 
+49 (0) 69 66 80 30-29 
 
e-Mail: luis.mendozaburgos@ecronacunova.com 

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Coordinator of Central 
Histopathology Laboratory: 
Shawn Cowper, MD 
 
Associate Professor of Dermatology and of 
 
Pathology 
 
Yale Dermatopathology 
 
15 York Street, LMP 5031 
 
New Haven, CT 06520, USA 
 
Tel.: 
+1 (203) 785-3524 
 
Fax.: 
+1 (203) 737-4307 
 
e-Mail: shawn.cowper@yale.edu 
Coordinator of Central 
Bioanalytical Laboratory: 
Ayaaz Hussain Khan, PhD 
 
Senior Vice President -  BA/BE 
 
Manipal AcuNova 
 
Mobius Towers, SJR i-Park, EPIP, Whitefield 
 
Bangalore, 560 066, India 
 
Tel.: 
+91 (080) 6691 5725 
 
Fax.: 
+91 (080) 6691 5719 
 
e-Mail: ayaaz.khan@ecronacunova.com 
A complete list of all participating centres, investigators (including names, titles, addresses 
and telephone numbers), and all required signature documents, will be filed in the trial 
master file (TMF). 
 

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SERIOUS ADVERSE EVENT REPORTING 
All Serious Adverse Events (SAEs) must be reported immediately (within one working day) 
to: 
Pharmacovigilance Team 
Ecron Acunova 
Hahnstrasse 70 
D-60528 Frankfurt/M. 
Tel.: 
+49 (01520) 166 80 36 
Fax.: +49 (69) 66 80 30-57 
e-Mail: pharmacovigilance@ecronacunova.com 
SAE reporting will be covered on a 24 hours / 7 days basis. 

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Long-Term Retention of Gadolinium in Bone 
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SIGNATURES 
The signatories are obliged to comply in all respects with 
- 
this clinical study protocol 
- 
the standards of Good Clinical Practice (GCP) as defined in the "Note for Good Clinical 
Practice" (CPMP/ICH 135/95) and related guidelines 
- 
the "Declaration of Helsinki" current valid version according to applicable national regula-
tory and legal requirements 
- 
all applicable regulatory requirements including national drug and data protection laws 
 
 
Co-ordinating  
Investigator 
 
Magdeburg 
  
 
Place / date 
 Prof. Christoph Lohmann, MD 
 
Responsible 
Representative 
(Sponsor) 
. 
 
Frankfurt a. M 
  
 
Place / date 
 Anders Malm 
 
 
 
Program Manager 
 
 
 
Frankfurt a. M. 
  
 
Place / date 
 Julia Flugel, MSc  
 
 
 
Biometrician 
. 
 
Frankfurt a. M 
  
 
Place / date 
 Ernst Blümner, MSc Math, MD 
 
 
Medical Advisor & 
Safety Lead 
 
 
Frankfurt a. M. 
  
 
Place / date 
 Luis Mendoza Burgos, MD 

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DECLARATION OF THE PRINCIPAL INVESTIGATOR  
I have read this study protocol and agree that it contains all the information required to con-
duct the study. I agree to conduct the study as set forth in this protocol. In particular, I agree 
to adhere to the moral, ethical and scientific principles governing clinical research as set forth 
in the current, valid versions of the "Declaration of Helsinki", all applicable national regulatory 
and legal requirements, and the guidelines for Good Clinical Practice. 
 
Name 
Affiliation / Address 
Dated Signature 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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AB B R E V I AT I O N S  
AE 
Adverse Event 
C 
Celsius 
CHMP 
Committee for Medicinal Products for Human Use 
CKD-EPI 
Chronic Kidney Disease Epidemiology Collaboration 
CPMP 
Committee for Proprietary Medicinal Products 
CRA 
Clinical Research Associate 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CV 
Coefficient of Variation 
DCF 
Data Clarification Form 
EAG 
Ecron Acunova GmbH (CRO) 
eCRF 
electronic Case Report Form 
eGFR 
estimated Glomerular Filtration Rate 
EMA 
European Medicines Agency 
ESRD 
End Stage Renal Disease 
FAS 
Full Analysis Population 
FDA 
Food and Drug Administration 
FPFV 
First Patient First Visit 
GCP 
Good Clinical Practice 
Gd 
Gadolinium 
GdCA 
Gadolinium based Contrast Agent 
GFR 
Glomerular Filtration Rate 
ICH 
International Conference on Harmonisation 
ICP-AES 
Inductively coupled plasma atomic emission spectroscopy 
ICP-MS 
Inductively coupled plasma mass spectrometry 
IEC 
Independent Ethics Committee 
IF 
Investigator File 
IRB 
Institutional Review Board 
i.v. 
Intravenous 
IWRS 
Interactive Web Response System 
LPLV 
Last Patient Last Visit 
LLOQ 
Lower Limit of Quantification 
MAH 
Marketing Authorisation Holder 
MDRD 
Modification of Diet in Renal Disease 

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MedDRA 
Medical Dictionary for Regulatory Activities 
MRI 
Magnetic Resonance Imaging 
N 
Number of non-missing observations 
NSF 
Nephrogenic Systemic Fibrosis 
PP 
Per Protocol 
PT 
Preferred Term 
RDC 
Remote Data Capture 
SADR 
Serious Adverse Drug Reaction 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAS 
Statistical Analysis Software 
SmPC 
Summary of Product Characteristics 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
TMF 
Trial Master File 
V 
Visit 
WHO-DD 
World Health Organization – Drug Dictionary 
 

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TABLE OF CONTENTS 
1 
Introduction 
15 
1.1 
Background 
15 
1.2 
Risk-benefit assessment 
16 
2 
Study Objectives and Purpose 
18 
3 
Overall study design and plan description 
18 
3.1 
Discussion of study design 
23 
4 
Selection of study population 
24 
4.1 
Patient inclusion criteria 
24 
4.2 
Patient exclusion criteria 
25 
4.3 
Patient withdrawal criteria 
26 
5 
Study treatments. Products and Interventions 
27 
5.1 
Products administered 
27 
5.1.1 
Products administered prior to enrolment 
27 
5.1.1.1 
Products under evaluation 
27 
5.1.1.2 
Dosage of products under evaluation 
27 
5.1.1.3 
Dosing frequency 
27 
5.1.1.4 
Route of administration 
28 
5.1.2 
Products administered after enrolment 
28 
5.1.3 
Prospective study interventions 
28 
5.2 
Method of assigning patients to treatment groups 
29 
5.3 
Selection of dose and timing for each patient 
29 
5.4 
Supply, packaging and labelling 
29 
5.5 
Blinding and randomisation 
29 
5.6 
Prior and concomitant therapy 
30 
5.6.1 
Prohibited previous treatments 
30 
5.6.2 
Admissible concomitant treatments 
30 
5.6.3 
Prohibited concomitant treatments 
30 
5.7 
Treatment compliance 
30 
5.8 
Management of drug overdose 
30 
6 
Variables and methods 
30 
6.1 
Evaluation 
30 
6.1.1 
Primary evaluation variable(s) 
30 
6.1.2 
Secondary evaluation variable(s) 
30 
6.1.3 
Evaluation methods – Bioanalytics 
31 
6.1.3.1 
Sample collection and handling: 
31 
6.1.3.2 
Method description 
31 
6.1.3.3 
Validation protocol 
32 

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6.1.4 
Evaluation methods – Histopathology 
32 
6.1.4.1 
Sample collection and handling: 
32 
6.1.4.2 
Method description 
32 
6.1.4.3 
Reporting of results 
32 
6.1.5 
GFR estimate 
32 
6.2 
Safety 
33 
6.2.1 
Vital signs 
33 
6.2.2 
Laboratory variables 
33 
6.2.3 
Additional safety assessments 
33 
6.2.4 
Adverse events 
33 
6.2.4.1 
Definition of adverse events 
33 
6.2.4.2 
Assessment of adverse events 
34 
6.2.4.3 
Follow-up of adverse events 
35 
6.2.4.4 
Documentation and reporting of adverse events 
35 
7 
Study conduct 
36 
7.1 
Flow-chart 
36 
7.2 
Evaluations and procedures by visits 
37 
7.2.1 
Screening Visit (Visit 0) 
37 
7.2.2 
Baseline examination (Visit 1) 
37 
7.2.3 
Scheduled orthopaedic surgical procedure (Visit 2) 
38 
7.2.4 
Follow-up visit 1 (Visit 3) 
38 
7.2.5 
Follow-up visit 2 (Visit 4) 
38 
7.2.6 
2nd surgery baseline examination (Visit 5) – if applicable 
39 
7.2.7 
2nd orthopaedic surgical procedure (Visit 6) – if applicable 
39 
7.2.8 
Follow-up visit 3 (Visit 7) – if applicable 
39 
7.2.9 
Follow-up visit 4 (Visit 8) – if applicable 
40 
7.3 
Duration of the study 
40 
7.3.1 
Planned duration for the individual patient 
40 
7.3.2 
Premature termination 
40 
8 
Statistics 
41 
8.1 
Statistical and analytical plans 
41 
8.1.1 
Analysis populations 
41 
8.1.2 
Primary and secondary analyses 
41 
8.1.3 
Analysis of safety data 
43 
8.1.4 
Missing data 
43 
8.1.5 
Multicentre study 
43 
8.1.6 
Subgroup analyses 
43 
8.1.7 
Patient data listings 
43 
8.1.8 
Deviations from the planned statistical analysis 
43 
8.1.9 
Interim analysis 
43 
8.1.10 
Software used for statistical analysis 
44 
8.1.11 
Determination of sample size 
44 

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8.2 
Data management 
45 
9 
Data handling and data quality assurance 
45 
9.1 
Documentation 
45 
9.1.1 
Patient identification list 
45 
9.1.2 
Source data and patient records 
45 
9.1.3 
Case report forms 
45 
9.2 
Direct access to source data/documents 
45 
9.3 
Monitoring 
46 
9.4 
Quality assurance 
46 
10 
Ethical, legal and administrative aspects 
46 
10.1 
General considerations 
46 
10.2 
Approval procedures 
47 
10.3 
Protocol amendments 
47 
10.4 
Informed consent 
47 
10.5 
Confidentiality 
47 
10.6 
Liability and insurance 
48 
10.7 
Publication and use of study findings 
48 
10.8 
Archiving of study records 
48 
11 
List of references 
49 
12 
Appendices 
51 
 

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1 
INTRODUCTION 
1.1 
Background 
Rationale for the Study 
This study was requested by the Committee for Medicinal Products for Human Use (CHMP) 
of the European Medicines Agency (EMA). The potential for long-term retention of Gd in hu-
man bone and skin after administration of GdCAs and co-factors that may increase the risk 
of nephrogenic systemic fibrosis (NSF) warrant further study. The analysis of bone and skin 
samples from patients undergoing hip or knee replacement surgery was recommended 
initially and has been widened to other suitable orthopaedic surgeries. 
Nephrogenic Systemic Fibrosis 
Nephrogenic systemic fibrosis was first reported in 2000 by Cowper et al. (1), who noted that 
since 1997, 15 dialysis patients presented with a disease that closely resembled scleromyx-
oedema, yet had significant enough clinical and histopathological differences to warrant its 
designation as a new clinicopathological entity. A possible association between the admin-
istration of GdCAs to patients with severe kidney impairment and NSF was first reported by 
Grobner in 2006 (2;3). NSF has been diagnosed in particular in patients with severe renal im-
pairment (estimated glomerular filtration rate (eGFR) < 30 mL/ min/1.73 m²). Patients with 
acute renal insufficiency due to hepato-renal syndrome and perioperative liver 
transplantation patients were also implicated (for review see (4;5)). 
Signs and symptoms of NSF may include progressive thickening and induration of the skin, 
contractures around the joints impairing mobility, swelling, redness, pruritus, and a burning 
sensation (4;6). On a microscopic level increased skin cellularity with fibroblast-like cells and 
collagen deposition were demonstrated (4;7;8). Systemic involvement of organs, including 
the lungs and heart may also progress rapidly, ultimately resulting in death in approximately 
5% of patients (4;5). 
Risk Factors in the Development of NSF 
Although the precise pathogenesis of NSF remains unknown, its causes are likely to be mul-
tifactorial. Risk factors include the type and dosage of GdCAs administered (9), repeated 
dosing, high cumulative dose (10), and degree of renal impairment (e.g. stage 4 or 5 chronic 
renal failure) at the time of contrast administration (9;11) (for review see (12)). 
NSF patients frequently have numerous co-morbidities and many co-factors may contribute 
to development of NSF. Among these, coagulation abnormalities, history of deep vein throm-
bosis (13), systemic and pre-existing inflammation (due to major surgery, infection, vascular 
events, etc.) (11), erythropoietin administration (10;14), hypothyroidism (13), and disorders of 
iron metabolism (15) have been evaluated. Additionally, high serum calcium levels (10) and 
high serum phosphate levels (10;16), renal dialysis equipment, unidentified microorganisms 
or pathogens, and unidentified “triggers” within the body have been reported as contributing 
factors. 
Deposition of Gd in Skin and Bone  
Abraham et al. (17) reported in 2008 that Gd was detected in skin lesions of 20 patients with 
NSF, whereas Gd was undetectable in a NSF-negative patient. Skin biopsies were obtained 
from 16 days to 1991 days after Gd contrast administration.  
Gibby et al. (18) directly measured Gd in samples taken from surgical bone specimens 
removed from patients undergoing hip arthroplasty between 3 and 8 days after GdCA 
administration. White et al. (19) confirmed that Gd deposition reached measurable levels in 

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bone within days following administration of GdCAs. Weinmann et al. (20) analysed 
specimens of cranial bone obtained 1 to 21 days after GdCA administration and observed 
0.1 to 0.8 µg Gd/g dry weight in specimens versus less than 0.1 µg Gd/g dry weight in 
untreated control specimens. Darrah et al. (21) reported measurable retention of Gd in the 
femoral heads of patients who had received GdCA up to 8 years prior to bone sampling. 
Clinical and Toxicological Significance of Gd in Bone 
A clinical study aimed at the assessment of Gd retained in healthy bone after GdCA expo-
sure may give data on the quantification of the retained Gd. However, similarly as in the case 
of the Gibby (18), White (19) and Darrah (21) studies, such a study will neither be able to 
give information on the form of Gd, nor will it yield any information about potential future re-
lease, and its kinetics. No information will be obtained on a potential link between Gd storage 
and the development of NSF. 
There are no data as yet, showing whether there is any clinical significance / toxicity of po-
tential release of Gd from bones. Such release would probably occur over years and in small 
amounts per time unit (e.g. per year), paralleling the slow processes of bone deminer-
alisation (e.g. osteoporosis, or, potentially, of renal osteodystrophy). However, this result 
does not provide information on the clinical and toxicological significance of the retained Gd. 
There also are no data regarding what threshold (if any) of gadolinium released from bone 
tissue might be necessary to trigger NSF in patients. 
While the precise pathogenesis of NSF has not been definitively determined, none of the cur-
rent hypotheses are premised on any direct link between the long-term retention of Gd in 
bone tissue translating into an increased risk of NSF in patients who subsequently develop 
severe renal impairment. Indeed, if retained Gd in bone were a long-term risk factor or more 
direct trigger for NSF, then new cases of NSF would be expected among the many patients 
with renal impairment who received GdCAs and did not initially develop NSF. On the con-
trary, the very low incidence of NSF since 2007 (22) suggests that contributing factors other 
than retention of Gd in bone are important. The virtual disappearance of new onset cases of 
NSF in recent years is hypothesised to be a result of the label changes and risk management 
activities of MAHs. 
Therefore, this study shall assess the potential of long-term retention of Gd in patients with 
varying degrees of renal function, who have received single or multiple doses of GdCAs for 
diagnostic imaging purposes. Various linear and macrocyclic chelates of GdCAs will be 
studied, and the concentration of Gd in bone will be compared with respective concentrations 
of Gd in skin tissue and correlated with histopathological changes of the skin. 
 
1.2 
Risk-benefit assessment 
This study may contribute further insight into the long-term retention of Gd in human tissues. 
In this study, the administration of GdCA to study patients must have occurred at least one 
month prior to a planned surgery, and all study evaluations will be performed retrospectively 
with regard to GdCA administration. Therefore, the administration of GdCAs does not 
constitute a study-related risk. 
The surgical intervention from which bone specimens will be obtained (i.e. an orthopaedic 
procedure provided that the required amount of trans-operatory collection of bone and skin 
as defined per-protocol is feasible and all inclusion criteria and no exclusion criteria are met) 
will take place for reasons unrelated to the conduct of the study. Two specimens will be 
taken from surgically removed bone, and such harvesting does not constitute any additional 
risk to the patient. The skin biopsy is a study initiated intervention and may carry minor risks, 
including infection, persistent bleeding, or scar formation at the biopsy site. 

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Overall, the risk-benefit assessment for the study is considered positive, based on the new 
data to be gained in relation to the non-significant added risk to patients. 

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2 
STUDY OBJECTIVES AND PURPOSE 
Primary objective: 
To prospectively explore the potential for long-term retention of Gd in bones in patients who 
have received a single dose of GdCA or multiple doses of the same GdCA, with moderate or 
severe renal impairment or stable normal renal function (eGFR > 60 ml/min/1.73 m2) at the 
time of GdCA injection.  
 
Secondary objectives: 
 
To evaluate skin samples for concentration of Gadolinium 
 
To evaluate bone and skin samples for concentrations of calcium, phosphorus, so-
dium, iron, zinc and potassium 
 
To evaluate skin samples for any dermatopathological changes that may be associ-
ated with NSF 
 
To describe potential co-factors for NSF, susceptibility factors and drug treatments 
with potential impact on bone metabolism 
3 
OVERALL STUDY DESIGN AND PLAN DESCRIPTION 
This is a multicentre, retrospective, prospectively interventional and exploratory, post authori-
sation study which will be conducted globally evaluating the potential for long-term retention 
of Gd in bones of patients who received single or multiple doses of GdCAs. The study is 
retrospective with respect to GdCA administration (no GdCA will be administered to patients 
during the study by the investigator), prospective with respect to bone sample collection 
(taken from surgically removed bone) and both, prospective and interventional regarding skin 
sample collection. Skin sampling is required for both dermatopathological assessment and 
quantification of Gd. 
Patients aged at least 18 years (or older if required by local regulations) who are scheduled 
for an orthopaedic surgery procedure (provided that the required amount of trans-operatory 
collection of bone and skin as defined in section 5.1.3 is feasible and all inclusion and no 
exclusion criteria are met) and agree to provide bone and skin samples at the time of the 
procedure will be included in the study after they sign a written informed consent form. In this 
study, a minimum of 99 evaluable patients will be enrolled, from which at least 84 patients 
have received GdCA (test group) and 15 patients have never received GdCA (control group) 
prior the orthopaedic surgery procedure. 
The products assessed are GdCAs which include one of the active ingredients Gadobutrol, 
Gadodiamide, Gadopentetic acid, Gadoteric acid, Gadoversetamide or Gadoxetic acid. 
Figure 1 and Table 1 describe enrolment targets per GdCA and the stratification of patients 
that will be prospectively controlled (see 5.5). 

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Figure 1: Target number of patients per GdCA 
For the test group, GdCA products must have been administered intravenously at least one 
month prior to the orthopaedic surgery procedure. Only patients for whom information 
regarding the active ingredient of the specific GdCA, the name of the product, the date(s) of 
administration and the dose(s) of the administered GdCA are available will be enrolled. 
Patients who received GdCAs containing any other active ingredient will not be enrolled. 
Furthermore, documentation of stable renal function prior to administration of the GdCA is 
required, and renal function must have been assessed at least once within approximately 
3 months prior to GdCA injection. 
In the group of patients who have received GdCA (test group), at least 13 patients will be 
included per GdCA active ingredient group for Gadodiamide, Gadopentetic acid, 
Gadoversetamide, and Gadoxetic acid and at least 16 patients will be included per GdCA 
active ingredient group for Gadobutrol and Gadoteric acid with the following distribution: 

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Table 1: Target number of patients per GdCA and renal function status 
GdCA 
Impaired renal function (at 
least moderate impairment, 
eGFR ≤ 60 ml/min) 
Stable normal  
renal function 
Single  
dose 
Multiple dose 
Single dose 
Multiple dose 
Gadobutrol 
5 
3 to 5* 
5 
3 to 5** 
Gadoteric acid 
5 
3 to 5* 
5 
3 to 5** 
Gadodiamide 
5 
0 to 5* 
5 
3 to 5** 
Gadopentetic acid 
5 
0 to 5* 
5 
3 to 5** 
Gadoversetamide 
5 
0 to 5* 
5 
3 to 5** 
Gadoxetic acid 
5 
0 to 5* 
5 
3 to 5** 
* Patients should be recruited to the Gadodiamide, Gadopentetic acid, Gadoversetamide, 
and Gadoxetic acid subgroups throughout the study duration up to a maximum of 5, but 
there is no minimum requirement to reach a specific number of patients in this subgroup to 
achieve study completion. At least 3 patients and a maximum of 5 patients are required for 
Gadobutrol and Gadoteric acid. If the target of 3 patients is reached, but the study has not 
yet completed, then recruitment to this subgroup should be continued during the remaining 
study time. 
** At least 3 patients are required for this subgroup. If the target of 3 patients is reached, 
but the study has not yet completed, then recruitment to this subgroup should be continued 
during the remaining study time, stopping when until 5 patients have been recruited to this 
subgroup, or when all other subgroups have reached their minimum target for recruitment, 
whichever comes first. 
Table 1 shows patient enrolment targets (see chapter 8 for statistical evaluation). 
Figure 2 shows the enrolment by renal functional status and GdCA dosing: 
a) 5 patients with stable impaired renal function (at least moderate impairment, eGFR ≤ 
60 ml/min/1.73 m2) who have received a single GdCA, 
b) Up to 5 patients with stable impaired renal function (at least moderate impairment, 
eGFR ≤ 60 ml/min/1.73 m2) who have received multiple doses of the same GdCA:  
 
Gadodiamide, Gadopentetic acid, Gadoversetamide, and Gadoxetic acid 
subgroups: no target number. Patients should be recruited to this subgroup 
throughout the study duration, but there is no requirement to reach a specific 
number of patients in this subgroup to achieve study completion.  
 
Gadobutrol and Gadoteric acid subgroups: at least 3 patients. If the target of 3 
patients is reached, but the study has not yet completed, then recruitment to this 
subgroup should be continued during the remaining study time. 
c) 5 patients with stable normal renal function (eGFR > 60 ml/min/1.73 m2) who have 
received a single GdCA dose, 
d) Up to 5 patients (target at least 3) with stable normal renal function (eGFR > 60 
ml/min/1.73 m2) who have received multiple doses of the same GdCA. If the target of 
3 patients is reached, but the study has not yet completed, then recruitment to this 
subgroup should be continued during the remaining study time, stopping when 5 

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patients have been recruited to this subgroup, or when all other subgroups have 
reached their minimum target for recruitment, whichever comes first. 
 
* Depending on the GdCA subgroup 
Figure 2: Stratification of patients for recruitment purposes by renal functional status and 
GdCA dosing  
Out of 15 patients in the control group, 5 patients shall be included in each of the following 
3 categories (Figure 3): 
e) patients with stable severe renal impairment (eGFR < 30 ml/min/1.73 m2) 
f) patients with stable moderate renal impairment (eGFR within the range 30 to 
60 ml/min/1.73 m2) 
g) patients with stable normal renal function (eGFR > 60 ml/min/1.73 m2) 

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Figure 3:  Stratification of control group patients by renal function 
The course of the study is depicted in Figure 4, showing the sequential relationship of GdCA 
administration prior to patient enrolment and the collection of bone and skin tissue samples 
during the orthopaedic surgery procedure (e.g. hip or knee replacement surgery).  
End of study for the individual patient is follow-up visit 2 (visit 4)1 taking place, approximately 
within 10-14 days after the orthopaedic surgery procedure (e.g. hip or knee replacement 
surgery) at the time of potential stitch removal under normal healing conditions2. A detailed 
schedule of study procedures and assessments is presented in section 7.1 (Flow Chart).  
                                               
1 Note: 
If the patient is scheduled for a second orthopaedic surgery procedure (e.g. hip or knee replacement surgery), end of 
study is the follow-up visit 4 (visit 8). 
2 Note: 
Any other wound closure technique used according to the local clinical practice is acceptable. 

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Figure 4: Course of the study 
The overall study period is expected to be approximately 4 ½ years from FPFV to end of 
study. This period includes the scheduled bone and skin sample collection in conjunction 
with a medically indicated orthopaedic surgery procedure. If the patient is scheduled for a 
second orthopaedic surgery procedure (e.g. hip or knee replacement surgery) to be 
performed within the study period, the patient can continue to participate in the study, 
provided that the required amount of trans-operatory collection of bone and skin as defined 
per-protocol is feasible during the second procedure. A second bone and skin sample shall 
be collected during the second scheduled orthopaedic procedure. The overall study period 
will not be extended in order to obtain the second bone and skin sample collection.  
Based on medical experience, it is assumed that approximately 10% of enrolled patients will 
undergo a second hip or knee replacement surgery of e.g. the contra lateral joint. During 
both surgeries (if applicable), portions of the femoral or tibial bones will be removed in the 
course of the respective procedure. From these ex-vivo remains, two samples (trabecular 
and cortical bone) will be harvested for analysis in the central bioanalytical laboratory. In 
addition, a skin sample will be collected from the edge of the surgical incision during each 
joint replacement procedure. 
Handling and analysis of trabecular and cortical bone and skin samples will be performed 
under blinded conditions at central sites. The dermatopathological examinations will be done 
at the Yale Dermatopathology, New Haven, USA, the bioanalytical examinations 
(quantification of Gd and other analytes from skin and bone samples) will be conducted by 
the Bioanalytical Laboratory of Manipal Acunova, Bangalore, India. 
 
3.1 
Discussion of study design 
The current study design is explorative in nature and will deliver descriptive data on the po-
tential for long-term retention of gadolinium in human bone. Restricting the study population 
to patients with stable normal renal function is unlikely to provide further insight into the 
mechanism of Gd retention and the potential development of NSF. Therefore, subgroups 
with different degrees of renal decrement are included. 
A limitation of the study is the retrospective nature of data associated with the single or multi-
ple administration of the GdCAs. It is anticipated that some of the specified analytical clinical 
and laboratory parameters will not be available within the patient records. However, it would 
be impossible to prospectively assess potential Gd retention in patients with moderate and 

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severe decrement in renal function, because the administration of GdCAs to such patients is 
now limited due to regulation. 
The current study, therefore, will enrol patients who received a specified GdCA at least 1 
month prior to an orthopaedic surgery procedure and will prospectively collect bone and skin 
samples for analysis. Conducting the study in patients who plan to undergo a medically 
indicated orthopaedic surgery procedure provides an accessible model for collecting samples 
without adding a significant interventional load onto the patients. The collection of bone and 
skin biopsies are required to correlate Gd content in bone and skin with potential 
histopathological findings associated with NSF. 
GdCA-naïve patients will be included as controls for any background concentration of Gd in 
bone, e.g. from the environment. For example, Gd has been found in skin biopsies of NSF 
patients who were considered to be “gadolinium-free” (23), as well as in bone samples from 
patients with no previous exposure to GdCA (21) 
In summary, the study design is adequately selected to contribute to the understanding of 
long-term Gd retention in patients who receive GdCAs. The study design  was developed 
through scientific discussions with the EMA/ CHMP. 
4 
SELECTION OF STUDY POPULATION 
In this study a minimum of 99 evaluable patients (see 8.1.1) will be recruited, according to 
the distribution per Assessed GdCA/Renal function status depicted in table 1. 
The patients will be recruited in at least 35 centres in America, Europe and Asia. Each 
patient must meet all inclusion criteria and not present any exclusion criteria. 
4.1 
Patient inclusion criteria 
Each patient must fulfil the following criteria to be eligible for the study: 
1. Patient must be at least 18 years of age (or older if required by local regulations) 
2. Patient scheduled for an orthopaedic surgical procedure provided that the required 
amount of trans-operatory collection of bone and skin as defined per-protocol in 
section 5.1.3 is feasible and all inclusion and no exclusion criteria are met.  
3. Patient is scheduled to have sufficient bone removed during the orthopaedic surgical 
procedure and sufficient non-scarred skin tissue from the edge of the surgical incision 
or amputated part to permit sample collection, in the investigator’s medical opinion 
4. Patient agreed to have bone and skin samples collected at the time of the surgical 
procedure(s) 
5. Patient’s surgical procedure and subsequent remission will not be altered by study-
specific skin biopsies, in the investigator’s medical opinion 
6. Patient is fully informed about the study and has signed the informed consent form 
Patients having received GdCA 
7. Patient belongs to one of the following subgroups with respect to the number of 
GdCA doses received and the status of their renal function: 
a) 
patient (total to enrol = 5) has stable impaired renal function (at least moderate 
impairment, eGFR ≤ 60 ml/min/1.73 m2) and has received one GdCA injection at 
the standard dose (0.025 mmol per kg body weight for Gadoxetic acid and 
0.1 mmol per kg body weight for all other agents) 

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or 
b) 
Up to 5 patients  with stable impaired renal function (at least moderate 
impairment, eGFR ≤ 60 ml/min/1.73 m2) and has received more than one 
injection of the same GdCA.  
 
Gadodiamide, Gadopentetic acid, Gadoversetamide, and Gadoxetic acid 
groups: no target number. Patients should be recruited to this subgroup 
throughout the study duration, but there is no requirement to reach a specific 
number of patients in this subgroup to achieve study completion. 
 
Gadobutrol and Gadoteric acid groups: at least 3 patients. If the target of 3 
patients is reached, but the study has not yet completed, then recruitment to 
this group should be continued during the remaining study time. 
or  
c) 
patient (total to enrol = 5) has stable normal renal function (eGFR > 60 ml/min 
/1.73 m2) and has received one GdCA injection at the standard dose 
(0.025 mmol per kg body weight for Gadoxetic acid and 0.1 mmol per kg body 
weight for all other agents) 
 
or 
d) 
patient (total to enrol = 3 to 5) with stable normal renal function (eGFR > 60 
ml/min/1.73 m2) who have received more than one injection of the same GdCA. 
If the target of 3 patients is reached, but the study has not yet been completed, 
then recruitment to this subgroup should be continued during the remaining study 
time, stopping when 5 patients have been recruited to this subgroup, or when all 
other subgroups have reached their minimum target for recruitment, whichever 
comes first. 
8. A minimum of 1 month have elapsed between GdCA dose and the scheduled 
orthopaedic surgical procedure.  
9. Patient GdCA history, including dose(s), date(s), and product(s) administered is com-
plete and accurate. 
GdCA naïve patients (control group) 
10. Patient has never received GdCA before the scheduled orthopaedic surgical 
procedure. 
11. Patient belongs to one of the following renal function categories:  
e) patient (total to enrol = 5) has stable severe renal impairment (eGFR < 30 ml/ 
min/1.73 m2); 
f) 
patient (total to enrol = 5) has stable moderate renal impairment (eGFR within the 
range 30 to 60 ml/min/1.73 m2); 
g) patient (total to enrol = 5) has stable normal renal function (eGFR > 60 ml/min 
/1.73 m2). 
4.2 
Patient exclusion criteria 
No patient may enter the study if any of the following exclusion criteria are fulfilled: 
1. Patient has received different GdCAs. 
2. Patient has received intra-articular GdCA or per any other non-i.v. route. 

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3. Patient has received or is scheduled to receive GdCA within 1 month prior to the date 
of the scheduled orthopaedic surgical and study sample collection procedures. 
4. Patient has received any investigational product or has participated in any other clini-
cal trial within 30 days prior to enrolling in this study. 
5. Patient suspected of, or diagnosed with, tumour of the skeletal system (i.e. tumour, 
metastatic bone, and bone marrow disease in the region from where the skin and 
bone will be harvested). 
Note: Patients shall not be excluded for other bone diseases with the exception of those with 
bone cancer as specified in exclusion criterion 5. 
6. Patient has diagnosed or suspected NSF at time of enrolment. 
Note: Patients shall not be excluded for diagnosis of NSF subsequent to enrolment. 
7. Patient presents with scarring in the region(s) of the scheduled surgical procedure(s) 
or of the skin sampling location, to the extent that collection of an unscarred skin 
sample is not feasible. 
8. Patient has a close affiliation with the investigational site; e.g., a relative of the investi-
gator, dependent person (e.g., employee or student of the investigational site). 
4.3 
Patient withdrawal criteria 
An enrolled patient must be withdrawn from the study immediately if any of the following oc-
curs: 
 
During screening: if the enrolment group for which the patient qualifies, has already 
been closed.  
 
Patient requires a prohibited concomitant medication, including the administration of a 
GdCA after enrolment. 
 
Patient withdraws consent. 
 
An illness occurs during the study period that is likely to influence the assessment of 
the study in the investigator’s medical opinion (i.e. patient is suspected of, or 
diagnosed with, tumour of the skeletal system (e.g. in knee / hip bone, metastatic 
bone and bone marrow disease in knee / hip or other location where the orthopaedic 
surgery is to be performed)). 
Furthermore, an enrolled patient may be withdrawn prematurely from the study, at the inves-
tigator’s discretion, under the following circumstances: 
 
One of the inclusion criteria listed in section 4.1 does not apply. 
 
One of the exclusion criteria listed in section 4.2 applies. 
 
Patient does not cooperate adequately to permit study procedures and assessments. 
 
Any adverse event (AE) after which a continuation in the study would constitute an 
unacceptably high risk for the patient. 
 
Investigator determines it is in the best interest of the patient to withdraw from the 
study. 
The Sponsor should be informed of any decision to withdraw an individual patient. If 
possible, a complete final examination according to the visit schedule should be carried out 
and documented on the corresponding pages of the electronic case report form (eCRF) for 

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those patients prematurely discontinuing the study. Although patients may withdraw from the 
study at any time without giving any reasons and without prejudice to future treatment, efforts 
should be made to document the reason for withdrawal in each case. 
Instructions for patient follow-up in case of withdrawal due to an AE are described in  sec-
tion  6.2.4.3. 
 
Withdrawal criterion for patients undergoing multiple GdCA doses: 
 
If a patient undergoes a second orthopaedic surgical procedure that would qualify for 
the collection of bone and skin as described elsewhere in the protocol section 5.1.3 
(e.g. hip or knee surgery) during the study period, and the patient receives any 
additional dose of a GdCA between the first and the second surgical procedure, the 
patient must be withdrawn from the study. No additional bone and skin samples shall 
be collected during the second surgery for the study. However, the data and tissue 
samples obtained in connection with the first surgery, prior to administration of 
disqualifying GdCAs, will be used for the statistical evaluation. 
5 
STUDY TREATMENTS. PRODUCTS AND INTERVENTIONS 
5.1 
Products administered 
5.1.1 Products administered prior to enrolment 
5.1.1.1 Products under evaluation 
Patients in the test groups (a to d) must have received only one of the following GdCAs, at 
least 1 month prior to scheduled orthopaedic surgery on study:  
1. 
Gadobutrol (Gadovist®, Gadavist® & Gadograf®); 
2. 
Gadodiamide (Omniscan®); 
3. 
Gadopentetic acid (Magnevist®); 
4. 
Gadoteric acid (Dotarem® & Magnescope®); 
5. 
Gadoversetamide (Optimark®); 
6. 
Gadoxetic acid (Primovist®, Eovist® & EOB-Primovist®) 
Patients in the control groups e), f) and g) must be treatment-naïve regarding any GdCA. 
5.1.1.2 Dosage of products under evaluation 
 
0.1 mmol per kg body weight for the products 1–5: GdCAs with the active ingredients 
Gadobutrol, Gadodiamide, Gadopentetic acid, Gadoteric acid, and Gadoversetamide; 
subgroups a) and c). 
 
0.025 mmol per kg body weight for the product 6: GdCAs with the active ingredient 
Gadoxetic acid; subgroups a) and c). 
 
Actual doses injected for all multiple doses subgroups for all products 1–6; subgroups 
b) and d). 
5.1.1.3 Dosing frequency 
 
Single GdCA dose (one injection) at least 1 month prior to the scheduled orthopaedic 
surgical procedure; products 1–6: subgroups a) and c). 

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 
Multiple doses (more than one injection) of the same GdCA, regardless of frequency. 
Last GdCA dose at least 1 month prior to the scheduled orthopaedic surgical 
procedure; products 1–6: subgroups b) and d). 
5.1.1.4 Route of administration 
 
Intravenous only 
5.1.2 Products administered after enrolment 
None  
Note: No GdCA will be administered to the patients during the study by the investigators. 
5.1.3 Prospective study interventions 
Patients must be scheduled for orthopaedic surgery (e.g. hip or knee replacement surgery, 
limb amputations and shoulder replacement) before enrolment in the study. This surgical 
intervention for the patient’s underlying condition will be completed during the study; 
however, the surgical procedure itself is not a study-driven intervention. 
The scheduled skin biopsy is the only interventional procedure to be performed  to patients 
participating in this study (i.e. the only procedure performed for study purposes and not part 
of the otherwise necessary care of the patients). This biopsy will be performed during the 
scheduled orthopaedic surgical procedure. Bone samples will be collected from a surgically 
removed bone specimen and therefore not considered being a study-related intervention. If a 
patient is scheduled for a second orthopaedic surgical procedure that would qualify for the 
collection of bone and skin as described in this section (e.g. hip or knee surgery), additional 
bone and skin samples will be collected. 
Bone tissue sampling: 
Bone tissue will be collected from bone removed during the scheduled orthopaedic surgical 
procedure. A portion of the removed bone (e.g.  the heads of femoral or tibial bone, 
whichever is removed during surgery), will be further processed ex-vivo. At surgical site, two 
aliquots will be taken, each with a minimum weight of 15 g. Further bone sample handling will 
be done in the bioanalytical central laboratory to harvest two samples from each aliquot, one 
consisting of trabecular and the other of cortical bone. Bone samples will precisely be 
weighed and analysed in the central bioanalytical laboratory (for the concentration of Gd, Ca, 
P, Na, Zn, K and Fe). 
Skin tissue sampling:  
Skin samples will be collected from the incisional site made for the scheduled orthopaedic 
surgical procedure or amputated part if applicable. A parallel linear sample of tissue will be 
cut from one edge of the incision wound to the other. It should be 2 mm thick, and as long as 
the incision (typically at least 10 cm of length, according to surgical practice). Depth should 
be the depth of the skin to the fascia (4 mm is a conservative estimate; the linear incision will 
be no longer or deeper than it would have been without removing a sample). Since thickness 
and depth of skin tissue slices are kept constant, the maximum amount of skin tissue 
collected is defined by the length of the surgical incision. The wound is closed in accordance 
to the sites’ clinical practice.  
From the linear sample, two aliquots of 5 mm length each are required for later histopatho-
logical analysis and will be evaluated in the central histopathology laboratory by an experi-
enced and independent (blinded) dermatopathologist in order to identify any skin changes 
associated with NSF. 

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The remaining linear sample will be divided into two aliquots for later bioanalytical analysis 
(yielding approximately 320 mg of fresh tissue per aliquot). The aliquots will be weighted and 
analysed in the central bioanalytical laboratory for the concentration of Gd, Ca, P, Na, Zn, K 
and Fe. 
5.2 
Method of assigning patients to treatment groups 
No randomisation of patients to treatments applies. However, ad-hoc stratification of patients 
to the enrolment groups will be managed centrally (see 5.5). 
5.3 
Selection of dose and timing for each patient 
This protocol focuses on the exploration of long-term Gd-retention in patients exposed to 
GdCAs. There is no upper limit for the time-interval between GdCA administration and sam-
ple collection during the scheduled orthopaedic surgical procedure, based on prior evidence 
that Gd may be detectable in bone 8 years after injection of GdCA (21). In this protocol, the 
time interval between the last dose of GdCA and surgery must be at least 1 month. The 
enrolment of patients with a wide range of times between GdCA injection and time of tissue 
sample collection during surgery may support the evaluation of long-term Gd-retention. 
The study will evaluate for the subgroups with a history of single GdCA dose administration 
only patients who received the approved standard dose for each of the GdCAs. For the 
products with the active ingredients Gadobutrol, Gadodiamide, Gadopentetic acid, Gadoteric 
acid, and Gadoversetamide this is 0.1 mmol per kg body weight. For Gadoxetic acid, a single 
dose is 0.025 mmol per kg body weight.  
Patients in the respective multiple doses subgroups will have received either repeated doses 
or a single or multiple higher than the approved standard dose, and thus higher cumulative 
concentrations of the same GdCA. Any higher dose than 120% of the standard dose of 
GdCA will be analysed as part of the multiple doses subgroup. In both dose subgroups, the 
individual and total combined doses administered will be documented and evaluated. 
5.4 
Supply, packaging and labelling 
Since qualifying GdCA was administered prior to patient enrolment, no supply of any study 
medication is required in the present study. Therefore, neither storage, shipment, packaging, 
nor labelling are applicable. 
5.5 
Blinding and randomisation 
There will be no randomisation. The analysis of bone and skin tissue samples will be done in 
a blinded manner. 
Patients will be registered centrally via an interactive web response system (IWRS). This 
system will be connected with the eCRF and will be accessible 24 hours/7 days a week. 
Each patient will be assigned to a stratified enrolment group defined by the GdCA ingredient 
administered (or control), renal function category (moderate impairment, severe impairment 
or stable normal renal function eGFR > 60 ml/min/1.73 m2) and dosing number 
(single / multiple). Confirmation of patient enrolment will be provided to the enrolling centre 
and shall be retained by the investigator.  
Once a stratification group is complete, no further enrolment into that group will be allowed. 
All participating centres will be notified upon the completion of each enrolment group.  
The data of all patients on study will be de-identified by allocation of a patient number to 
each patient enrolled. No identifying information will be contained in the study eCRF. Patient 
numbers will be issued sequentially to each centre upon patient enrolment. 

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5.6 
Prior and concomitant therapy 
Concomitant therapies and medications administered during the study period are to be doc-
umented. The recording should be limited to diseases, medications that are relevant to the 
setting, e.g. osteoporosis, hormone therapy, etc. (see 7.2.2). This also includes all medical 
and non-medicinal treatment and hormonal contraception. The following details are to be 
recorded in the source documentation: disease indication, date of diagnosis, name of each 
medicine (including active ingredient(s)) or specification of measures, dosage, route of ad-
ministration and the dates of the start and end of treatment. 
The investigator should advise each patient to undergo other medical treatment only after 
having consulted the investigator - except for emergencies. 
5.6.1 Prohibited previous treatments 
 
GdCA within 1 month prior to the date of the scheduled orthopaedic surgical 
procedure. 
 
Intra-articular administrated GdCAs or per any other non-i.v. route. 
 
Combination of different GdCAs. 
5.6.2 Admissible concomitant treatments 
 
Medically indicated, non-GdCA treatments 
5.6.3 Prohibited concomitant treatments 
 
GdCA re-administration prior to completion of all surgeries and tissue collection 
procedures on study 
5.7 
Treatment compliance 
Only patients who have received one of the qualifying GdCAs and for whom a full history of 
GdCA administration and dosage is available, are considered for enrolment into one of the 
respective test groups of this study. In this regard treatment compliance reflects the adher-
ence to the protocol inclusion criteria and not to be assessed separately. 
5.8 
Management of drug overdose 
Not applicable 
6 
VARIABLES AND METHODS 
6.1 
Evaluation 
6.1.1 Primary evaluation variable(s) 
 
Concentration of total Gd in trabecular bone (determined by ICP-MS). 
 
Concentration of total Gd in cortical bone (determined by ICP-MS). 
6.1.2 Secondary evaluation variable(s) 
 
Concentration of total Gd in skin tissue samples (determined by ICP-MS), collected at 
the time of the scheduled orthopaedic surgical procedure, from a biopsy from the 
edge of the surgical wound or the amputated part. 

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 
Concentrations of calcium, phosphorus, sodium, iron, zinc and potassium in bone 
(both trabecular and cortical) and skin tissue samples (determined by ICP-MS or al-
ternatively ICP-AES if the feasibility evaluation of ICP-MS does not show reliable re-
sults). 
 
Histopathological evaluation of skin samples with regard to the possibility of findings 
associated with NSF (determined by an experienced dermatopathologist). 
 
Description of potential co-factors for NSF, susceptibility factors and drug treatments 
with potential impact on bone metabolism. 
Please note: Sample handling, analysis and dosage will be performed under blinded conditions at the 
central sites. 
6.1.3 Evaluation methods – Bioanalytics 
6.1.3.1 
Sample collection and handling: 
Sample collection for the bioanalytical quantification of Gd and the other analytes will be pre-
pared with a sample collection kit. Precise description of the collection procedures, including 
sample harvesting, sample size, transfer of specimens into collection tubes, and sample 
storage until transport to the central bioanalytical laboratory will be provided. The Sponsor 
will take care of secure transportation of the samples under adequate transport conditions. 
The transport conditions will be adjusted according to the test results obtained by the 
bioanalytical central lab during method set-up. All bone and skin tissue samples will be 
identified by a numbering system that does not reveal any information on the patient’s 
identity or history to the blinded investigators in the central bioanalytical laboratory (Manipal 
Acunova, Bangalore, India). 
 
Sample collection: Samples of trabecular and cortical bone must be harvested from 
bone removed during the scheduled orthopaedic surgical procedure, according to the 
type of surgery performed on the individual patient. Skin will be collected during 
surgery by a biopsy of the edge of the surgical incision or the amputated part. If the 
patient is scheduled for a second orthopaedic surgical procedure within the study 
period, additional bone and skin samples will be harvested. 
 
Tissue samples will be kept frozen at at least -20 °C during storage at sites and 
during the transport to the central bioanalytical laboratory. The weight of the samples 
will be measured in the central bioanalytical laboratory. 
 
Bone and skin sample processing and analysis will be performed under blinded 
conditions at the central bioanalytical laboratory. 
 
Central laboratory sample storage: tissue samples are kept frozen at at least –20oC 
until analysis. 
 
A detailed manual of sampling handling procedures and transport logistics will be pro-
vided. 
6.1.3.2 
Method description 
A ICP-MS bioanalytical method (based on (19;24;25)) will be developed and validated 
according to EMA and FDA requirements (26;27) for the quantification of Gd and other speci-
fied analytes, including calcium, phosphorus, sodium, iron, zinc and potassium in tissue 
samples.  The validated methods will be employed for the study sample analysis. In case 
that the reliable analysis of all planned analytes is not possible with the ICP-MS (based on 
the method setup results), alternative methods for analysis of some of the parameters will be 
done with an ICP-AES technique (18;28). 

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6.1.3.3 
Validation protocol 
The bioanalytical method to quantify Gd, Ca, P, Na, Zn, K and Fe in skin and bone tissue will 
be developed and validated according to current regulatory requirements and guidelines 
(26;27).  
6.1.4 Evaluation methods – Histopathology 
Sample collection for the histopathological analysis will be performed using a sample collec-
tion kit. Precise description of the collection procedures, including sample harvesting, 
transfer of specimens into collection tubes, and sample storage until transport to the central 
bioanalytical laboratory will be provided. The Sponsor will take care of secure sample trans-
portation under adequate transport conditions. The skin tissue samples will be identified by a 
numbering system that does not reveal any information on the patient’s identity or history to 
the blinded investigators in the central histopathology laboratory Yale Dermatopathology, 
New Haven, USA. 
6.1.4.1 
Sample collection and handling: 
 
Sample collection: Skin will be collected during the orthopaedic surgical procedure by 
a biopsy from the edge of the surgical incision or the amputated part. If the patient is 
scheduled for a second orthopaedic surgical procedure within the study period, an 
additional skin sample will be harvested. 
 
Skin specimens will be fixed and preserved in formaldehyde solution for later paraffin 
embedding and histopathological examination at the central histopathology labora-
tory. Samples will shipped under ambient conditions to the central histopathology la-
boratory. There the paraffin embedding will be completed, further stabilising the sam-
ples until analysis. 
 
A detailed manual of sampling handling procedures and transport logistics will be pro-
vided. 
6.1.4.2 
Method description 
The histopathological analysis will be completed by an experienced dermatopathologist in 
the central laboratory at the Yale Dermatopathology, New Haven, USA. Methods will include 
routine light microscopy evaluation of skin biopsy samples (stained e.g. for mucin and elastic 
fibres) and immunostaining for CD34-positive “circulating” fibrocytes (4;25;29). Electron 
microscopy for ultra-structural analysis and in situ localisation of Gd will not be performed 
(29). 
6.1.4.3 
Reporting of results 
The results of the individual histopathology parameters, including a dermatopathological ex-
pert statement, will be reported to the respective study centres and to EA, allowing assess-
ment of potential AEs, medical review and further data handling. The results of the individual 
histopathology parameters will be transferred to EA data management electronically, consid-
ered for descriptive statistics and included in the data listing of the study report. However, the 
study centres will not enter the results into the patient specific eCRF. 
6.1.5 GFR estimate 
Various methods have been previously established for the estimate of GFR. Most commonly, 
the Cockgroft/Gault method, the Modification of Diet in Renal Disease (MDRD) or the 
Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) methods are used (30). In 
the present study, any of the clinically accepted, serum creatinine-based methods of GFR 

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estimation will be accepted as indicator of renal function. In case eGFR was not computed 
prior to GdCA administration, eGFR will be estimated by the investigator at enrolment based 
on serum creatinine, age, sex, biometric and/or other laboratory data required for the 
application of one of the above-mentioned eGFR formulas.  
6.2 
Safety 
6.2.1 Vital signs 
No vital signs will be measured for this study. 
6.2.2 Laboratory variables 
No routine clinical laboratory tests will be performed in this study. 
6.2.3 Additional safety assessments 
It will be left to the investigator’s discretion whether safety assessments in addition to the 
documentation of AEs as outlined below (6.2.4) are required. Unless useful for specific pur-
poses (e.g. individual serious adverse events), the data gained from these additional safety 
assessments will not be part of the study’s data base. However, if the investigator considers 
the finding to be clinically significant and of importance regarding safety assessment (e.g. 
severe bleeding following surgery), it must be documented in the eCRF as an adverse event. 
6.2.4 Adverse events 
After signature of the informed consent form the investigator will ask the patient to report any 
significant clinical abnormality and will monitor the patient’s medical records. Any AE occur-
ring from the date the patient enrols in the study until follow-up visit 2 (visit 4) taking place 
approximately within 10-14 days post-surgery (at the time of potential stitch removal3 under 
normal healing conditions) after the scheduled orthopaedic surgical procedure, must be 
documented by the investigator in the eCRF. Complications related to the operation wound 
and its healing will be followed-up as an adverse event until consolidation. In case the patient 
is scheduled for a second orthopaedic surgical procedure that would qualify for the collection 
of bone and skin as described in this protocol in section 5.1.3, AE monitoring will be handled 
like the AE monitoring of the first surgery. 
AEs of interest are: NSF-like events after enrolment, wound related problems, and Serious 
Adverse Drug Reactions (SADRs). 
All AEs, including intercurrent illnesses, must be documented in detail, including the date and 
time of occurrence, the date of event resolution and the outcome (6.2.4.2). The related treat-
ments of the event will be documented in the eCRF as well as event intensity, potential 
causal relationship to any of the categories specified below (6.2.4.2) and seriousness of the 
AE (6.2.4.2). 
6.2.4.1 Definition of adverse events 
An adverse event (AE) is any untoward medical occurrence in a patient or clinical investiga-
tion subject administered a pharmaceutical product and which does not necessarily have a 
causal relationship with this treatment. An AE can, therefore, be any unfavourable and unin-
tended sign (including abnormal laboratory finding), symptom, or disease temporally associ-
ated with the use of a medicinal (investigational) product, whether or not related to the me-
dicinal (investigational) product. 
                                               
3 Note:  Any other wound closure technique used according to the local practice is acceptable. 

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6.2.4.2 Assessment of adverse events 
Each AE will be assessed by the investigator regarding potential causal relationship with one 
or more of the following categories: 
 
(1) related to the orthopaedic surgery (bone resection included). 
 
(2) related to the skin biopsy. 
 
(3) related to GdCA exposure in the past (e.g. NSF signs after enrolment). 
 
(4) related to other health conditions of the patient. 
The investigator must assess each AE as either unrelated or causally related to any of the 
categories (1) – (4). Related means possibly, probably or certainly related. 
Each AE will be characterised by the investigator according to intensity of the event and 
whether any of the seriousness criteria apply. The definitions are given below: 
Intensity 
Regardless of the classification of an AE as serious or non-serious (see below), its intensity 
must be assessed according to medical criteria alone (taking into account the patient’s limita-
tions in routine activities due to the surgical indication before or status after joint replace-
ment) using the following categories: 
Mild: 
does not interfere with routine activities of the patient in the review or opinion 
of the investigator 
Moderate: 
interferes with routine activities of the patient in the review or opinion of the in-
vestigator 
Severe: 
impossible to perform routine activities of the patient in the review or opinion of 
the investigator 
It should be noted that a severe AE does not necessarily have to be serious in nature and 
that a serious adverse event need not be severe. 
Seriousness 
A serious adverse event (SAE) is an AE that, at any dose,: 
 
results in death;  
 
is life-threatening; 
 
requires in-patient hospitalisation or prolongation of existing hospitalisation unless it 
lasts less than 12 hours, or hospitalisation is pre-planned (e.g. standard of care or for 
respite care); 
 
results in persistent or significant disability/incapacity; 
 
is a congenital anomaly or birth defect 
or 
 
is an important medical event that does not have to be immediately life-threatening or 
result in death or hospitalisation, but which may jeopardise the patient or may require 
medical intervention to prevent one of the outcomes listed above. 
NSF-like events will be considered medically important events, and thus are serious AEs. 
All SAEs must be reported by the investigator immediately (within one working day) to 
the pharmacovigilance team of EA (page 4). Unreported SAEs (e.g. not noticed by the 
investigator) must be reported by the Clinical Research Associate (CRA) directly to the 
pharmacovigilance team of EA. A study-specific SAE reporting form is to be used. 

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All AEs that do not fall into any of the above categories are defined as non-serious. 
Expectedness 
Expectedness for potential AEs in response to GdCA exposure in the past (e.g. NSF signs 
after enrolment), category 3 of the list above: The Summary of Product Characteristics 
(SmPC) of the respective GdCA as applicable locally and at the time of the event is consid-
ered as reference document of expectedness. 
Expectedness for potential AEs related to the interventional part of the study (skin biopsy), 
category 2 of the list above, or in a broader sense to the participation in the study: Medical 
judgement will be applied by the investigator. If the event is considered related to the skin bi-
opsy - or in a broader sense to the participation in the study - and it is reasonably expected 
according to the medical knowledge, then it will be considered expected for the study. 
Outcome 
The outcome of the AE is to be documented as follows:  
 
Recovered. 
 
Recovered with sequelae. 
 
Not recovered yet. 
 
Fatal. 
 
Unknown. 
6.2.4.3 Follow-up of adverse events 
Regardless of the duration of the study, each AE must be followed up until it resolves, the 
cause is documented, or an adequate final assessment can be given. If follow-up is not per-
formed or possible, justification must be given by the investigator.  
6.2.4.4 Documentation and reporting of adverse events 
Any AE occurring while a patient is in the study (from informed consent until follow-up visit 2 
(visit 4)4 taking place approximately within 10-14 days post-surgery (at the time of potential 
stitch removal under normal healing conditions5) after the surgical intervention must be 
documented and reported by the investigator. Complications related to the surgical wound 
and its healing will be followed-up as an adverse event until consolidation. Each AE must be 
documented in the eCRF according to the requirements set forth in section 6.2.4.2. 
 
                                               
4 Note: If the patient is scheduled for a second orthopaedic surgery procedure that would qualify for the collection of bone and 
skin as described in the protocol, end of study is the follow-up visit 4 (visit 8). 
5 Note: Any other wound closure technique used according to the local clinical practice is acceptable. 

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7 
STUDY CONDUCT 
7.1 
Flow-chart 
Table 1: Schedule of Procedures and Assessments 
 
Visit 0 
Screening 
Visit 
Visit 1 (V1) 
Baseline 
(within 3 days 
prior to surgery) 
Visit 2 (V2) 
1st surgery  
(day 0) 
Visit 3 (V3) 
Follow-up 1 
(3-5 days af-
ter surgery) 
Visit 4 (V4) 
Follow-up 2 
(approximately within 
10-14 days after sur-
gery) 
If applicable: Patients receiving a 2nd surgery only 
Visit 5 (V5)* 
Baseline 
(within 3 days 
prior to surgery) 
Visit 6 (V6)* 
2nd Surgery 
(within study 
timeframe ) 
Visit 7 (V7)* 
Follow-up 3 
(3-5 days after 
surgery) 
Visit 8 (V8)* 
Follow-up 4 
(approximately 
within 10-14 days 
after surgery) 
Patient information and signa-
ture on Medical Data Release 
Form 
X 
 
 
 
 
 
 
 
 
Patient information, written in-
formed consent  
 
X 
 
 
 
 
 
 
 
Written informed re-consent, if 
applicable 
 
 
 
 
 
X 
 
 
 
Demographic data 
X 
 
 
 
 
 
 
 
 
Diagnosis and medical history 
 
X 
 
 
 
X 
 
 
 
Inclusion and exclusion criteria 
X 
X 
 
 
 
X 
 
 
 
Renal status (retrospective with 
regard to GdCA administrations) 
X 
 
 
 
 
 
 
 
 
GdCA history / verification of 
GdCA history 
X 
X 
X 
 
 
X 
X 
 
 
Connection to IWRS for stratified 
enrolment 
 
X 
 
 
 
 
 
 
 
Concomitant diseases and ther-
apies 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study-specific parameters: 
 
 
 
 
 
 
 
 
 
 
Bone sample collection 
 
 
X 
 
 
 
X 
 
 
 
Skin sample collection 
 
 
X 
 
 
 
X 
 
 
Visual check of wound/scar 
 
 
 
X 
X 
 
 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
* Additional visit for patients scheduled for second  orthopaedic surgical procedure within study timeframe  In case no second surgery is planned at completion of visit 2, the study ends with the end of the follow-up 
visit 2 (V4) 
 

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7.2 
Evaluations and procedures by visits 
7.2.1 
Screening Visit (Visit 0) 
The investigator will use the inclusion and exclusion criteria (section 4.1 and 4.2) to deter-
mine the eligibility of each candidate patient for enrolment in the study. Patients who are eli-
gible and willing to participate in the study will receive appropriate information and sign a 
Medical Data Release Form allowing the screening of out-clinic patient files prior to enrol-
ment. 
At the screening examination the following will be carried out and/or documented: 
 
date and time of visit; 
 
check of inclusion and exclusion criteria; 
 
demographic data (height, weight, age, sex); 
 
diagnosis of qualifying study indication (specify duration, severity as requested); 
 
retrospective renal status (eGFR value(s) at time point of first and (if applicable) subse-
quent GdCA administration, including date(s) of sampling); 
 
GdCA history, i.e. prior GdCA administration (brand name of product(s), date(s) of 
administration, dosing, and route of administration and patient’s body weight determined 
within 4 weeks prior to GdCA administration); 
Patients meeting the study entry criteria will complete the baseline visit of the study.  
Note: The screening visit 0 can be combined with the baseline examination (Visit 1) if feasible for the site / patient 
and if in accordance with local regulations 
7.2.2 
Baseline examination (Visit 1) 
At the baseline examination the patient will sign the Informed Consent Form when it has 
been validated that the patient is suitable for study participation and ample time has been 
ensured for the subject to decide. Afterwards, the following will be carried out and/or docu-
mented: 
 
date and time of visit; 
 
verification of inclusion and exclusion criteria (if baseline visit is performed separately 
from screening visit 0); 
 
GdCA history: verification that no GdCA has been given between the visits (not applica-
ble if Visit 0 and Visit 1 are combined); 
 
connection to IWRS (via eCRF system) for stratified enrolment; 
Note: In cases where the applicable stratified enrolment group is completed, the patient must be withdrawn 
from the study.  
 
relevant medical history and concomitant disease(s) (including date of diagnoses), 
concomitant therapies (brand name, dose, route, frequency, start and stop dates); 
 
other relevant medical history and past therapies since first GdCA administration(s), 
where possible, including: 
- 
vascular, thrombotic and/or pro-inflammatory events; 
- 
serum concentrations of calcium, phosphorus, sodium, iron, potassium and zinc; 
- 
any event which may have led to iron mobilization, including concomitant iron drug; 
- 
cumulative dose of erythropoietin; 
- 
T4 and TSH; 
- 
Drug treatments with potential impact on bone metabolism, including long-term 
chronic drug treatments (i.e. biphosphonates, estrogens, calcitonin, calcitriol, 
fluoride salts, vitamin D, corticosteroids); 
 
AEs (from informed consent on); 

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 
a physical examination of the skin for any clinical signs of NSF according to clinical rou-
tine (4). 
In addition to the general documentation of concomitant diseases, bone-related diseases in 
the medical history should especially be focussed on (e.g. osteoporosis, fractures, 
menopausal effects on bone, etc.) with the exception of suspected or diagnosed tumour of 
the skeletal system , metastatic bone and bone marrow disease (which are exclusionary). 
7.2.3 Scheduled orthopaedic surgical procedure (Visit 2) 
On the day of surgery the following will be carried out and/or documented: 
 
date and time of visit; 
 
check for withdrawal criteria; 
 
GdCA history: verification that no GdCA has been given between the visits; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
AEs; 
 
bone sample collection; 
 
skin sample collection; 
 
schedule next appointment or study visit date. 
7.2.4 Follow-up visit 1 (Visit 3) 
This visit should be performed in connection with a routine wound inspection (about 3-5 days 
after surgery). The following will be carried out and/or documented: 
 
date and time of visit; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
inspection of the surgery wound in order to assess if the wound healing process can be 
assessed as normal (any finding needs to be documented as AE); 
 
AEs; 
 
schedule next appointment or study visit date. 
7.2.5 Follow-up visit 2 (Visit 4) 
This visit should be performed approximately within 10-14 days (at the time of potential stitch 
removal under normal healing conditions6) but not later than 18 days post-surgery. 
The following will be carried out and/or documented: 
 
date and time of visit; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
inspection of the surgery wound in order to assess if the wound healing process can be 
assessed as normal (any finding needs to be documented as AE); 
 
AEs; 
                                               
*AE related changes or bone-disease related changes should be considered as relevant 
6 Note: 
Any other wound closure technique used according to the local practice is acceptable. 

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 
end of study documentation or in case that a second orthopaedic surgical procedure is 
planned surgery date and appointment for the 2nd baseline visit. 
7.2.6 2nd surgery baseline examination (Visit 5) – if applicable 
For patients scheduled to receive a 2nd orthopaedic surgical procedure (that would qualify for 
the collection of bone and skin as described in this protocol) within the study period, the 
following will be carried out and/or documented: 
 
date and time of visit; 
 
re-consent: the patient should be asked to confirm with actual date and signature that 
the provided written informed consent is still valid; 
(Note: If the patient does not agree to re-consent, the patient must be withdrawn from the study.) 
 
verification of inclusion and exclusion criteria; 
 
GdCA history: verification that no GdCA has been given between the visits; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date) *; 
 
AEs; 
 
a physical check of skin for any clinical signs of NSF according to clinical routine (4). 
In addition to the general documentation of concomitant diseases, bone-related diseases 
other than the study indication shall especially be focussed on.  
7.2.7 2nd orthopaedic surgical procedure (Visit 6) – if applicable  
On the day of the second surgery the following will be carried out and/or documented: 
 
date and time of visit; 
 
check for withdrawal criteria; 
 
GdCA history: verification that no GdCA has been given between the visits; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
AEs; 
 
bone sample collection; 
 
skin sample collection; 
 
schedule next appointment or study visit date. 
7.2.8 Follow-up visit 3 (Visit 7) – if applicable 
This visit should be performed in connection with a routine wound inspection (about 3-5 days 
post-surgery). The following will be carried out and/or documented: 
 
date and time of visit; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
check of the surgery wound in order to assess if the wound healing process can be as-
sessed as normal (any finding needs to be documented as AEs); 
 
AEs; 
 
schedule next appointment or study visit date. 
                                               
* AE related changes or bone-disease related changes should be considered as relevant 

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7.2.9 Follow-up visit 4 (Visit 8) – if applicable 
This visit should be performed approximately within 10-14 days (at the time of potential stitch 
removal under normal healing conditions7) but not later than 18 days post-surgery. 
The following will be carried out and/or documented: 
 
date and time of visit; 
 
relevant changes in concomitant disease(s) (including date of diagnoses), relevant 
changes in concomitant therapies (brand name, dose, route, frequency, start and stop 
date)*; 
 
inspection of the surgery site in order to assess if the wound healing process can be as-
sessed as normal (any finding needs to be documented as AE); 
 
AEs; 
 
end of study documentation. 
7.3 
Duration of the study 
The study is scheduled to start in March 2013 and will be completed with the LPLV in 
October 2017. Enrolment will be competitive over all study centres and per stratified 
enrolment group. As soon as a stratified enrolment group is completed, centres will be 
informed that the respective group is closed, and enrolment shall continue for the remaining 
open enrolment groups. 
7.3.1 Planned duration for the individual patient 
For each participating patient, the study lasts until the second follow-up visit (visit 4) is com-
pleted. If a patient is scheduled for a second orthopaedic surgical procedure (to be 
performed within the overall study period), the duration of participation will be extended for 
that patient until completion of the last follow-up visit (visit 8). 
7.3.2 Premature termination 
Study 
At any time, the study as a whole may be terminated prematurely by the Sponsor, at the 
Sponsor’s discretion, if important reasons call for this step. 
Centre 
At any time, an individual centre participating in the study may be excluded, at the Sponsor’s 
discretion, for the following reasons: 
 
The centre fails to comply with the requirements of the protocol. 
 
The centre fails to comply with GCP standards. 
 
No patients are enrolled by the centre within a reasonable period after initiation of the 
centre. 
In addition, each centre shall have the right to discontinue (reasonable written notice ex-
pected) participation if the study can no longer be carried out for organisational or other rea-
sons. 
Patient 
Individual patients shall be withdrawn from the study according to the criteria specified in 
section 4.3, including termination due to suspected breach. 
                                               
7 Note: 
Any other wound closure technique used according to the local practice is acceptable. 

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8 
STATISTICS 
8.1 
Statistical and analytical plans 
8.1.1 Analysis populations 
All patients who have undergone the planned orthopaedic surgical procedure will be included 
in the safety analysis (safety population). 
The primary analysis will be performed on the full analysis population (FAS) and the per 
protocol (PP) population (see definitions below). 
Definition of analysis populations 
Population 
Description 
Screening population 
All patients who entered the study 
Safety population 
All patients who have undergone the 
planned orthopaedic surgical procedure  
Full analysis population (FAS) 
All patients in the safety population for whom 
Gd measurements from the bone are availa-
ble 
Per protocol (PP) population 
All patients in the full analysis population 
who meet the defined requirements of GdCA 
treatment history, all inclusion and exclusion 
criteria, and whose tissue samples yield data 
for Gd in bone (trabecular as well as cortical) 
and skin. 
The evaluability of patients /samples shall be 
assessed by a blinded data review prior to 
final unblinding and analysis. 
The primary analysis will be conducted on the per protocol population. 
The full analysis population will be used for sensitivity analyses, as the FAS could potentially  
encompass patients not fulfilling the requirements for addressing study objectives. 
8.1.2 Primary and secondary analyses 
Statistical methods: 
Study data will be analysed descriptively. No formal hypothesis testing is planned. 
All parameters will be analysed for the per protocol population using descriptive statistics 
including confidence intervals whenever appropriate. Details will be defined in a statistical 
analysis plan (SAP), which will be signed prior to unblinding of the samples. 
Descriptive statistical methods will be used to summarise the results of the study. The 
following descriptive statistics will be calculated for continuously distributed data and for 
ordered categorical data (ordinal data) if applicable: 
 
N (number of non-missing measurements) 
 
Arithmetic mean 
 
Standard deviation  
 
Coefficient of variation (CV), 
 
Geometric mean 

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 
Geometric standard deviation (re-transformed standard deviation of the logarithms) 
 
Corresponding CV 
 
Minimum  
 
Median 
 
Maximum 
For ordered categorical data and nominal data, absolute and relative frequencies (in %) will 
be calculated. 
Group or stratification variables due to the study design are: 
 
GdCA test group or control 
 
Renal function category (moderate impairment, severe impairment or stable normal 
renal function eGFR > 60 ml/min/1.73 m2, Figure 3) 
 
Single (one injection of standard dose) or multiple (more than one injection or one 
injection with higher than standard) doses of GdCA administered 
 
The elapsed time from dosing of GdCA until surgery will be classified and will also be used 
for stratification. 
Statistical tables will compare all GdCA groups pooled as well as each GdCA group sepa-
rately versus the control group. They will be further stratified according to renal function cate-
gory (3 groups), single / multiple doses of all patients (2 groups), and the combination of “re-
nal function with “single / multiple doses”.  
The primary analysis encompasses the evaluation of Gd concentration in trabecular and cor-
tical bone. The secondary analysis deals with Gd concentration in skin as well as the 
parameters specified below. 
Descriptive analyses include 
 
Gd concentration in bone (trabecular and cortical) and skin will be expressed as nmol 
Gd / g bone or skin. 
 
Gd concentration in bone (trabecular and cortical) and skin as a function of time 
elapsed between GdCA injection and surgery. Additional stratification classifications 
of time after dosing of Gd will be specified in the SAP. 
 Analyses will be performed separately for trabecular bone, cortical bone, and skin. 
 
Time elapsed between GdCA injection and surgery, cumulative GdCA dose, number 
of doses and time intervals of dosing. 
 
eGFR. 
 
Potential co-factors for NSF and susceptibility factors, based on the following data 
and in the limit of their availability in medical history of the patients: 
o 
eGFR; 
o 
cumulative dose of GdCA, 
o 
co-existing vascular, thrombotic and/or pro-inflammatory events; 
o 
serum concentrations of calcium, phosphorus, sodium, iron, potassium and zinc; 
o 
any event which may have led to iron mobilization, including concomitant iron 
drug; 
o 
cumulative dose of erythropoietin; 
o 
T4 and TSH. 
 
Concomitant drug treatments with potential impact on bone metabolism: 
biphosphonates, 
estrogens, 
calcitonin, 
calcitriol, 
fluoride 
salts, 
vitamin 
D, 
corticosteroids. 

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 
Concentration of Ca, P, Na, Zn, K and Fe in skin and in tissue of both trabecular and 
cortical bone, determined by ICP-MS (or ICP-AES if the feasibility evaluation of ICP-
MS does not show reliable results). 
 
Histopathological evaluation of skin samples (taken at time of surgery / surgeries) 
with regard to the possibility of findings associated with NSF by an experienced 
dermatopathologist under blinded conditions at a central site. 
8.1.3 Analysis of safety data 
The AEs will be encoded using the MedDRA thesaurus in the most recent version available 
at study start. This version will be used throughout the entire study without subsequent up-
date. Frequency tables for the preferred terms (PTs) will be compiled, based on patients ex-
periencing an AE and based on the number of AEs. These frequency tables will also be 
stratified by system organ class (SOC). 
Concomitant diseases and medical history will also be encoded using MedDRA. These data 
will be presented applying frequency tables. 
Previous and concomitant medication will be encoded using the WHO-DD dictionary. Fre-
quency tables will be compiled based on medication coding. 
8.1.4 Missing data 
Missing values will not be replaced. 
8.1.5 Multicentre study 
This study will be performed as a multinational multicentre study. Due to the small sample 
size of each stratification group, results will not be further stratified by country or centre. 
8.1.6 Subgroup analyses 
Due to the small number of patients in each stratification subgroup, special subgroup 
analyses are not planned.  
The patients who have undergone two surgeries on study will be analysed as a subgroup, at 
least for Gd concentration in bone and skin. Descriptive statistics will be calculated for the 
difference of Gd concentration in bone (trabecular and cortical) and in skin at the time of first 
and the time of second surgery. Stratification of the results will depend on the number of pa-
tients in this subgroup (8.1.2). 
8.1.7 Patient data listings 
All recorded data will be presented in patient data listings. 
8.1.8 Deviations from the planned statistical analysis 
Any deviations from the planned statistical analysis shall be defined in the statistical analysis 
plan prior to unblinding the sample results. They shall also be described and justified in the 
final study report. If a deviation has an impact on the primary analysis, the Sponsor may elect 
to document such deviation in a protocol amendment. 
8.1.9 Interim analysis 
An interim analysis will be carried out on all patients enrolled in the single dose subgroups for 
Gadobutrol, Gadoteric acid, Gadodiamide and Gadopentetic acid once at least three patients 
have been recruited to all the single dose exposure subgroups for the 4 agents.  

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The interim analysis will be based on the PP population to determine the Gd concentration in 
bone (trabecular and cortical) and skin (expressed as nmol Gd / g). Gd concentrations will be 
descriptively evaluated (as defined in section 8.1.2) by: 
 
Renal function status: Stable normal renal function (eGFR > 60 ml/min/1.73 m2), 
impaired renal function (eGFR <30 ml/min/1.73 m2 (severe) and ≥30 to <=60 
ml/min/1.73 m2 (moderate)) versus control 
 
GdCA: Each of the 4 GdCAs (Gadobutrol, Gadoteric acid, Gadodiamide, and 
Gadopentetic acid) versus control 
No statistical tests are to be calculated. 
All data used in this interim analysis will be listed. All listings will include patient identifier, 
GdCA type, renal function, and will be sorted by GdCA type, renal function, and patient 
identifier. 
Study Investigational sites and analytical laboratories will be blinded to the Interim Analysis 
results. Details on the interim analysis evaluation will be described in the Statistical Analysis 
Plan (SAP). 
8.1.10 Software used for statistical analysis 
The SAS software version 9.2 or higher will be used for the statistical analysis and for the re-
porting of this study. 
8.1.11 Determination of sample size 
There are no prior expectations or assumptions relative to the measured concentrations of 
Gd in the bone (primary objective) and in skin (secondary objective). Due to the exploratory 
nature of the study, the sample size was not determined based on formal statistical consider-
ation, but rather on the feasibility of conducting the study as a whole. The study is intended 
to be analysed descriptively. No formal hypothesis testing is planned.  
There are six groups for active GdCA ingredients (Gadobutrol, Gadodiamide, Gadopentetic 
acid, Gadoteric acid, Gadoversetamide, and Gadoxetic acid).  
In each group, three categories of renal function (stable (normal) renal function (eGFR > 60 
ml/min/1.73 m2) versus impaired renal function (eGFR <30 ml/min/1.73 m2 (severe) and ≥30 
to <=60 ml/min/1.73 m2 (moderate)) and two subgroups of dosing of GdCA (single / multiple) 
are to be evaluated.  
 
Per active GdCA ingredient the recruitment targets are defined as follows 
 
5 patients for stable normal renal function (eGFR > 60 ml/min/1.73 m2) and single 
dose 
 
at least 3 patients and up to 5 patients for stable normal renal function and multiple  
doses  
 
5 patients for impaired renal function (eGFR <=60 ml/min/1.73 m2) and single dose  
 
up to 5 patients for impaired renal function (eGFR <=60 ml/min/1.73 m2) and multiple 
doses. For Gadobutrol and Gadoteric acid, at least 3 patients are required. For 
Gadodiamide, Gadopentetic acid, Gadoversetamide, and Gadoxetic acid, there is no 
requirement to reach a specific number of patients to achieve study completion. 
 
The total number of patients enrolled in these groups will be at least 84.  

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The number of subgroups in the GdCA-naïve population is 3  according to renal function 
category (i.e. severe or moderate impairment, and stable normal renal function). Five 
patients will be enrolled per each sub-group. Therefore, the total number of GdCA-naïve 
patients enrolled will be at least 15.  
Consequently, a minimum of 99 patients in total shall be included in the study. 
 
8.2 Data management 
The data management will be performed using Oracle Clinical version 4.5.3 or later. Details 
will be defined in the data management manual, which will be signed by the Sponsor prior to 
start of the data entry. 
9 
DATA HANDLING AND DATA QUALITY ASSURANCE 
9.1 
Documentation 
9.1.1 Patient identification list 
All patients who have given informed consent to study participation – regardless if the patient 
has received any product under evaluation or not – shall be entered on the patient identifica-
tion list by the assigned study staff, giving full name, initials, date of birth and patient number. 
The patient identification list will be kept in the Investigator's File (IF). 
9.1.2 Source data and patient records 
All data entered into the eCRF shall have corresponding source documentation available at 
the site. 
9.1.3 Case report forms 
This study will use an eCRF for data capture. The Oracle Clinical Remote Data Capture 
(RDC) System version 4.5.3 or later will be applied. An eCRF completion manual for the use 
of the RDC system will be provided prior to study start. 
The system used shall be validated and is compliant with Food and Drug Association (FDA) 
Title 21 CFR part 11 and the requirements of ICH GCP.  
For each patient, the investigator must enter all requested data and findings as they occur 
during the study in the eCRF. The eCRFs should be made available at all times for monitor-
ing visits (even for visits arranged at short notice). The investigator must keep the eCRFs in 
good order and up to date so that they always reflect the latest observations on the patients 
enrolled in the study. 
Any discrepancies in the eCRF data detected by the study personnel are to be resolved via 
data clarification forms (DCFs). 
9.2 Direct access to source data/documents 
Monitoring the study progress requires checking the eCRFs for completeness and clarity as 
well as their cross-checking with source documents. The CRAs are entitled to compare 
eCRF entries to source data and to inform the investigator about any errors and omissions. 
The investigator will provide direct access to source data/documents for the Sponsor’s des-
ignated representatives (CRAs and auditors) as well as IRB/IRC members and regulatory in-
spections. 
Regulatory authorities and/or the Sponsor's Clinical Quality Assurance Group may also carry 
out such source data checks and/or on-site audit inspections. They will be carried out giving 

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due consideration to data protection and medical confidentiality. The investigator is to give 
the Sponsor whatever support is necessary. 
9.3 Monitoring 
Monitoring will be conducted by Sponsor CRAs in accordance with the stipulations of 
chapter 5.18 of the ICH GCP Guideline. 
During the course of the study, a CRA will visit each centre to review protocol compliance, 
compare eCRFs to corresponding patient medical records, and ensure that the study is being 
conducted according to pertinent regulatory requirements and the protocol. eCRF entries will 
be verified against source documentation in accordance with the applicable Standard Oper-
ating Procedures (SOPs) of the Sponsor. CRAs will maintain and protect the confidentiality of 
personal data of patients. 
Data monitoring will include 100% source data verification of every patient’s documentation. 
For patients who are withdrawn from the study prior to surgery, only the written informed 
consent form shall be verified. 
The CRA will determine whether all AEs and SAEs have been appropriately reported. 
The Sponsor reserves the right to order special examinations of laboratory samples in case 
of doubt concerning the validity of individual patient data or the accuracy of data generation 
at an investigational centre. 
9.4 Quality assurance 
Pre-study site visits will be performed by representatives of the Sponsor in order to assure 
the eligibility of the study centres to implement the protocol, with specific focus on staff quali-
fication and/or technical equipment requirements. 
Furthermore it is planned that a member of the Sponsor’s quality assurance unit will perform 
on-site audits (approximately one audit per active country). The auditor(s) will usually be 
accompanied by a CRA. The investigator will be informed about the outcome of any audit of 
their respective centre. 
In addition, inspections by health authority representatives - including foreign authorities - 
and IEC(s) / IRB(s) are possible at any time. The investigator should immediately notify the 
Sponsor of any such inspection announcement. 
As other planned quality measures: 
 
A protocol audit 
 
A TMF audit at the end of the study 
 
An audit of the final study report. 
will be performed. 
10 ETHICAL, LEGAL AND ADMINISTRATIVE ASPECTS 
10.1 General considerations 
The procedures regarding the conduct, evaluation, and documentation of this study as de-
scribed in this protocol are designed to ensure that the study is conducted according to GCP 
guidelines and under the guiding principles detailed in the Declaration of Helsinki. The study 
will also be carried out in accordance with FDA Title 21 CFR part 11 and in accordance with 
applicable local laws and regulations. 

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Each investigators of this study shall ensure that this clinical investigation is conducted in ac-
cordance with the signed investigator agreement, the study protocol, and all applicable reg-
ulations. The investigator is responsible ensuring that the rights, safety, and welfare of the 
study patients are protected at all times.  
10.2 Approval procedures 
Before the start of the study, the study protocol and/or other relevant documents will be ap-
proved by the appropriate ethics committee. 
The relevant authorities, in accordance with local legal requirements will be notified/asked for 
approval of the intended study. 
10.3 Protocol amendments 
After initiation of the study, any change in this protocol will require a formal amendment. The 
amendment must be signed by all of the signatories to the original protocol. Once the study 
has started, amendments will be made only in exceptional cases. 
All protocol amendments will be submitted to ethics committee(s) and the regulatory authori-
ties, as required by national law. 
Changes to the protocol may only be implemented after all appropriate requirements listed 
above (ethics, regulatory approval of all responsible personnel) have been fulfilled. 
10.4 Informed consent 
Before any patient can be enrolled or admitted into the study, their informed consent will be 
obtained according to the national regulatory and legal requirements. To this end, the inves-
tigator or an authorised designee will explain the nature, purpose, significance and scope of 
the study, including its potential risks, to the patient. In addition to this oral information, the 
patient will receive for his/her own records a written patient information sheet summarising 
the relevant information. Sufficient time will be allowed to discuss any questions raised by the 
patient. Only after this information has been provided can informed consent for participation 
be given. The consent form must be personally signed and dated by the patient giving con-
sent, and it must be retained by the investigator as part of the study records. A copy of the 
signed informed consent form will be given to the patient. 
The investigator will not undertake any investigation required for the clinical study until in-
formed consent has been obtained. The terms of the consent and the date when it was ob-
tained should also be entered in the eCRF.  
After releasing an amendment to the protocol, the contents of which might influence the pa-
tient's decision for participation, the patient information sheet and the informed consent form 
must be amended accordingly. They must be submitted to the relevant ethics committee and 
the relevant authority as requested by local law. Depending on the nature of the amendment 
it might be necessary that patients already enrolled must confirm their informed consent on 
the basis of the new information by reviewing and signing the amended informed consent 
form. 
10.5 Confidentiality 
All local legal requirements regarding protection of personal patient data will be adhered to. 
The anonymity of study patients will be maintained. Throughout documentation and evalua-
tion, the patients will be identified on eCRFs and other documents by an identification (pa-
tient) number. Documents which identify the patient (e.g. the signed informed consent) must 

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be maintained in confidence by the investigator. The patients will be informed that all study 
findings will be stored on computer and handled in the strictest confidence. 
Any results derived from the study and documents will also be regarded as confidential. The in-
vestigators and members of their research teams will be not be allowed to disclose such in-
formation without prior written approval from the Sponsor. 
10.6 Liability and insurance 
Where required by the laws and regulations of the country in which the study is performed, in-
surance of patients against health impairment occurring as a result of participation in the study 
will be obtained in accordance with the applicable laws and regulations. All relevant documenta-
tion regarding such insurance will be filed in the TMF and/or IF, as appropriate.  
The General Insurance Conditions will be kept in the investigator's file and shall be made 
available for patients at any time that the centre is open. 
10.7 Publication and use of study findings 
By signing the study protocol, the investigator agrees with the use of results of the study for 
the purposes of national and international registration, publication and information for 
medical and pharmaceutical professionals. If necessary, the authorities will be notified of the 
investigator's name, address, qualifications and extent of involvement. 
An integrated study report covering clinical and biometrical aspects will be prepared by the 
Sponsor. 
All relevant aspects regarding publication will be part of the contract between the Sponsor 
and the investigator/institution. 
10.8 Archiving of study records 
Essential documents as listed in ICH GCP, chapter 8, will be retained for at least 15 years 
after study end. The documents may be retained for a longer period if required by other ap-
plicable regulatory requirements or by a separate agreement between the Sponsor and the 
investigator. 
Patient medical records will be archived according to local regulations and in accordance 
with the maximum period of time permitted by the hospital, institution, or private practice.  
The investigator’s file is not to be destroyed without the Sponsor’s approval. The investiga-
tor’s contract will contain all regulations relevant for the study centre. The Sponsor will inform 
the investigator when the prescribed period for archiving study documents has elapsed and 
the investigator no longer needs to retain the records relating to the study. 

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11 LIST OF REFERENCES 
 
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Nephrogenic systemic fibrosis: risk factors and incidence estimation. Radiology 2007 
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Nephrogenic systemic fibrosis, gadolinium, and iron mobilization. N Engl J Med 2007 
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Incidence of nephrogenic systemic fibrosis at two large medical centers. Radiology 
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Incorporation of excess gadolinium into human bone from medical contrast agents. 
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 (28)  Zaksas NP, Sultangazieva TT, Gerasimov VA. Determination of trace elements in 
bone by two-jet plasma atomic emission spectrometry. Anal Bioanal Chem 2008 
May;391(2):687-93. 
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12 APPENDICES 
None.