Biomarker-guided Implementation of Angiotensin-II (AT-II) to Reduce the Occurrence of Kidney Damage After Cardiac Surgery
Phase: PHASE3
Conditions: Cardiac Surgery, Vasoplegia, Hyperreninemia
Sponsor: Universität Münster

S t u d y  P r o t o c o l  
 
 
 
 
BIOMARKER-GUIDED IMPLEMENTATION OF ANGIOTENSIN II TO 
REDUCE THE OCCURRENCE OF KIDNEY DAMAGE AFTER CARDIAC 
SURGERY (ANGIOTENSIN II TO REDUCE KIDNEY DAMAGE)  
ACRONYM 
(AIDED-TRIAL) 
 
 
 
EudraCT-No.: 2021-003088-87 
 
Sponsor: 
Westfälische Wilhelms-Universität Münster 
Schlossplatz 2 
48149 Münster 
 
Investigator: 
Univ.-Prof. Dr. med. A. Zarbock  
University Hospital Muenster 
Department of Anesthesiology,  
Intensive Care and Pain Medicine 
Albert-Schweitzer-Campus 1, A1 
48149 Muenster 
Germany 
 
 
 
 
Sponsor’s study code:  
WWU20_0016 
 
Final V1.2 
NCT05199493 
 
 
 
 

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TABLE OF CONTENTS 
 
1 
General Information ....................................................................................................... 5 
1.1 
Responsible Persons, Institutions and Committees . Fehler! Textmarke nicht definiert. 
1.2 
Signatures ............................................................... Fehler! Textmarke nicht definiert. 
1.3 
Synopsis ....................................................................................................................... 5 
1.4 
Flow Chart .................................................................................................................... 9 
1.5 
Abbreviations .............................................................................................................. 10 
2 
Introduction .................................................................................................................. 11 
2.1 
Background Information and Rationale ....................................................................... 11 
2.2 
Risk-Benefit Analysis .................................................................................................. 12 
3 
Objectives and Endpoints ........................................................................................... 12 
3.1 
Objectives ................................................................................................................... 13 
3.1.1 
Primary Objective ..................................................................................................... 13 
3.1.2 
Secondary Objectives .............................................................................................. 13 
3.1.3 
Additional Research Program .................................................................................. 14 
3.2 
Endpoints .................................................................................................................... 14 
3.2.1 
Primary Endpoint...................................................................................................... 14 
3.2.2 
Secondary Endpoints ............................................................................................... 14 
4 
Study Design ................................................................................................................ 15 
5 
Study Sites and Study Population .............................................................................. 15 
5.1 
Study Site Selection .................................................................................................... 15 
5.2 
Study Population ......................................................................................................... 15 
5.2.1 
Inclusion Criteria ...................................................................................................... 15 
5.2.2 
Exclusion Criteria ..................................................................................................... 15 
5.2.3 
Distribution of Gender in the Study Population ......................................................... 16 
6 
Patient Inclusion, Registration and Randomization .................................................. 16 
7 
Study Medication ......................................................................................................... 16 
7.1 
Investigational Medicinal Product: ............................................................................... 16 
7.1.1 
Drug Characterization .............................................................................................. 16 
7.1.1.1 
Name of the medicinal product .............................................................................. 16 
7.1.1.2 
Qualitative and quantitative composition ............................................................... 17 
7.1.1.3 
List of excipients .................................................................................................... 17 
7.1.1.4 
Pharmacodynamic properties ................................................................................ 17 
7.1.1.5 
Pharmacokinetic properties ................................................................................... 18 
7.1.1.6 
Shelf-life ................................................................................................................ 18 
7.1.1.7 
Special precautions for storage ............................................................................. 18 
7.1.1.8 
Marketing authorization holder .............................................................................. 18 
7.1.1.9 
Marketing authorization numbers .......................................................................... 18 
7.1.2 
Contraindications ..................................................................................................... 18 
7.1.3 
Special Warnings and precautions for use ............................................................... 19 
7.1.4 
Interaction with other Medicinal Products and other Forms of Interaction ................. 19 
7.1.5 
Undesirable Effects .................................................................................................. 19 
7.1.6 
Administration .......................................................................................................... 19 
7.1.7 
Dose Selection Rationale ......................................................................................... 20 
7.1.8 
Dose Modification..................................................................................................... 20 
7.1.9 
Overdose ................................................................................................................. 20 
7.1.10 
Manufacturing, Blinding and Labeling ..................................................................... 21 
7.1.11 
Supply, Drug Accountability, Storage Conditions, Disposal .................................... 21 

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8 
Treatment Plan ............................................................................................................. 21 
8.1 
Treatment Plan ........................................................................................................... 21 
8.2 
Dose Modification/ Termination of Treatment .............................................................. 21 
8.3 
Control of Patients Compliance ................................................................................... 21 
8.4 
Concomitant Medication / Therapy .............................................................................. 21 
8.4.1 
Permitted Concomitant Medication / Therapy ........................................................... 21 
8.4.2 
Forbidden Concomitant Medication / Therapy .......................................................... 22 
8.4.3 
Rescue Medication and Emergency Measures ........................................................ 22 
8.5 
Pregnancy, Breast Feeding and Fathering of a Child .................................................. 22 
8.6 
Continuation of Treatment after the End of the Clinical Trial ........................................ 22 
8.7 
Unblinding ................................................................................................................... 22 
9 
Study Conduct and Study Assessments .................................................................... 23 
9.1 
Screening (and Baseline) Visit .................................................................................... 23 
9.2 
Intermediate Visits ...................................................................................................... 23 
9.3 
Study Termination Visit ............................................................................................... 24 
9.4 
Follow up .................................................................................................................... 24 
9.5 
Study Assessments..................................................................................................... 24 
10 
Assessment of Efficacy and Safety .......................................................................... 25 
10.1 
Assessment of Efficacy ............................................................................................. 25 
10.2 
Assessment of Safety ............................................................................................... 25 
10.2.1 
Definitions .............................................................................................................. 25 
10.2.2 
Period of Observation, Documentation and Assessment of Adverse Events .......... 27 
10.2.3 
Reporting of Serious Adverse Events (SAE) by the Investigator ............................. 28 
10.2.4 
Assessment of Serious Adverse Events by the Sponsor ........................................ 28 
10.2.5 
Legal Reporting Requirements of the Sponsor ....................................................... 28 
10.2.6 
Pregnancies ........................................................................................................... 29 
10.3 
Data Monitoring Committee ....................................................................................... 29 
11 
Study duration, Premature Termination of the Study .............................................. 29 
11.1 
Study Duration .......................................................................................................... 29 
11.2 
Definition of the End of the Study .............................................................................. 30 
11.3 
Premature Study Termination ................................................................................... 30 
11.3.1 
Premature Termination of Study Participation of a Single Patient ........................... 30 
11.3.2 
Premature Termination of the Entire Study ............................................................. 30 
12 
Statistical Considerations ......................................................................................... 30 
13 
Documentation, Data Management, Archiving ........................................................ 32 
13.1 
Patient Identification List ........................................................................................... 32 
13.2 
Source Data / Source documents .............................................................................. 32 
13.3 
Recording of Data / Case Report Form (CRF) ........................................................... 32 
13.4 
Data Management ..................................................................................................... 32 
13.5 
Archiving ................................................................................................................... 33 
13.6 
Investigator Site File .................................................................................................. 33 
14 
Monitoring, Audits and Inspections.......................................................................... 33 
14.1 
Monitoring ................................................................................................................. 33 
14.2 
Audits und Inspections .............................................................................................. 34 
15 
Ethical and Regulatory Requirements ...................................................................... 34 
15.1 
Declaration of Helsinki and Legal Requirements ....................................................... 34 
15.2 
Patient Information and Informed Consent ................................................................ 34 
15.3 
Patient Insurance ...................................................................................................... 35 

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15.4 
Financing .................................................................................................................. 35 
15.5 
Adherence to the Protocol ......................................................................................... 35 
15.6 
Data Protection ......................................................................................................... 35 
16 
Reporting and Publication Policy ............................................................................. 36 
16.1 
Reporting .................................................................................................................. 36 
16.1.1 
Interim Report ........................................................................................................ 36 
16.1.2 
Final Report ........................................................................................................... 36 
16.1.3 
Safety Reports ....................................................................................................... 36 
16.2 
Publication Policy ...................................................................................................... 36 
17 
References ................................................................................................................. 36 
18 
Appendices ................................................................................................................ 37 
18.1 
Measurement of [TIMP-2]*[IGFBP7] .......................................................................... 37 
18.2 
KDIGO criteria ........................................................................................................... 37 

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1 General Information 
1.1 Synopsis 
Title: 
Biomarker-guided implementation of angiotensin-II (AT-II) to 
reduce the occurrence of kidney damage after cardiac surgery  
Short Title: 
Aided-Trial 
Sponsor’s Study Code: 
WWU20_0016 
EudraCT-No.: 
2021-003088-87 
Sponsor: 
Westfälische Wilhelms-Universität Münster 
Investigator: 
Univ.-Prof. Dr. med. A. Zarbock 
Indication: 
Cardiac surgical patients at high risk for AKI 
Study Design: 
Single-centre clinical Trial 
Two-arm, randomised, blinded, controlled, parallel-group trial 
Investigational Medicinal 
Product: 
Test product: Angiotensin II acetat (Giapreza 2,5 mg/ml)  
Reference therapy: Placebo (0.9 % NaCl) 
Therapy 
After identifying cardiac surgery patients at high risk for AKI by 
renin levels (Δ-renin (difference between post- and pre-
operation) ≥ 3.7 µU/ml 4h after CPB) who require vasopressors, 
patients will be randomly allocated to the control or intervention 
group.  
Experimental intervention: Angiotensin II will be added to the 
first-line vasopressor (norepinephrine) and the angiotensin II 
dose and norepinephrine will be adjusted so that the mean 
arterial pressure is above 65 mmHg and the first-line 
vasopressor (norepinephrine) can completely be weaned..  
Control intervention: The control substance (0.9% NaCl) will be 
added to the first-line vasopressor (norepinephrine) and the 
dose of the control substance and norepinephrine will be 
adjusted so that the mean arterial pressure is above 65 mmHg. 
 
The treatment with study medication will be performed for 12 
hours. If the patient requires a vasopressor after the intervention 
period, 
the 
first-line 
vasopressor 
(norepinephrine) 
is 
administered..  
Objectives: 
The primary objective of this trial is to investigate the efficacy of 
AT-II vs. standard of care on the biomarkers [TIMP-2]*[IGFBP7] 
in high-risk patients undergoing cardiac surgery. 
HYPOTHESIS: Superiority of AT-II in cardiac surgery patient 
with a hyperreninemia and vasopressor use compared to 
standard of care with respect to kidney damage (personalized 
approach). 
Endpoints: 
Primary Endpoint:  
 
kidney damage after cardiac surgery identified by the 
difference between [TIMP-2]*[IGFBP7] levels 12h after 

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randomization 
and 
[TIMP-2]*[IGFBP7] 
levels 
at 
randomization 
Secondary Endpoints: 
 occurrence of AKI within 72h after cardiac surgery 
(according to the KDIGO criteria) 
 occurrence of moderate and severe AKI within 72h after 
cardiac surgery (according to the KDIGO stage 2 and 3) 
 amount of volume application 
 transient (<72h) and persistent (<72h) AKI 
 fluid status 
 dose and duration of vasopressor use  
 creatinine clearance on day one after cardiac surgery 
 free-days through day 28 of vasoactive medications and 
mechanical ventilation 
 renal recovery at day 90 (renal recovery is defined as 
serum creatinine levels < 0.5 mg/dl higher than baseline 
serum creatinine (creatinine level before surgery) 
 30-day, 60-day and 90-day mortality 
 length of ICU stay 
 length of hospital stay 
 use and duration of renal replacement therapy within 
hospital stay 
 use of RRT at days 30, 60, 90 
 MAKE90 (major adverse kidney events consisting of 
mortality, 
dialysis 
dependency, 
persistent 
renal 
dysfunction (defined as serum creatinine ≥ 2x compared 
to baseline value) at day 90 
 Effect of ACEi/ARBs use on the AT II effect 
 Correlation between the severity of hyperreninemia and 
the AT II effect 
Other variables: 
 Surveillance of vital parameters on ICU 
 Safety laboratory parameters 
 Occurrence of thromboembolism 
 Adverse events  
Add-on study: 
 
determination of further biomarkers (e.g. KIM-1, 
chitinase, NGAL, hyaluronic acid) and anti- and pro-
inflammatory mediators (IL-6, IL-10…) 
Planned Number of Study 
Centers: 
1 
Number of Patients/ 
Sample size: 
Expected [TIMP-2]*[IGFBP7] level in the control group: 
median=0.84, Q1=0.35, Q3=1.57 and in the AT-II group: 
median=0.58, Q1=0.26, Q3=1.20 (based on Meersch et al., 
Intensive Care Med 2017). A total number of 64 patients will be 
recruited and a number of 32 patients will be randomized to 
each of the two treatment arms. With an expected 5% dropout 
rate, up to 2 patients per treatment arm will be non-evaluable. 
With a number of n=30 evaluable patients per treatment arm, 
the location shift between the distributions of the biomarker 
[TIMP-2]*[IGFBP7] in the AT-II and the control group can be 

AIDED Study Protocol, Final V1.2 
  
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estimated with an expected precision ±0.35ng/ml2/1000 (half-
width of the 95% confidence interval). 
Inclusion Criteria: 
Inclusion criteria for registration 
1. Adult patients scheduled for cardiac surgery with 
cardiopulmonary bypass (CPB),  
2. 18 years of age or older,  
3. cardiac index > 2.1 l/min per square meter,  
4. Written informed consent. 
 
Inclusion criteria for randomization 
Registered patients will be randomized only if  
1. Δ-renin (difference between post- and pre-operation) ≥ 3.7 
µU/ml 4h after CPB. 
2. postoperative hypotension requiring vasopressors 
Exclusion Criteria: 
1. Preexisting AKI (stage 1 and higher) 
2. Patients with cardiac assist devices (ECMO, LVAD, RVAD, 
IABP) 
3. Pregnant women, breastfeeding women and women of 
childbearing potential 
4. Known (Glomerulo-) Nephritis, interstitial nephritis or 
vasculitis 
5. Chronic kidney disease with eGFR < 20 ml/min/1.73m2 
6. Dialysis dependent CKD 
7. Prior kidney transplant within the last 12 months 
8. Emergency surgery in the context of an acute coronary 
syndrome  
9. Hypersensitivity to the active substance, or to any of the 
excipients of the study medication 
10. Bronchospasm 
11. Liver failure 
12. Mesenteric ischemia 
13. Participation in another intervention trial in the past 3 
months 
14. Persons with any kind of dependency on the investigator or 
employed by the institution responsible or investigator 
15. Persons held in an institution by legal or official order 
Visits: 
Screening: 
T1: Screening 
 
T2: Surgery until 4h after terminating CPB 
Treatment: 
T3: Operation Day 
Observation: T4: POD 1 
 
T5: POD 2 
 
T6: POD 3 
 
T7: POD 7/Discharge 
 
T8: Follow-up POD 30 
 
T9: Follow-up POD 60 
 
T10: Follow-up POD 90 
Statistical Methods 
Efficacy:  
The randomized groups will be descriptively compared on all 
baseline variables using summary statistics such as mean and 
standard deviation, median and quartiles, or frequency and 
percentage, as appropriate. In inferential statistical analyses 
two-sided significance tests will be applied with a local 

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Page 8 of 37 
 
significance level alpha=0.05. All point estimates of parameters 
of interest will be supplemented by 95% confidence intervals 
unless otherwise stated. SAS or SPSS statistical software will 
be used for all data analyses.  
Description of the primary efficacy / test accuracy analysis and 
population:  
The primary efficacy analysis will include all randomized 
subjects (full analysis set) and will be performed according to 
the intention-to-treat principle, i.e. all subjects are analyzed in 
the group to which they were randomized. Additional sensitivity 
analyses will be performed according to the per-protocol 
principle. The effect of AT-II versus placebo on the biomarker 
[TIMP-2]*[IGFBP7] will be estimated with a non-parametric 95% 
confidence interval of the location shift between the distributions 
of the biomarker [TIMP-2]*[IGFBP7] in the AT-II and the placebo 
group, respectively.  
Safety:  
Safety data will be evaluated descriptively, including all 
recruited study patients who received at least one dose of study 
therapy (safety population). Results are reported by mean 
parameter estimates and associated 95% confidence intervals. 
Secondary endpoints: 
Statistical analysis of the pre-specified secondary endpoints will 
be performed with descriptive and inferential statistical 
methods.  
Financial Support: 
The project is supported by the DFG  
Schedule 
Planned start date of the study (FPFV): 01.10.2021 
Planned end date of recruitment (LPFV): 15.04.2022 
Planned end date of the study (LPLV): 15.07.2022 
 
Planned recruitment duration: 6,5 months 
Duration of single patient participation: 90 days 
Planned overall duration of the study: 9,5 months 
 
 
 

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1.2 Flow Chart 
 
T1 
T2 
T3 
T4-T6 
T7 
T8 
T9 
T10 
Visit 
S1 
R2 
B3 
OD 
POD 
1-3 
Dis-
charge
/POD 7 
POD 
30 
POD 
60 
POD 
90 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Inclusion and Exclusion criteria 
X 
 
 
 
 
 
 
 
 
Renin measurement before and after cardiac 
surgery (4 hours after cardiopulmonary bypass) 
 
 
X 
X 
 
 
 
 
 
Registration 
 
X 
 
 
 
 
 
 
 
Demographic data 
Age, sex, BMI, comorbidities (EuroSCORE, hypertension, 
coronary artery disease, congestive heart failure, NYHA, 
peripheral vascular disease, diabetes, previous stroke or 
transient ischemic attack, chronic liver disease, chronic kidney 
disease, chronic obstructive pulmonary disease, cancer), 
medication (b-blockers, ACEi/ARBs, diuretics, anticoagulation) 
 
 
X 
 
 
 
 
 
 
Admission diagnosis, Category of admission 
(elective, emergency) 
 
 
X 
 
 
 
 
 
 
Surgical parameters  
nature of surgical procedure, duration of surgical procedure, 
duration of CPB, duration of aortic cross clamp 
 
 
 
X 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
Urinary [TIMP-2]*[IGFBP] measurement  
At randomization and 12 h after start of intervention 
 
 
 
X 
 
 
 
 
 
Intervention / Study medication 
 
 
 
X 
 
 
 
 
 
APACHE II 
 
 
 
X 
 
 
 
 
 
Hemodynamics (MAP, HR, CVP)  
 
 
 
X 
X 
 
 
 
 
Pressors 
 
 
 
X 
X 
 
 
 
 
SOFA-Score 
 
 
 
X 
X 
 
 
 
 
KDIGO criteria 
 
 
 
 
X 
 
 
 
 
Fluid balance / 24h urine volume 
 
 
 
X 
X 
 
 
 
 
Concomitant Medication  
 N-acetylcysteine, amphotericin, aminoglycosides, 
cyclosporine, tacrolimus, radiocontrast agents, diuretics 
 
 
 
X 
X 
 
 
 
 
Safety laboratory test 
Complete blood count, potassium-, sodium-, , creatinine and 
BUN and eGFR, pH, bicarbonate, bilirubin,  CRP, PCT, 
coagulation parameter 
 
 
X 
 
X 
 
 
 
 
Add-on study 
 
 
 
X4 
X5 
 
 
 
 
Mortality 
 
 
 
 
 
X 
X 
X 
X 
Length of stay (ICU, Hospital) 
 
 
 
 
 
X 
 
X 
 
Duration of ventilator support / duration of 
administration of vasopressors 
 
 
 
 
 
X 
X 
 
 
Number of days of RRT/RRT dependence 
 
 
 
 
 
X 
 
 
X 
(Serious) adverse events  
 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
                                               
1 Screening 
2 Registration 
3 Baseline ( prior operation until randomization) 
4 Blood and urine samples will be collected 4h after CPB, 12h and 24h after start of study medication  
5 Blood samples will be collected on POD 2 and 3 

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1.3 Abbreviations 
 
ADL 
Activities of Daily Living 
AE 
Adverse Event  
AMG 
Arzneimittelgesetz 
AKI 
Acute Kidney Injury  
BfArM 
 Federal Institute for Drugs and Medical Devices (Bundesinstitut für 
Arzneimittel und Medizinprodukte) 
CKD 
Chronic kidney disease 
CRRT 
Continuous Renal Replacement Therapy 
CRF 
Case Report Form  
CTCAE 
Common Terminology Criteria for Adverse Events 
DMC 
Data Monitoring Committee  
DSUR 
Development Safety Updat Report 
ICU 
Intensive Care Unit 
eCRF 
Electronic Case Report Form  
FPFV 
First patient first visit 
GCP 
Good Clinical Practice  
 
ICH 
International Conference on Harmonisation of Technical Requirements 
for Registration of Pharmaceuticals for Human Use 
IMP 
Investigational Medicinal Product 
ISF 
Investigator Site File  
KDIGO 
Kidney Disease: Improving Global Outcomes 
ZKS 
 
Zentrum für Klinische Studien 
LPFV 
 
Last patient first visit 
LPLV 
 
Last patient last visit 
NA 
 
Not applicable  
ND 
Not done   
OD 
Operative day 
POD 
postoperative day 
RAAS 
Renin-angiotensin-aldosterone system 
RRT 
Renal Replacement Therapy 
SAE 
Serious Adverse Event   
SAR 
Serious Adverse Reaction  
SAS 
 
Statistical Analysis System 
SOFA 
Sequential Organ Failure Assessment 
SOP 
 
Standard Operating Procedure 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TMF 
 
Trial Master File  
 

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2 Introduction 
Vasoplegic syndrome is a form of distributive shock that is characterized by low arterial 
pressure with reduced systemic vascular resistance and normal or elevated cardiac output[1] 
that occurs in 5 to 25% of patients undergoing cardiac surgery. Patients with vasoplegia after 
cardiac surgery are at higher risk of organ failure, including acute kidney injury (AKI)[2, 3]. 
Postsurgical AKI is associated with several adverse outcomes. Attempts to prevent AKI have 
largely been futile so far. Prior studies often started with the interventions after an AKI event, 
when a decline of kidney function (i.e. glomerular filtration rate) was already established. 
Application of norepinephrine is currently considered as the first-line therapy for vasoplegia, 
but all catecholamines have adverse effects, including myocardial ischemia and 
arrhythmias[4]. In a recent observational trial, we demonstrated that there is a dysregulation in 
the renin-angiotensin-aldosterone system (RAAS) likely caused by a reduced angiotensin-
converting enzyme (ACE) activity after cardiac surgery. Elevated renin levels identified patients 
at risk for AKI and were associated with cardiovascular instability and increased AKI rate after 
cardiac surgery[5]. Furthermore, elevated renin levels could be used to identify high-risk 
patients for cardiovascular instability and AKI who would benefit from timely intervention with 
angiotensin II (AT-II) that could improve their outcomes[5]. Therefore, the application of AT-II 
to treat a postoperative hypotension would mean a hormone substitution. We hypothesize that 
the application of AT-II added to standard of care in cardiac surgery patients with a high risk 
for AKI as identified by AKI biomarkers reduces kidney damage. 
 
2.1 Background Information and Rationale 
Acute kidney injury (AKI) can be defined by changes of serum creatinine and/or urine output, 
according to the KDIGO criteria[6]. In cardiac surgery patients, the AKI rate is up to 30%, with 
1–2% of patients requiring renal replacement therapy (RRT)[7-9]. Cardiac-surgery associated 
AKI (CSA-AKI) is associated with increased short- and long-term morbidity and mortality as 
well as increasing hospital costs[7-9]. 
Shock after cardiac surgery is associated with increased mortality[10, 11]. Cardiopulmonary 
bypass (CPB) represents a common clinical setting of sympathetic nervous system activation 
and cardiovascular instability. Vasoplegia is a form of distributive shock that is characterized 
by low arterial pressure with reduced systemic vascular resistance and normal or elevated 
cardiac output[1]. It occurs in 5 to 25% of patients undergoing cardiac surgery. Patients with 
vasoplegia after cardiac surgery are at higher risk of organ failure, including AKI, and have an 
increased mortality rate and longer hospital length of stay[2, 3].  
Application of norepinephrine is currently considered as the first-line therapy for vasoplegia but 
all catecholamines have adverse effects, including myocardial ischemia and arrhythmias[4]. In 
addition, in vasoplegic states, vascular smooth muscle cells may become unresponsive to 
catecholamines. The underlying mechanisms are complex and include adrenoceptor 
desensitization, increased nitric oxide synthesis, activation of adenosine triphosphate–
sensitive K+ channels, and vasopressin and corticosteroid deficiency[12]. 
The renin-angiotensin-aldosterone system (RAAS) is a hormone system that plays a central 
role in regulating blood pressure and fluid, glomerular filtration rate, and electrolyte balance[13, 
14]. Renin, a proteolytic enzyme released by juxtaglomerular cells in response to hypotension, 
decreases sodium delivery to the distal tubule, activates the sympathetic nerve system, and 
cleaves angiotensinogen to angiotensin (AT)-I which is a precursor of the vasoactive AT-II. 
The RAAS system is regulated by a biofeedback loop. AT-II generation inhibits renin release, 
whereas renin levels increase when there is insufficient activation of the AT-II type 1 receptor. 
Administration of Angiotensin Converting Enzyme (ACE) inhibitors and AT-II receptor blockers 
and reduced AT-II generation cause a corresponding increase in renin levels.[15, 16] 
Despite numerous clinical trials using several interventions, [17] a reliable means to prevent 
AKI remains elusive. Clinical trials focusing on septic patients suggest that AT-II is a potent 
vasopressor. However, no human data exist whether the application of AT-II in high-risk 

AIDED Study Protocol, Final V1.2 
  
Page 12 of 37 
 
patients identified by renin levels (individualized approach) reduces kidney damage and 
improves kidney function after cardiac surgery. Furthermore, leukocyte function and mediators 
modulating inflammation will be investigated in an add-on study.  
 
2.2 Risk-Benefit Analysis 
Patients included in this trial are at high risk for AKI. Currently, there is no pharmacologic option 
available to prevent the development of AKI. However, it is well known that AKI is associated 
with an 8-fold increased risk for the development of chronic kidney disease (CKD) as well as 
end-stage renal disease and an increased risk for mortality.  
AT-II is a synthetic peptide hormone which is approved for refractory hypotonia in adults in 
septic or other forms of distributive shock. Vasoplegia, the clinical condition treated in this 
clinical trial, is a form of distributive shock. Preliminary data have shown that treatment with 
AT-II reduced hyperreninemia in cardiac surgical patients with vasoplegia. As hyperreninemia 
is supposed to be associated with AKI [5], it is conceivable that a treatment of AT-II reduces 
kidney damage. Known interactions or side effects of AT-II are limited to thromboembolic 
complications. Therefore, patients with any form of prothrombotic conditions will not be 
included in this trial. Moreover, patients with hypersensitivity to the active substance, or to any 
of the excipients of the study medication will be excluded from the trial. The application of AT-
II will be gradually decreased since patients may experience hypotension or worsening of the 
underlying diagnosis of shock on abrupt withdrawal or premature discontinuation if 
complications occur that might be related to the use of AT-II. The burdens and predictable risks 
will be closely supervised by the treating physicians. To mitigate the risk of thromboembolic 
events in the clinical trial laboratory tests of coagulation (e.g. PTT, INR, Thrombocytes and – 
if applicable antifactor Xa are implemented to detect and treat hypercoagulation during the 
treatment period (see 8.4.3 Rescue Medication and Emergency Measures). Furthermore – 
depending on the operation and the previous illnesses – all patients are started with at least 
prophylactic anticoagulation on the first evening. 
 
Patients assigned to the control group receive only standard care and may not have a 
treatment benefit. However, since a renoprotective effect is still unknown, patients participating 
in the trial have the same risks as not participating in the trial. Patients with vasoplegia receive 
vasopressors in order to increase the systemic vascular resistance (SVR) and subsequently 
the mean arterial blood pressure (MAP). This ensures organ perfusion and oxygen delivery. 
Norepinephrine is currently the first-line treatment to treat vasoplegia induced by different 
causes. However, other vasopressors are also available which can increase the SVR and 
MAP. Although the available vasopressors (norepinephrine, vasopressin, angiotensin II) have 
different mode of actions, they are all used to secure organ perfusion. As both groups 
(intervention group and control group) have the same MAP target, leaving out norepinephrine 
and replacing it by another vasopressor is without an increased risk for the patient. 
 
This trial may result in a substantial improvement in the management of patients at risk of AKI 
with a potential improvement of patients’ outcome. A participation in this trial will not influence 
the therapeutic treatment of patients after cardiac surgery. All patients receive standard 
treatment according to the current standards. 
 
3 Objectives and Endpoints 
 

AIDED Study Protocol, Final V1.2 
  
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3.1 Objectives 
3.1.1 Primary Objective 
The primary study outcome is kidney damage after cardiac surgery identified by measuring the 
biomarkers [TIMP-2]*[IGFBP7] in high risk. 
 
3.1.2 Secondary Objectives 
Secondary objectives include: 
 
 
Occurrence of AKI  
The rate of AKI within 72h after cardiac surgery will be evaluated according to the 
KDIGO guidelines using both serum-creatinine and/or urinary output criteria. 
 
 
Occurrence of moderate and severe AKI within 72h after cardiac surgery  
The rate of moderate and severe AKI within 72h after cardiac surgery will be evaluated 
according to the KDIGO stages 2 and 3 . 
 
 
Creatinine clearance on day one after cardiac surgery 
 
 
Free days through days 28 of vasoactive medications and mechanical ventilation 
 
 
Renal recovery at day 90 
Recovery of renal function will be defined as serum creatinine levels < 0.5 mg/dl higher 
than baseline (level prior to surgery). 
 
 
Mortality at day 30, 60, and 90 
 
 
Vasopressor use 
 
 
Fluid application and volume status 
 
 
ICU length-of-stay AND Hospital length-of-stay 
Both ICU and hospital length-of-stay will be defined based on the ICU and acute 
hospital admissions during patients’ randomization. Length-of-stay will be evaluated on 
the basis of both the mean number of days of ICU/hospital stay following randomization 
and Kaplan- Meier survival, censored for patient drop out or death. Hospital discharge 
will be defined as discharge from acute care, whether to acute rehabilitation, transitional 
care, long-term care or home. 
 
 
Use and duration of renal replacement therapy within 72h after cardiac surgery, and 
30, 60 and 90 days after randomization 
The duration of renal support will be defined as the number of days from the initiation 
of RRT to final dialysis treatment (last data collection 90 days after randomization). 
Duration of renal support will be censored if the patient is still dialysis dependent at the 
time of death. Duration of renal support will be evaluated on the basis of both the mean 
number of days of renal support and Kaplan-Meier survival, censored for patient death. 
The optimal outcome in AKI is the ability of the patient to return to his or her prior living 
situation not requiring RRT on an ongoing basis. 
 
 
Major adverse kidney events at day 90 
Major adverse kidney event (MAKE) will be defined as the composite of death, use of 
renal replacement therapy and persistent renal dysfunction (defined as serum 

AIDED Study Protocol, Final V1.2 
  
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creatinine ≥ 2x compared to baseline value) at day 90. 
 
3.1.3 Additional Research Program 
To understand the mechanisms of illness and recovery and how AT-II affects them, further 
biomarkers will be measured (e.g. KIM-1, NGAL, renin, HA and anti- and proinflammatory 
mediators (IL-6, IL-10…)). Blood and urine samples from recruited patients will be collected 4h 
after CPB, 12h, and 24h after start of intervention. The details of the additional research 
program will be contained in a separate plan, which will be finalized before the final analysis. 
 
3.2 Endpoints 
 
3.2.1 Primary Endpoint 
The primary study endpoint is 
- 
Difference between [TIMP-2]*[IGFBP7] levels 12h after randomization and [TIMP-
2]*[IGFBP7] levels at randomization. 
 
  
3.2.2 Secondary Endpoints 
 occurrence of AKI within 72h after cardiac surgery (according to the KDIGO criteria) 
 occurrence of moderate and severe AKI within 72h after cardiac surgery (according to 
the KDIGO stage 2 and 3) 
 amount of volume application within 12h after randomization 
 fluid status 12h after randomization 
 dose of vasopressor use during intervention 
 creatinine clearance on day one after cardiac surgery 
 free-days through day 28 of vasoactive medications and mechanical ventilation 
 renal recovery at day 90 (renal recovery is defined as serum creatinine levels < 0.5 
mg/dl higher than baseline serum creatinine (creatinine level before surgery) 
 30-day, 60-day and 90-day mortality 
 length of ICU stay 
 length of hospital stay 
 use and duration of renal replacement therapy within hospital stay 
 use of RRT at days 30, 60, 90 
 MAKE90 (major adverse kidney events consisting of mortality, dialysis dependency, 
persistent renal dysfunction (defined as serum creatinine ≥ 2x compared to baseline 
value) at day 90 
 Effect of ACEi/ARBs use on the AT II effect 
 Correlation between the severity of hyperreninemia and the AT II effect 
 
 Other variables: 
 
Surveillance of vital parameters on ICU 
 
Safety laboratory parameters 
 
Occurrence of thromboembolism 
 
Adverse events  
Add-on study: 
 
determination of further biomarkers (e.g. KIM-1, chitinase, NGAL, renin, hyaluronic 
acid and anti- and pro-inflammatory cytokine levels (IL-6, IL-10…), leukocyte 
functions 

AIDED Study Protocol, Final V1.2 
  
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4 Study Design 
The Aided-trial is a single center, prospective, interventional, phase IIIa, two-arm parallel 
group, randomized-controlled, double blinded trial including 64 patients at high risk for the 
development of AKI after cardiac surgery with CPB.  
 
Discussion of trial design 
To the best of our knowledge, no trial has been performed investigating the effect of AT-II on 
kidney damage in patients at high risk for AKI undergoing cardiac surgery. Our preliminary 
data demonstrate that elevated renin levels were associated with cardiovascular instability and 
increased rates of AKI after cardiac surgery. In order to investigate whether AT-II can also 
prevent kidney damage in high-risk patients undergoing cardiac surgery, we will perform a 
feasibility trial. If we can demonstrate that AT-II mitigates kidney damage in high-risk patients 
undergoing cardiac surgery, a follow-up trial could investigate whether AT-II can significantly 
reduce the occurrence of AKI after cardiac surgery. Therefore, this study is necessary to 
demonstrate that biomarker-guided implementation of AT-II can mitigate kidney damage after 
cardiac surgery. If the trail is positive, we will use the data and study protocol to apply for an 
interventional trial showing that renin-level-guided AT-II application reduces kidney damage 
after cardiac surgery. 
 
5 Study Sites and Study Population  
5.1 Study Site Selection 
The study will be performed as a single-center randomized-controlled trial. The Department of 
Anesthesiology, Intensive Care and Pain Medicine at the University Hospital of Muenster has 
a lot of experience with randomized-controlled trials. The study team consists of experienced 
investigators and study nurses. The measurement of [TIMP-2]*IGFBP7] will be performed with 
the NephroCheck test (Astute, San Diego, CA, USA) which is available at the corresponding 
cardiac surgical ICU. The IMP will be prepared and the applied through independent personnel 
to ensure blinding of the process. 
 
5.2 Study Population 
Patients at high risk for AKI after cardiac surgery with CPB will be identified by hyperreninemia 
(-renin (difference between post- and pre-operation) ≥ 3.7 µU/ml 4 h after CPB).   
 
5.2.1 Inclusion Criteria  
Inclusion criteria for registration 
1. Adult patients undergoing cardiac surgery with CPB 
2. 18 years of age or older 
3. Cardiac index > 2.1 l/min per square meter 
4. Written informed consent 
Inclusion criteria for randomization 
Registered patients will be randomized only if 
1. -renin (difference between post- and pre-operation) ≥ 3.7 µU/ml 4 h after CPB 
2. Postoperative hypotension requiring vasopressors 
 
5.2.2 Exclusion Criteria  
1. Preexisting AKI (stage 1 and higher) 

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2. Patients with cardiac assist devices (ECMO, LVAD, RVAD, IABP) 
3. Pregnant women, nursing women and women of childbearing potential 
4. Known (Glomerulo-) Nephritis, interstitial nephritis or vasculitis 
5. CKD with eGFR < 30 ml/min 
6. Dialysis dependent CKD 
7. Prior kidney transplant within the last 12 months 
8. Emergency surgery in the context of an acute coronary syndrome 
9. Hypersensitivity to the active substance, or to any of the excipients of the study 
medication 
10. Bronchospasm 
11. Liver failure 
12. Mesenteric ischemia 
13. Participation in another intervention trial in the past 3 months 
14. Persons with any kind of dependency on the investigator or employed by the institution 
responsible or investigator 
15. Persons held in an institution by legal or official order 
 
5.2.3 Distribution of Gender in the Study Population 
We expect a gender distribution of (male: female) 70:30. No patient will be excluded from the 
study on the basis of gender. Gender will be used for covariate adjustment in the final analysis. 
A subgroup analysis will be performed according to gender. 
 
6 Patient Inclusion, Registration and Randomization   
Patients who are cared for at the study sites and who are possibly eligible will be invited for 
study participation until the desired number of patients is achieved. Once written informed 
consent for participation has been given (cf. section 15.215.2), a subject identification code will 
be assigned. 
 
After successful registration, when patients meet all designated inclusion criteria (including 
identifying a high risk patient (-renin (difference between post- and pre-operation) ≥ 3.7 µU/ml 
4 h after CPB), and none of the exclusion criteria, patients will be randomized using an internet-
based randomization tool at https://www.randomizer.at. Randomization will be performed in a 
proportion of 1:1.  
The time interval between patient fulfilling eligibility criteria and start of infusion may not exceed 
30 minutes. 
 
7 Study Medication 
7.1 Investigational Medicinal Product:  
The trial sites will use the study medication as article of trade, which will be used routinely in 
the hospital. 
Patients randomized to the intervention group will receive AT-II (10,000ng/ml Giapreza) for 
12 h after randomization. The starting dose will be 20 ng/kg/min and the dose will be adjusted 
(up to 80 ng/kg/min) so that the other vasopressors can completely weaned and the mean 
arterial pressure is > 65 mmHg. Patients randomized to the control group will receive placebo 
(0.9 % NaCl). 
 
7.1.1 Drug Characterization  
7.1.1.1 Name of the medicinal product 
Giapreza, concentrate for solution for infusion 

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Control/Placebo: Isotone Natriumchloridlösung 0,9 % Braun  
Infusionslösung. 
 
7.1.1.2 Qualitative and quantitative composition 
Giapreza,  
1 ml contains:  
Active substance Quantity  
Angiotensin-II-Acetat 2.5mg 
osmolarity: 130 to 170 mOsmol/kg  
pH value: 5.0 - 6.0 
 
 
Control/Placebo: 
100 ml contains: Natrium chloride: 0,9 g 
Electrolyte concentrations: Na+: 154 mmol/l, Cl-: 154 mmol/l 
Theoretical osmolarity: 308 mosmol/l 
Titration acidity (pH 7,4): < 0,3mmol/l 
 
7.1.1.3 List of excipients 
Giapreza:  
Excipients: Mannitol, Water for injections, Sodium hydroxide (for pH adjustment), 
Hydrochloric acid (for pH adjustments 
 
Control/Placebo: 
Water for injections 
 
7.1.1.4 Pharmacodynamic properties 
Giapreza 
Angiotensin II (AT II)increases blood pressure by vasoconstriction; the increased release of 
aldosterone by direct action of AT-II on the vessel wall is mediated by binding to the G-protein-
coupled AT-II receptor type 1 on vascular smooth muscle cells, stimulating Ca2+/calmodulin-
dependent phosphorylation of myosin and causing smooth muscle contraction. 
GIAPREZA is titrated for each individual patient by effect. In the ATHOS-3 study, the median 
time to increase in blood pressure was approximately 5 minutes. The effect on blood pressure 
is sustained for at least the first three hours of continuous intravenous infusion. Because of the 
short half-life of GIAPREZA (less than one minute), abrupt discontinuation of AT may result in 
rebound hypotension. 
Therefore, after sufficient improvement of the underlying shock, slow down-titration in 
increments of up to 15 ng/kg per minute, as controlled by blood pressure values, is 
recommended as needed. 
 
Control/Placebo: 
Sodium is the major cation of the extracellular fluid space and regulates its size along with 
various anions. Sodium and potassium are the main carriers of bioelectrical processes in the 
organism. 
The sodium content and fluid metabolism of the organism are closely linked. Any change in 
plasma sodium concentration that deviates from the physiological level simultaneously 
influences the fluid status of the organism. Regardless of the serum osmolality, an increased 
sodium content means an increased fluid content or a reduced sodium content of the organism 
a decrease in body water. 
A 0.9% sodium chloride solution corresponds to plasma osmolarity. Upon delivery of this 
solution, it comes first to replenish the interstitium, which makes up about 2/3 of the 

AIDED Study Protocol, Final V1.2 
  
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extracellular space. Only about 1/3 of the volume delivered remains intravasal. The solution is 
thus hemodynamically effective only for a short time. 
 
7.1.1.5 Pharmacokinetic properties 
Giapreza 
No specific studies have been conducted to investigate the metabolism and excretion of 
GIAPREZA. The half-life of intravenously administered AT-II in plasma is less than one minute. 
It is metabolized by end cleavage (at both the amino and carboxy terminals) in various tissues, 
including erythrocytes, plasma, and major organs (e.g., intestines, kidneys, liver, and lungs). 
No trials have been conducted to investigate the pharmacoginetics of AT-II in renally impaired 
patients and/or in patients with hepatic impairment since the kidneys and the liver are not a 
major organ for AT-II metabolism or excretion.  
 
 
7.1.1.6 Shelf-life 
Giapreza 
3 years. 
To be used immediately after the bottle is opened.  
Giapreza is not to be stored after addition of other components. 
 
Control/Placebo: 
3 years.  
To be used immediately after the bottle is opened. 
 
For microbiological reasons, the ready-to-use preparations should be used immediately. 
Normally, blends with other components should not be stored for more than 24 hours at 2°C – 
8°C unless they have been prepared under controlled and validated aseptic conditions  
 
7.1.1.7 Special precautions for storage 
Giapreza 
Store in a refrigerator ( 2-8°C). For storage conditions after dilution of the medicinal product 
see 7.1.1.6. 
 
Control/Placebo: 
This medicinal product does not require special storage conditions. 
 
7.1.1.8 Marketing authorization holder 
Giapreza: PAION AG, Aachen, Deutschland 
 
Control/Placebo: B. Braun Melsungen AG, Melsungen, Deutschland 
 
7.1.1.9 Marketing authorization numbers 
Giapreza: EU/1/19/1384/001; EU/1/19/1384/002; EU/1/19/1384/003 
 
Control/Placebo (Isotone Natriumchloridlösung 0,9% Braun): 6697366.00.00; 
6726174.00.00 
 
7.1.2 Contraindications 
Giapreza: Hypersensitivity to the active substance or to any of th excipients listed in 7.1.1.2 
 
Control/Placebo:  

AIDED Study Protocol, Final V1.2 
  
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None 
 
7.1.3 Special Warnings and precautions for use 
Giapreza 
The clinical experience with GIAPREZA is limited to septic or other distributive shock. The use 
of GIAPREZA is not recommended in other types of shock (e.g. cardiogenic shock, etc 
aspatients with non-distributive shocks were excluded from clinical trials. 
Thromboembolic events have reported with the use of angiotensin II in clinical trials. The major 
imbalance compared to placebo was in venous thromboembolism (6.1% vs 0%). Concurrent 
venous thromboembolism prophylaxis should be used unless contraindicated during treatment 
with GIAPREZA. Non-pharmacologic venous thromboembolism prophylaxis may be 
considered where pharmacologic prophylaxis is contraindicated. 
Peripheral ischaemia has been reported with the use of AT-II. It is important to administer 
GIAPREZA at the lowest compatible dose to achieve or maintain adequate mean arterial 
pressure and tissue perfusion. 
 
Control/Placebo: 
Isotonic sodium chloride solution 0,9% should be used with caution in 
- Hypernatremia 
- hyperchloremia 
 
7.1.4 Interaction with other Medicinal Products and other Forms of Interaction 
Giapreza:  
No interaction studies have been performed. No invitro metabolism studies have been 
performed with GIAPREZA. 
Concomitant administration of GIAPREZA and other vasopressors may have an additive effect 
on mean arterial pressure (MAP). The addition of GIAPREZA may require a reduction in doses 
of other vasopressors. 
Patients who have recently received angiotensin converting enzyme (ACE) inhibitors may be 
more sensitive to GIAPREZA’s action with an increased response. Patients who have recently 
received angiotensin II receptor blockers (ARBs) may be less sensitive to GIAPREZA’s actions 
with a reduced response 
 
Control/ Placebo:  
No interactions are known to date. 
 
7.1.5 Undesirable Effects 
Giapreza: The most frequent adverse reactions (≥1/10) reported more often are 
thromboembolic events (12.9% vs 5.1%) and transient hypertension. Common adverse 
reaction ((≥1/100 to < 1/10) were Tachycardia and peripheral ischaemia.) 
 
 
Control/Placebo: Side effects are not expected under normal use. 
 
7.1.6 Administration 
After identifying cardiac surgery patients at high risk for AKI by renin levels, patients will be 
randomly allocated to the control or intervention group. 
 
Giapreza 
Solution for infusion after mixture with a compatible infusion solution should be infused via the 

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central venous route.  
 
Daily dose 
Giapreza will be added to the first-line vasopressor (norepinephrine) and the dose will be 
adjusted so that the mean arterial pressure is above 65 mm Hg and first-line vasopressor can 
be weaned to a low level. The recommended starting dosage of GIAPREZA is 20 nanograms 
(ng)/kg per minute via continuous intravenous infusion. 
GIAPREZA must be diluted in sodium chloride 9 mg/ml (0.9%) solution for injection prior to 
use. One or two millilitres of GIAPREZA must be diluted in sodium chloride 9 mg/ml (0.9%) 
solution for injection to achieve a final concentration of 5,000 ng/ml or 10,000 ng/ml. 
 
When initiating GIAPREZA, it is important to closely monitor blood pressure response and 
adjust dose accordingly. 
Once an infusion has been established, the dose may be titrated as frequently as every 5 
minutes in steps of up to 15 ng/kg per minute, as needed, depending on the patient’s condition 
and target mean arterial pressure. Approximately one in every four patients experienced 
transient hypertension with the angiotensin II 20 ng/kg per minute starting dose in clinical trials 
(see 7.1.5), thus needing dose down-titration. For critically ill patients, the usual target mean 
arterial pressure is 65 – 75 mmHg. Do not exceed 80 ng/kg per minute during the first 3 hours 
of treatment. Maintenance doses should not exceed 40 ng/kg per minute. Doses as low as 
1.25 ng/kg per minute may be used. 
It is important to administer GIAPREZA at the lowest compatible dose to achieve or maintain 
adequate arterial blood pressure and tissue perfusion (see 7.1.3). The median duration of 
treatment in clinical trials was 48 hours (range: 3.5 to 168 hours). 
In order to minimise the risk of adverse events derived from prolonged vasoconstriction, 
treatment with GIAPREZA should be withdrawn once underlying shock is sufficiently improved 
(see 7.1.3 and 7.1.5). Down-titrate by gradual decrements of up to 15 ng/kg per minute, as 
needed, based on blood pressure, in order to avoid hypotension due to abrupt withdrawal (see 
7.1.3). 
 
Control/Placebo 
The Placebo will be added to the first-line vasopressor (norepinephrine) and the dose of the 
control substance will be adjusted so that the mean arterial pressure is above 65 mm Hg. 
 
 
7.1.7 Dose Selection Rationale 
Patients allocated to the intervention group will receive Giapreza according to the package 
leaflet for a time of 12h. 
 
7.1.8 Dose Modification 
In case of the occurrence of expected or unexpected side effects, GIAPREZA should be 
gradually decreased since patients may experience hypotension or worsening of the 
underlying diagnosis of shock on abrupt withdrawal or premature discontinuation. 
 
7.1.9 Overdose 
Overdose may result in severe hypertension. Down-titration of therapy, careful observation, 
and initiation of appropriate supportive measures are the indicated treatment of overdose of 
angiotensin II. Hypertensive effects are expected to be brief because the half-life of angiotensin 
II is less than one minute. 
 

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7.1.10 Manufacturing, Blinding and Labeling 
The trial site will use the study medications as article of trade, which will be used routinely in 
the hospital. Labeling and blinding will be performed by medical staff who are independent 
from the AIDED investigational team. Fluids and matching placebo will be packaged in identical 
drug syringes. Each package will contain 250 ml of fluids and will be labeled with a subject 
identification number. 
 
 
7.1.11 Supply, Drug Accountability, Storage Conditions, Disposal 
Giapreza from PAION AG will be used. The study site is responsible for ordering GIAPREZA 
at least 7 working days before it is needed. At the study site the receipt of Giapreza including 
date of receipt, amount, batch number and expiry date will be documented. The investigator is 
responsible for the correct storage at the study site in a locked room. GIAPREZA must be 
stored at 2 to 8°C.  
For each dispensed GIAPREZA or Control/Placebo to a patient, the subject identification code, 
the date of release, the batch number, and the expiry date will be recorded on the drug 
accountability form. 
 
 
8 Treatment Plan 
8.1 Treatment Plan 
Renin will be measured 4h after CPB. Patients with a -renin (difference between post- and 
pre-operation) ≥ 3.7 µU/ml 4 h after CPB are at high risk and will be randomized. Immediately 
after randomization (not longer than 30 min after fulfilling eligibility criteria), patients will receive 
intravenous infusions with the investigational drug or the control drug, according to 7.1.6. 
 
8.2 Dose Modification/ Termination of Treatment 
For dose modification see 7.1.8.  
When the treatment is terminated, the nature of the termination must be documented 
(scheduled end or premature termination/discontinuation). In the event of premature 
termination/discontinuation, justification has to be given and it is to be recorded who took the 
decision to discontinue. 
 
8.3 Control of Patients Compliance  
It is not necessary to control/monitor the patient compliance. The administration of the 
investigational medicinal product is carried out exclusively by the investigator and/or the 
attending physician and is controlled by these persons and documented in the medical record. 
 
8.4 Concomitant Medication / Therapy  
The concomitant medication is not restricted. 
 
8.4.1 Permitted Concomitant Medication / Therapy 
Any medication / therapy for the treatment of the underlying disease is allowed. 
 

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8.4.2 Forbidden Concomitant Medication / Therapy 
There is no forbidden concomitant medication / therapy. 
 
8.4.3 Rescue Medication and Emergency Measures 
Thromboembolic events are very common side effects of Angiotensin II in distributive shock. 
To mitigate the risk of thromboembolic events laboratory tests of coagulations are implemented 
at regular time points.  
 
Patients with normal risk profile will receive prophylactic heparine (unfractionated heparin or 
low-molecular weight heparin. 
The target apTT will be 40-60 s (unfractionated heparin). 
The target antifactor Xa will be 0.1-0.39 IU/ml. 
 
Patients with higher risk profiles and/or therapeutic heparin have the following thresholds: 
Target aPTT: 60-100 s 
Target antifactor Xa: 0.4 – 0.90 IU/ml 
  
 
 
 
8.5 Pregnancy, Breast Feeding and Fathering of a Child 
As there is currently insufficient data on administration of GIAPREZA to pregnant women, 
nursing mothers and children, administration of GIAPREZA is not recommended. 
This study does not include pregnant women. For women of childbearing potential, a 
pregnancy test must be performed before inclusion in the clinical trial. Inclusion in the clinical 
trial is not possible if the test result is positive.  
Breastfeeding women are also not included in the study. 
 
8.6 Continuation of Treatment after the End of the Clinical Trial 
Specific post-treatment is not required. The study interventions do not have consequences for 
the subsequent medical care. According to the current state of knowledge, there is no 
indication for the occurrence of long-term consequences after a therapy with Giapreza. 
Nevertheless, a follow-up at day 30 and 90 will be conducted to clarify the objectives of the 
clinical trial.  
The further treatment is carried out according to the local standard of the study site.  
 
8.7 Unblinding 
Emergency unblinding can be done through the randomizer through dedicated authorized 
personnel (Investigator / Safety Desk ). To unblind a randomization, first display the list of 
randomizations (using the "Randomizations" link from the menu), then, in the row 
corresponding to the randomization to unblind, click on the "Unblind" link. Enter a reason why 
you want to break the randomization's blinding, confirm the operation by entering your 
password and click on the "Unblind" button. The randomization details, including the treatment 
name, will be displayed and users subscribed to unblind notifications will be notified. 
 
Unless the trial user has the access right to unblind randomizations of all sites, only 
randomizations made by the user's site can be unblinded. 

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In case the Randomizer is not available the trial coordinator saved a local copy of the treatment 
codes (blinding tables) for emergency purposes. 
 
Unblinding may only occur when this is relevant for the safety of the patient. Any premature 
code break (e.g. unblinding due to a Serious Adverse Event, accidental unblinding) should 
promptly be documented and reported to the sponsor including explanation/justification. 
 
9 Study Conduct and Study Assessments 
 
9.1 Screening (and Baseline) Visit 
All patients scheduled for cardiac surgery with CPB will be documented in a screening log. If 
a patient fulfills all inclusion criteria and does not have any exclusion criteria ("eligible"), it 
should be documented in the screening log whether inclusion in the clinical trial has occurred. 
If the patient is not included in the clinical trial, the cause should be documented in the 
screening log.  
A patient must provide written consent before undergoing any protocol-required assessments. 
 
T1 Screening (Day -1) 
 Verification of in-/exclusion criteria, including informed consent 
 
Registration  
Registration of patient 
 
T1 Baseline (after registration) 
 Demographic data, admission diagnosis, category of admission 
 Safety laboratory test 
 Concomitant medication 
 
9.2 Intermediate Visits 
T2 Baseline (during surgery until 4 h after terminating CPB) 
 Nature of surgical procedure 
 Time of skin incision, time of skin suture 
 Duration of CPB 
 Duration of aortic cross clamp 
 Fluid input and output 
 Hemodynamics (MAP, HR, CVP) 
 Concomitant Medication / Pressors 
 
T3 End of surgery until the 1st post-operative morning 
 APACHE II 
 SOFA-Score 
 Hemodynamics 
 Concomitant medication / Pressors 
 Urinary [TIMP-2]*[IGFBP] measurement (at randomization and 12 h after start of 
intervention) 
 Urinary renin test 
 Blood and urine samples for laboratory evaluations (4 h after CPB, 0, 12, and 24 h after 
randomization) 
 

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 Randomization (after obtaining 4h renin test result) 
 Start of study medication 
 IMP-application 
 Fluid input and output 
 KDIGO-criteria 
 Adverse events / reactions 
 Transfer to ICU/intermediate care 
 
T4 – T6 1st, 2nd and 3rd post-operative morning 
 Safety laboratory test 
 SOFA-Score 
 KDIGO-criteria 
 Hemodynamics (MAP, HR, CVP) 
 Fluid input and fluid output 
 Concomitant Medication / Pressors 
 Plasma samples for laboratory evaluation (POD 2 and POD 3) (Add-on-Trial) 
 Adverse events / reactions 
 
9.3 Study Termination Visit 
7 4th until 7th post-operative morning, or hospital discharge, whatever occurs first 
 Need of RRT 
 Length of stay (ICU, Hospital) 
 Duration of ventilator support 
 Major adverse kidney events 
 Adverse events / reactions 
 
 
9.4 Follow up 
T8 (day 30 after surgery ±5 days) 
 KDIGO criteria 
 Duration of ventilator support 
 Mortality 
 
T9 (day 60 after surgery ±10 days) 
 Mortality 
 Need of RRT 
 Length of hospital stay/ICU stay (if not already documented at T6) 
 
T10 (day 90 after surgery ±14 days) 
 Mortality 
 Need of RRT 
 Major adverse kidney events 
 
9.5 Study Assessments 
 
Blood and urine samples for Add-o-Trial 
Blood and urine samples will be collected at 4h after CPB and at 0, 12, and 24h after 
randomization through routinely placed catheters. The samples will be centrifuged and stored 
immediately at -80°C until measurement of biomarkers (e.g. NGAL, KIM-1). New renal 
biomarkers will be assessed. For this the samples will be stored not more than 10 years. 
 
Safety laboratory test 

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- 
complete blood count (thrombocytes included), 
- 
potassium-, sodium-, ionized and total calcium levels 
- 
creatinine, creatinine-clearance, BUN and eGFR, 
- 
pH, bicarbonate 
- 
bilirubine,  
- 
CRP 
- 
PCT 
- 
Coagulation parameter (INR, prothrombin time, thrombin time, fibrinogen, 
antithrombin) 
 
 
Acute kidney injury 
- 
AKI will be defined according to the KDIGO criteria (see 18.1.2) 
 
 
Length of hospital stay 
- 
Cumulative days from hospital admission until hospital discharge 
 
 
Length of ICU stay 
- 
Cumulative days from ICU admission until ICU discharge 
 
 
Major adverse kidney events (MAKE) 
- 
combined endpoint consisting of mortality, dialysis dependency, persistent renal 
dysfunction (defined as serum creatinine ≥ 2x compared to baseline value) at day 
90 
 
10 Assessment of Efficacy and Safety 
10.1 Assessment of Efficacy 
Kidney damage after cardiac surgery identified by the difference between [TIMP-2]*[IGFBP7] 
levels 12h after start of study medication and [TIMP-2]*[IGFBP7] levels at randomization 
 
To understand the mechanisms of illness and recovery and how AT-II affects them, markers 
of inflammation, oxidative stress, cellular hypoxia, and coagulation will be measured. 
Furthermore, leukocyte functions will be investigated. 
 
10.2 Assessment of Safety  
10.2.1 Definitions 
Adverse Events are defined according to the Directive 2001/20/EC, the European Detailed 
Guidance CT 3, corresponding to the relevant German definitions in the GCP-Verordnung.  
 
Adverse Event (AE) 
An adverse event is any untoward medical occurrence in a patient or clinical trial subject 
administered an investigational medicinal product and which does not necessarily have a 
causal relationship with this treatment.  
Thus, any new unfavourable and unintended sign, symptom or disease, or clinically significant 
increase in the intensity of an existing sign, symptom or disease, should be considered as an 
AE, whether or not considered related to the investigational medicinal product. 
A pathological finding, improved or unchanged in comparison to its status before first 
administration of the study drug, does not constitute an adverse event. 

AIDED Study Protocol, Final V1.2 
  
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Adverse Reaction (AR) 
An adverse reaction is any untoward and unintended response to an investigational medicinal 
product related to any dose administered. 
All adverse events judged by either the reporting investigator or the sponsor as having a 
reasonable causal relationship to a medicinal product qualify as adverse reactions. The 
expression reasonable causal relationship means that there is evidence or argument to 
suggest a causal relationship. 
The definition covers also medication errors and uses outside what is foreseen in the protocol, 
including misuse and abuse of the product. 
 
Serious Adverse Event (SAE) 
A serious adverse event is any untoward medical occurrence or effect that at any dose 
1. 
results in death 
2. 
is life-threatening at the time of the event 
3. 
requires inpatient hospitalisation or prolongation of existing inpatient hospitalisation 
4. 
results in persistent or significant disability or incapacity, 
5. 
is a congenital anomaly or birth defect. 
lnpatient hospitalisation is defined as any stay in hospital on the part of a trial subject that 
includes at least one night (midnight to 06:00). 
Hospitalisation without underlying adverse event is not an SAE, e.g. admission to hospital as 
an inpatient planned before the first administration of the investigational treatment, for a pre-
existing condition that has not worsened. Such a situation must be documented in the proper 
manner in the trial subject's medical records and eCRF. 
6. 
Medical judgment should be exercised in deciding whether an adverse event is serious in 
other situations. Important adverse events that are not immediately life-threatening or do 
not result in death or hospitalization but may jeopardize the subject or may require 
intervention to prevent one of the other outcomes listed in the definition above, may also 
be considered serious. 
For reasons of drug safety, the occurrence of a pregnancy during the conduct of this trial is to 
be regarded as serious. 
 
Unexpected Adverse Reaction 
“Unexpected” means that the nature, severity or outcome of the adverse reaction is not 
consistent with the applicable product information for the investigational medicinal product. 
 
Expected ARs are listed in the reference document, passage 4.8, Undesirable effects. 
Reference document is the respective Summary of Product Characteristics for an 
investigational medicinal product, as submitted to the competent Authority.  
 
The term “severe” is often used to describe the intensity (severity) of a specific event. This is 
not the same as “serious,” which is based on patient/event outcome or action criteria. 
 
Reports which add significant information on the specificity, increase of occurrence, or severity 
of a known, already documented serious adverse reaction constitute unexpected events. 
 
An increase in the rate of occurrence of an expected AR, which is judged to be clinically 
important, is considered as unexpected. 

AIDED Study Protocol, Final V1.2 
  
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 
An expected adverse reaction with fatal outcome has to be considered as unexpected as 
long as the fatal outcome is not explicitly mentioned in the reference document. 
 
Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A suspected unexpected serious adverse reaction (SUSAR) is a serious adverse reaction that 
has been judged to be unexpected. 
 
10.2.2 Period of Observation, Documentation and Assessment of Adverse 
Events  
AEs and SAEs will be recorded from the time the first dose of study drug is administered, up 
to and including follow-up-Visit d90 (T10) 
 
All AEs, including SAEs, have to be recorded in the trial subject’s medical records and on the 
adverse event pages in the CRF, regardless of whether or not the AE is considered related to 
the use of study drug. 
 
Documentation and assessment by the investigator includes: 
 
Diagnosis or Description of AE 
o If possible, a diagnosis rather than a list of signs, symptoms and laboratory 
abnormalities should be given. 
 
Date of onset and date of end of AE 
 
Seriousness (yes/no) 
 
Severity (graded according to the general Common Terminology Criteria for Adverse 
Events (CTCAE) v5.0 scale. A semi-colon indicates ‘or’ within the description of the 
grade.): 
o Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
o Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting 
age-appropriate instrumental ADL (preparing meals, shopping for groceries or 
clothes, using the telephone, managing money, etc.). 
o Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting 
self care ADL (bathing, dressing and undressing, feeding self, using the toilet, 
taking medications, and not bedridden). 
o Grade 4: Life-threatening consequences; urgent intervention indicated.  
o Grade 5: Death related to AE. 
 
Causality (reasonable possibility / no reasonable possibility) 
o Reasonable possibility: there are facts or arguments to suggest a causal 
relationship 
o No reasonable possibility: time relationship is improbable, and/or another 
explanation is more likely (e.g. disease or other drugs provide plausible 
explanation) 
 
Action taken with investigational medicinal product (Dose not changed, Dose 
reduced, Dose increased, Drug withdrawn, Unknown, Not applicable) 
 
Outcome (recovered/resolved, recovering/resolving, not recovered/not resolved, 
recovered/resolved with sequelae, fatal, unknown) 
All AEs and SAEs must be followed up until the condition resolves or stabilizes. The 
investigator should ensure that adequate medical care is provided to a subject for any adverse 
events. Transferring a patient from ICU to a normal ward ensures medical care. 
 

AIDED Study Protocol, Final V1.2 
  
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10.2.3 Reporting of Serious Adverse Events (SAE) by the Investigator 
The investigator has to report any SAE immediately (“immediately”, without undue delay) after 
obtaining knowledge by fax or by encrypted email (if available) on the SAE form to the Safety 
Desk, Muenster, Germany. This applies regardless of severity (CTCAE v5.0) or whether or not 
the SAE is considered related to the use of study drug. Personal data have to be replaced by 
the trial patient number before forwarding any information. 
 
Safety Desk Contact 
Zentrum für Klinische Studien (ZKS) Münster 
Von-Esmarch-Straße 62 
48129 Münster 
Germany 
Phone: +49 (0)251 83 57109 
Fax:     +49 (0)251 83 57112 
E-Mail: mssd@ukmuenster.de 
Where possible, a diagnosis rather than a list of symptoms should be given. The investigator 
is responsible for assessment of seriousness, severity and causality of the SAE. The SAE form 
should be completed with as much information as possible. The investigator should not wait 
for full details before making the initial report.  
Minimum information to be included in any initial report:  
1. Unique patient number 
2. SAE details 
3. Details about administration of investigational medicinal product  
4. Causality assessment of SAE to investigational medicinal product  
5. Reporting investigator 
The investigator must fax any relevant follow-up information as soon as possible. In case of 
death a copy of an autopsy protocol should be provided, if any. The investigator should answer 
any query on SAE reports as soon as possible.  
In case the competent authority or an ethics committee would request details concerning a 
fatal case, the investigator has to supply the requested information.  
In case the investigator gets knowledge of an SAE occurring after the end of the reporting 
period, for which he suspects a reasonable causal relationship to the investigational treatment, 
the investigator should also report such an SAE to the Safety Desk. Late SAEs do not have to 
be documented in the eCRF. 
 
10.2.4 Assessment of Serious Adverse Events by the Sponsor  
The Safety Desk will document each SAE, check it and query additionally required information. 
The Coordinating Investigator, or a named delegate, will review each SAE again for 
seriousness and relatedness. 
The Coordinating Investigator or his delegate will also assess whether an SAR is expected or 
unexpected (SUSAR) according to the applicable reference document (see 10.2.1), and 
whether any SAE might influence the benefit-risk-ratio or might require changes in the conduct 
of the trial. 
 
10.2.5 Legal Reporting Requirements of the Sponsor 
It is the duty of the Safety Desk to inform the competent authority, the ethics committee, and 
participating investigators about all suspected unexpected serious adverse reactions 
(SUSARs) in accordance with legal requirements (immediately, fatal or life threatening SUSAR 

AIDED Study Protocol, Final V1.2 
  
Page 29 of 37 
 
by the latest within 7 days, detailed follow-up information within an additional 8 days, if any; all 
other SUSARs by the latest within 15 days). SUSAR follow-up reports will be submitted, as 
appropriate. 
The Safety Desk will observe SUSAR cross reporting obligations with other trials of the same 
sponsor investigating any of the same active substances, if any.  
The Coordinating Investigator is responsible for the ongoing safety evaluation of the trial. The 
Safety Desk and the Coordinating Investigator will inform each other immediately about any 
relevant safety information coming to their knowledge. In case of safety relevant issues 
(besides SUSAR) which require expedited reporting, the Safety Desk will support the 
Coordinating Investigator in submitting an appropriate report in due time. This includes issues 
which might materially alter the current benefit-risk assessment of an investigational medicinal 
product or that would be sufficient to consider changes in the investigational medicinal 
products administration or in the overall conduct of the trial as well as urgent safety measures 
to protect the subjects against any immediate hazard. 
Annual safety reports will be prepared and submitted in accordance with legal requirements 
(Development Safety Update Report, DSUR). The reports will be trial specific reports covering 
both investigational medicinal products of the trial. Data lock point for the report will be the day 
before the anniversary of the first authorization of the trial by the competent authority. The 
Coordinating Investigator is responsible for providing the updated benefit-risk assessment and 
passages requiring medical assessment. The Data Management is responsible for providing 
information on subject exposure. The Safety Desk is responsible for preparing the template, 
adding the other parts of the report, finalizing it and submitting it to the competent authority 
and the ethics committee within 60 days of the data lock point. On request by the competent 
authority or the ethics committee, additional reports will be prepared. 
Details of all AEs will be reported to the competent authority on request. 
 
10.2.6 Pregnancies 
In order to identify and follow-up on outcome of pregnancy and on any congenital 
abnormalities, a positive pregnancy test is reportable on an SAE form within the following time 
frame: a) during active trial participation, b) thereafter while pregnancy probably was already 
present during active trial participation. The report should be made as soon as the investigator 
gains knowledge of the event. Follow-up of a pregnancy will be done using specific additional 
questionnaires. The Safety Desk will supply these trial-adapted forms, when required. 
However, onset of pregnancy during trial participation is very unlikely, due to the intensive care 
setting. Information will be collected as far as covered by informed consent (e.g., information 
about the child needs to be covered by consent of the patient's partner, too). When required, 
the Project Management will check and assure coverage by informed consent. 
 
10.3 Data Monitoring Committee 
The Data Monitoring Committee consist of three independent clinicians and one independent 
statistician. The board will monitor the trial on a regular basis (every 4 months) and will assess 
the safety of the trial. Procedures governing the convening and execution of the responsibilities 
of the DMC will be specified separately in a written DMC Charter. 
 
11 Study duration, Premature Termination of the Study 
11.1 Study Duration  
Start of the trial:  
Date of randomization of first patient  
  

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Planned end of recruitment  
6,5 months (LPFV, last patient first visit) 
 
Last Patient Last Visit: 
3 months (LPLV, last patient last visit) 
 
Planned duration of single patient participation:  90 days 
 
 
11.2 Definition of the End of the Study 
The study will end at the last visit of the last patient. 
 
11.3 Premature Study Termination 
11.3.1 Premature Termination of Study Participation of a Single Patient 
A patient is free to withdraw consent and discontinue participation in the study at any time, 
without prejudice to further treatment according to standard clinical practice. In this case the 
patient will be asked to permit the conduct of the study termination visit (cf. section 9.3). 
In certain circumstances the investigator may exclude a patient from further study participation 
irrespective of the patient’s will. Reasons may be: 
 
 
treatment failure 
 
insufficient compliance 
 
further participation might jeopardize the patient’s health or well-being 
 
termination of the entire study. 
If, after treatment initiation, a patient’s participation is realized not to agree with the inclusion 
and exclusion criteria, the principal investigator will decide on further participation. 
In case of premature termination, the reason will be recorded on the CRF. 
 
11.3.2 Premature Termination of the Entire Study 
The sponsor may terminate the entire study for relevant medical or administrative reasons. 
Reasons for termination will be documented in detail. If, in the view of an investigator, there 
are ethical issues or any other issues contradicting study continuation, the principle 
investigator must immediately be informed. Particular reasons for termination of the study may 
be: 
 
 
insufficient recruitment 
 
serious problems with the quality of the study data which cannot be solved 
 
discovery of an unexpected, serious or unacceptable risk to patients enrolled in the 
study 
 
new scientific evidence suggesting that study continuation is not justified. 
 
12 Statistical Considerations 
The randomized groups will be descriptively compared on all baseline variables using 
summary statistics such as mean and standard deviation, median and quartiles, or frequency 
and percent, as appropriate. In inferential statistical analyses two-sided significance tests will 
be applied with a local significance level alpha=0.05. All point estimates of parameters of 

AIDED Study Protocol, Final V1.2 
  
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interest will be supplemented by 95% confidence intervals unless otherwise stated. SAS or 
SPSS statistical software will be used for all data analyses.  
 
Description of the primary efficacy / test accuracy analysis and population 
The primary efficacy analysis will include all randomized subjects (full analysis set) and will be 
performed according to the intent-to-treat principle, i.e. all subjects are analyzed in the group 
to which they were randomized. Additional sensitivity analyses will be performed according to 
the per-protocol principle. The effect of AT-II versus control on the biomarker [TIMP-
2]*[IGFBP7] will be estimated with a non-parametric 90% confidence interval of the location 
shift between the distributions of the biomarker [TIMP-2]*[IGFBP7] in the AT-II and the control 
group, respectively. 
 
Safety 
Safety data will be evaluated descriptively, including all recruited study patients who received 
at least one dose of study therapy (safety population). Results will be reported by mean 
parameter estimates and associated 95% confidence intervals.  
 
Secondary endpoints 
Statistical analysis of the pre-specified secondary endpoints will be performed with descriptive 
and inferential statistical methods. Secondary outcomes will be evaluated and compared 
between the randomized treatment arms using the following methods. In case of normally or 
non-normally distributed metric outcomes, Student’s t test or the Mann-Whitney U test will be 
applied, respectively. Categorical outcomes will be analyzed using Fisher’s exact test (2x2 
tables) or the Chi² test (>2x2 tables). Survival data will be analyzed using the Kaplan-Meier 
method and the log-rank test. Hazard ratios will be estimated based on Cox proportional 
hazards models after checking the proportional hazards assumption based on the Schoenfeld 
residuals. 
 
Multivariable statistical analyses 
Multivariable statistical analyses will be applied in order to identify independent prognostic 
factors of clinical outcomes. The identified prognostic factors will allow determining risk groups 
of patients with expected outcomes of different severity. Survival data will be analyzed using 
multivariable Cox proportional hazards models after checking the proportional hazards 
assumption based on the Schoenfeld residuals. Binary outcomes will be analyzed by 
multivariable logistic regression. Model building will be performed using stepwise variable 
selection based on Akaike’s information criterion (AIC) in order to identify relevant and 
meaningful independent variables of a respective outcome. Models will be fitted and model 
parameters will be estimated using Maximum Likelihood methods. The final models will be 
validated using cross-validation techniques.  
 
Sample size 
The expected median [TIMP-2]*[IGFBP7] level in the control group is median control=0.84 
(Q1=0.35, Q3=1.57) and in the AT-II group median AT-II=0.58 (Q1=0.26, Q3=1.20), based 
on Meersch et al., Intensive Care Med 2017. A total number of 64 patients will be recruited 
and a number of 32 patients will be randomized to each of the two treatment arms. With an 
expected 5% dropout rate, up to 2 patients per treatment arm will be non-evaluable. With a 
number of n=30 evaluable patients per treatment arm, the location shift between the 
distributions of the biomarker [TIMP-2]*[IGFBP7] in the AT-II and the control group can be 
estimated with an expected precision ±0.285ng/ml2/1000 (half-width of the 90% confidence 
interval). 
 

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13 Documentation, Data Management, Archiving 
13.1 Patient Identification List 
All subject data will be collected in a pseudonymized form. Every trial subject can be identified 
by a unique subject identification code. A confidential subject identification list which links the 
patients’ names with the subject identification code will be stored in the investigator site file. 
 
13.2 Source Data / Source documents 
Source data are, within the meaning of the ICH E6 Guideline, all information in original records 
and certified copies of original records of clinical findings, observations, or other activities in a 
clinical trial necessary for the reconstruction and evaluation of the trial. Source data will be 
documented in various source documents (e.g. hospital records, doctor's report, subjects' 
diaries or evaluation checklists, x-rays) and then entered into the electronic Case Report Form 
(eCRF).  
 
The following study specific data will be recorded directly in the eCRF and therefore will be 
considered as source data: 
 
KDIGO-criteria 
 
[TIMP-2]*[IGFBP7] 
 
The following study specific data will only be recorded electronically in separate files and is 
not going to be entered in the eCRF  
 
Biomarkers for add-on study (e.g. KIM-1, chitinase, NGAL, hyaluronic acid) and anti- 
and pro-inflammatory mediators (IL-6, IL-10…), leukocyte function)  
 
13.3 Recording of Data / Case Report Form (CRF) 
Data will be recorded electronically using an EDC (Electronic Data Capture) system. Only 
persons authorized to enter data into the eCRF will have access to the EDC system. All users 
will be trained to use the EDC system and will comply with the instructions in the study-specific 
user manual. They will have continuous access to the data and reports of subjects at their own 
study site. The investigator is responsible for ensuring that the study data will be documented 
correctly, completely and in a timely manner. A study team physician takes on responsibility 
for the collected data by signing electronically. The electronic signature according to FDA 21 
CFR Part 11 is the legally binding equivalent of the study team physician's handwritten 
signature. 
 
13.4 Data Management 
For data management, the validated data management system MACROTM v4 (Elsevier 
Limited) will be used. All entered data will be stored on servers of the University Hospital 
Muenster. The servers are located in a secure data center and behind a firewall in the network 
of the University Hospital Muenster. A backup of the data will be saved on a daily basis and all 
data changes will be recorded in an audit trail. 
 
All data will be checked for plausibility during initial data entry. Missing or non-plausible data 
are highlighted by the system right at input at the clinical study site and may be corrected 
immediately. Thereafter, according to the data validation plan, further data checks will be 
performed with regard to completeness and plausibility by the data management of the ZKS 
Muenster. In case of non-plausible or missing data, queries will be sent to the study site. The 
queries must be resolved by authorized members of the investigator`s staff in the respective 
study site in a timely manner. 

AIDED Study Protocol, Final V1.2 
  
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After completion of data entry and data processing, the database will be locked and the data 
will be exported for statistical analysis. The investigator will receive a CD-ROM of the eCRF 
data for archiving at the clinical study site. 
 
13.5 Archiving 
After the end of the trial, the originals of all trial-specific documents (Trial Master File) including 
originals of the CRFs must be stored by the sponsor according to national regulations. 
Furthermore, the investigator stores the ISF (Investigator Site File) including copies of the 
CRFs for the time period given above. 
 
No trial data or documents must be destroyed without prior written agreement between the 
sponsor and the investigator(s) or his/her designee. 
 
13.6 Investigator Site File 
The Investigator Site File (ISF) will be checked regularly for completeness and actuality during 
monitoring. After the clinical trial is finished or stopped, the ISF has to be stored according to 
national regulations. 
 
14 Monitoring, Audits and Inspections 
14.1 Monitoring 
In order to ensure a high degree of data quality, the study site will be monitored during the 
recruitment and follow-up period (frequency depending on the site’s recruitment).  
The objectives of the monitoring procedures are to ensure that the study safety and rights of 
the study subjects as a study participant are respected and that accurate, valid and complete 
data are collected, and that the study is conducted in accordance with the study protocol, the 
principles of GCP and local legislation. 
The principal investigator agrees that the monitor will visit the study site in appropriate intervals. 
During these visits the monitor will check the quality of the data recording and ensure that the 
study site adheres to the timeframe as set in the study protocol. The investigators agree to 
provide any relevant information and documentation whenever the monitor requires this 
information. This includes access to all original study documents and source data. 
 
It is the responsibility of the investigator to keep the participant’s chart as complete as possible 
(e.g. history, concomitant diseases, inclusion in the clinical study, visit dates, results of 
laboratory tests, distribution of the study medication, and adverse events). Source data are 
checked and compared with entries in the eCRF. The participant has given consent with this 
procedure by signing the patient information and written informed consent form. Additional 
tasks of the monitor are: 
 
to check, whether the study site fulfils requirements of the clinical study (e.g. participant 
population, technical equipment), 
 
instruction of the investigators and personnel for the clinical study, 
 
to check the ISF for completeness and actuality, 
 
documentation of the status of the participant, 
 
matching of original data, 
 
to check SAE reports according to regulations. 

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The monitor has the responsibility to treat all information confidentially and to safeguard the 
integrity and personal privacy of the study participants. 
The exact extent of the monitoring procedures is described in a separate monitoring manual. 
 
14.2 Audits und Inspections 
For the purpose of ensuring compliance with the study protocol, the principles of GCP and 
local legislation, the sponsor may initiate an audit at any study site during the study and after 
completion. All study-related documentation must be made available to the designated 
auditor(s).  
 
In addition, representatives of the regulatory authorities may choose to inspect the study site 
at any time prior to, during, or after completion of the clinical study. In this case, all pertinent 
study data should be made available as requested to the regulatory authority for verification, 
or inspection purposes. The investigator has to be available during these visits. 
 
15 Ethical and Regulatory Requirements 
15.1 Declaration of Helsinki and Legal Requirements 
The study will be conducted in compliance with the declaration of Helsinki (current version, 
October 
2013, 
Fortaleza), 
the 
requirements 
of 
the 
current 
German 
drug 
law 
(“Arzneimittelgesetz”), the current legal provisions regarding data protection, and the principles of 
Good Clinical Practice. 
The present study will not be started before the ethics committee has given a favorable opinion 
and an approval by the responsible federal authority has been obtained.  
 
In case of substantial amendments, a new application will be submitted to the ethics committee 
and/or the competent federal authority. Changes will not be implemented unless the competent 
ethics committee has given a favorable opinion and/or the competent authority has granted an 
approval. 
 
Issues, which always require a favorable opinion of the ethics committee are for example: 
 
change of the investigator or his deputy, 
 
changes in any documents addressed to study participants or in any study information 
addressed to potential study participants. 
 
According to German drug law §67, the investigator is required to notify the local surveillance 
authority about the beginning, the end and a premature termination of the study, about any 
substantial amendments and if the study is on hold. These notifications will be performed by a 
delegate of the sponsor (GCP-V, §12(3)).  
Additionally, the investigator is required to notify the corresponding federal authority of the 
beginning of the study. 
 
15.2 Patient Information and Informed Consent 
Prior to inclusion into the study, the investigator informs each patient about the nature, 
significance, implications, and risks of the study as well as about the patient’s right to withdraw 
from study participation at any time point without any resulting disadvantage. Further, the 
patients will be informed about insurance that covers risks originating from the study. 
According to the insurance conditions, they are advised to immediately inform the investigator 
if they were treated for an emergency and not to undergo any other medical treatment without 
prior consultation with the investigator.  

AIDED Study Protocol, Final V1.2 
  
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Additionally, patients are handed out the patient information sheet and the informed consent 
form which are provided for this study. Patient consent in study participation must be given in 
writing. Before informed consent is requested, patients are left sufficient time for consideration. 
They are provided the opportunity for clarification of any study issues. 
According to the German drug law (“Arzneimittelgesetz”) §40(2a), patients are informed that 
their disease related data are stored in a pseudonymized way and used for scientific 
evaluations. For study participation they must agree in writing. 
The informed consent form is dated and signed by the patient and by the investigator. The 
originally signed informed consent form is archived in the investigator site file. A copy of the 
signed informed consent form (or a second original) is handed over to the patient together with 
a copy of the patient information sheet and a copy of the general conditions of the patient 
insurance. 
If the patient is unable to write, in exceptional cases, instead of the written consent required, 
oral consent in the presence of at least one witness, who was also included when the patient 
was being informed may be given. The witness may not be a member of the investigating team. 
The orally given consent has to be documented in writing, dated and signed by the witness. 
In case of any study issue which requires a change of the patient information sheet, patients 
already included into the study must, if relevant to them, be informed about these issues orally 
and in writing and their written consent in further study participation must be obtained. 
 
15.3 Patient Insurance  
As required by German drug law, patients will be insured against risks originating from the 
study. 
Insurance:  
HDI-Gerling Industrie Versicherung AG 
Riethorst 2 
30659 Hannover. 
 
15.4 Financing 
The study is financed by a research grant from the German Research Foundation (ZA 
428/21-1) 
 
15.5 Adherence to the Protocol 
The investigator must adhere to the protocol as detailed in this document. Substantial changes 
to the protocol will require a written favorable opinion from the corresponding ethics committee 
and written approval by the corresponding authority prior to implementation. This does not 
apply when the modification is needed to eliminate an immediate hazard to patients. Any 
deviations from the protocol must be fully documented in the source documentation and 
recorded and explained in the CRF (if applicable). 
 
15.6 Data Protection 
This study will be performed in compliance with the applicable data protection laws. Study 
personnel will handle all patient data in a strictly confidential way. 
To prevent the identification of a person to whom study data belongs, study data will be 
pseudonymized by means of the patient identification number (cf. sections 6, 13.1). If patient 
documents (e.g., examination results) are transferred to an institution outside the study site, 
copies will be used on which the patient’s name and initials are obscured and the patient 
identification number is indicated. 
 

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16 Reporting and Publication Policy 
16.1 Reporting 
16.1.1 Interim Report 
Not applicable. 
 
16.1.2 Final Report 
After completion of the biometric evaluation, the principal investigator prepares a study report. 
The report includes all trial results, irrespective of whether favorable or not. It is signed by him 
and the person who is responsible for the evaluation. 
Within 12 months after the end of the study, the principal investigator submits a summary of 
the final report to the ethics committee and to the competent federal authority. The summary 
is prepared in the format provided for report synopses by the ICH Guideline E3 “Guidance on 
Structure and Content of Clinical Study Reports”. After review by the competent federal 
authority the report is published on the web site of DIMDI (German drug law, §42 b). 
According to European Commission Guideline 2012/C 302/03 the study results should be 
posted within 12 months to the EU Database on Clinical Trials (EudraCT).  
 
16.1.3 Safety Reports 
The rules for the annual safety reports are specified in chapter 10.2.5 (Legal Reporting 
Requirements of the Sponsor). 
 
16.2 Publication Policy 
Any publication will take account of the ‘International Committee of Medical Journal Editors’ 
(ICMJE).  Any published data will observe data protection legislation covering the trial subject 
and investigators.  
 
17 References 
1. 
Fischer, G.W. and M.A. Levin, Vasoplegia during cardiac surgery: current concepts and 
management. Semin Thorac Cardiovasc Surg, 2010. 22(2): p. 140-4. 
2. 
Luckner, G., et al., Arginine vasopressin in 316 patients with advanced vasodilatory 
shock. Crit Care Med, 2005. 33(11): p. 2659-66. 
3. 
Weis, F., et al., Association between vasopressor dependence and early outcome in 
patients after cardiac surgery. Anaesthesia, 2006. 61(10): p. 938-42. 
4. 
Schmittinger, C.A., et al., Adverse cardiac events during catecholamine vasopressor 
therapy: a prospective observational study. Intensive Care Med, 2012. 38(6): p. 950-8. 
5. 
Kullmar, M., et al., Kinetic Changes of Plasma Renin Concentrations Predict Acute 
Kidney Injury in Cardiac Surgery Patients. Am J Respir Crit Care Med, 2021. 203(9): 
p. 1119-1126. 
6. 
Group, K.A.W., KDIGO clinical practice guideline for acute kidney injury. Kidney Int, 
2012: p. 1-138. 
7. 
Chew, S.T.H. and N.C. Hwang, Acute Kidney Injury After Cardiac Surgery: A Narrative 
Review of the Literature. J Cardiothorac Vasc Anesth, 2019. 33(4): p. 1122-1138. 
8. 
Hobson, C.E., et al., Acute kidney injury is associated with increased long-term 
mortality after cardiothoracic surgery. Circulation, 2009. 119(18): p. 2444-53. 
9. 
Hoste, E.A.J., et al., Global epidemiology and outcomes of acute kidney injury. Nat Rev 
Nephrol, 2018. 14(10): p. 607-625. 

AIDED Study Protocol, Final V1.2 
  
Page 37 of 37 
 
10. 
Lassnigg, A., et al., Minimal changes of serum creatinine predict prognosis in patients 
after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol, 2004. 
15(6): p. 1597-605. 
11. 
Mekontso-Dessap, A., et al., Risk factors for post-cardiopulmonary bypass vasoplegia 
in patients with preserved left ventricular function. Ann Thorac Surg, 2001. 71(5): p. 
1428-32. 
12. 
Landry, D.W. and J.A. Oliver, The pathogenesis of vasodilatory shock. N Engl J Med, 
2001. 345(8): p. 588-95. 
13. 
Chawla, L.S., et al., The use of angiotensin II in distributive shock. Crit Care, 2016. 
20(1): p. 137. 
14. 
Paul, M., A. Poyan Mehr, and R. Kreutz, Physiology of local renin-angiotensin systems. 
Physiol Rev, 2006. 86(3): p. 747-803. 
15. 
Goldberg, M.R., et al., Effects of losartan on blood pressure, plasma renin activity, and 
angiotensin II in volunteers. Hypertension, 1993. 21(5): p. 704-13. 
16. 
Kono, T., et al., Effects of angiotensin I-converting enzyme inhibitor, SQ 14225, in 
nomal men. Endocrinol Jpn, 1979. 26(3): p. 411-8. 
17. 
Landoni, G., et al., Reducing mortality in acute kidney injury patients: systematic review 
and international web-based survey. J Cardiothorac Vasc Anesth, 2013. 27(6): p. 1384-
98. 
 
 
 
 
 
18 Appendices 
18.1 Measurement of [TIMP-2]*[IGFBP7] 
[TIMP-2]*[IGFBP7] will be measured with the Astute140 Meter. It employs a sandwich 
immunoassay technique and converts the fluorescent signals from each of the two 
immunoassays (TIMP-2 and IGFBP7) contained within the Nephrocheck test cartridge into 
a single numerical risk result (AKIRisk). The result is calculated as the product of the measured 
concentrations of the two biomarkers, divided by 1000 
AKIRisk = ([TIMP-2] * [IGFBP7]) / 1000 (units = (ng/ml)2/1000) 
 
 
18.2 KDIGO criteria