The Practical Anemia Bundle for SusTained Blood Recovery (PABST-BR) Clinical Trial
Phase: PHASE2
Conditions: Anemia, Critical Illness
Sponsor: Mayo Clinic

 
 
The Practical Anemia Bundle for Sustained 
Blood Recovery (PABST-BR) in Critical Illness 
Randomized Clinical Trial 
 
NCT#05167734 
 
11October2022 

 
 
 
 
The Practical Anemia Bundle for Sustained Blood Recovery 
(PABST-BR) in Critical Illness Randomized Clinical Trial 
 
Protocol Number: IRB # 21-006511 
National Clinical Trial (NCT) Identified Number:  < TBD> 
 
Principal Investigator: Matthew A. Warner, MD 
Funded by: NHLBI 
Version Number:5.0 
11 October 2022 
 
 
Initial version: 5 October 2021, Version 1.0 
Revised: 28 March 2022, Version 2.0 
 
Revised: 11 May 2022, Version 3.0 
 
Revised: 26 July 2022, Version 4.0 
 
Revised: 11 October 2022, Version 5.0  
 

  
 
Dr. Matthew Warner 
 
CONFIDENTIAL 
 
ii 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 3 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 4 
2 
INTRODUCTION ............................................................................................................................................ 4 
2.1 
Study Rationale .................................................................................................................................... 4 
2.2 
Background........................................................................................................................................... 5 
2.3 
Risk/Benefit Assessment .................................................................................................................... 7 
2.3.1 
Known Potential Risks ..................................................................................................... 7 
2.3.2 
Known Potential Benefits ................................................................................................ 8 
2.3.3 
Assessment of Potential Risks and Benefits ................................................................ 8 
3 
OBJECTIVES AND ENDPOINTS .............................................................................................................. 10 
4 
STUDY DESIGN ........................................................................................................................................... 11 
4.1 
Overall Design .................................................................................................................................... 11 
4.2 
Scientific Rationale for Study Design.............................................................................................. 13 
4.3 
Justification for Dose ......................................................................................................................... 13 
4.4 
End of Study Definition ..................................................................................................................... 13 
5 
STUDY POPULATION ................................................................................................................................ 13 
5.1 
Inclusion Criteria ................................................................................................................................ 13 
5.2 
Exclusion Criteria ............................................................................................................................... 14 
5.3 
Lifestyle Considerations .................................................................................................................... 14 
5.4 
Screen Failures .................................................................................................................................. 14 
5.5 
Strategies for Recruitment and RetentioN ..................................................................................... 15 
6 
STUDY INTERVENTION ............................................................................................................................ 16 
6.1 
Study Intervention(s) Administration ............................................................................................... 16 
6.1.1 
Study Intervention Description ..................................................................................... 16 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 17 
6.2.1 
Acquisition and accountability ...................................................................................... 17 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 17 
6.2.3 
Product Storage and Stability ....................................................................................... 17 
6.2.4 
Preparation ...................................................................................................................... 18 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 18 
6.4 
Study Intervention Compliance ........................................................................................................ 18 
6.5 
Concomitant Therapy ........................................................................................................................ 18 
6.5.1 
Rescue Medicine ............................................................................................................ 18 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL. ................................................................................................................... 18 
7.1 
Discontinuation of Study Intervention ............................................................................................. 18 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 19 

  
 
Dr. Matthew Warner 
 
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7.3 
Lost to Follow-Up ............................................................................................................................... 19 
8 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................................... 19 
8.1 
Efficacy Assessments ....................................................................................................................... 19 
8.2 
Safety and Other Assessments ....................................................................................................... 20 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 20 
8.3.1 
Definition of Adverse Events (AE) ............................................................................... 20 
8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 21 
8.3.3 
Classification of an Adverse Event .............................................................................. 21 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 22 
8.3.5 
Adverse Event Reporting .............................................................................................. 22 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 22 
8.3.7 
Reporting Events to Participants ................................................................................. 23 
8.3.8 
Events of Special Interest ............................................................................................. 23 
8.3.9 
Reporting of Pregnancy ................................................................................................ 23 
8.4 
Unanticipated Problems .................................................................................................................... 23 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 23 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 23 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................... 24 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 24 
9.1 
Statistical Hypotheses ....................................................................................................................... 24 
9.2 
Sample Size Determination .............................................................................................................. 24 
9.3 
Populations for Analyses .................................................................................................................. 24 
9.4 
Statistical Analyses............................................................................................................................ 25 
9.4.1 
General Approach .......................................................................................................... 25 
9.4.2 
Analysis of the Primary Efficacy Endpoint(s) ............................................................. 25 
9.4.3 
Analysis of the Secondary Endpoint(s) ....................................................................... 26 
9.4.4 
Safety Analyses .............................................................................................................. 26 
9.4.5 
Baseline Descriptive Statistics ..................................................................................... 27 
9.4.6 
Planned Interim Analyses ............................................................................................. 27 
9.4.7 
Sub-Group Analyses ..................................................................................................... 27 
9.4.8 
Tabulation of Individual participant Data .................................................................... 27 
9.4.9 
Exploratory Analyses ..................................................................................................... 27 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 27 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 27 
10.1.1 
Informed Consent Process ........................................................................................... 27 
10.1.2 
Study Discontinuation and Closure ............................................................................. 28 
10.1.3 
Confidentiality and Privacy ........................................................................................... 28 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 29 
10.1.5 
Key Roles and Study Governance .............................................................................. 29 
10.1.6 
Safety Oversight ............................................................................................................. 29 
10.1.7 
Clinical Monitoring .......................................................................................................... 29 

  
 
Dr. Matthew Warner 
 
CONFIDENTIAL 
 
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10.1.8 
Quality Assurance and Quality Control ....................................................................... 30 
10.1.9 
Data Handling and Record Keeping ............................................................................ 30 
10.1.10 
Protocol Deviations ........................................................................................................ 31 
10.1.11 
Publication and Data Sharing Policy ........................................................................... 31 
10.1.12 
Conflict of Interest Policy .............................................................................................. 31 
10.2 
Additional Considerations ................................................................................................................. 31 
10.3 
Abbreviations ...................................................................................................................................... 35 
10.4 
Protocol Amendment History ........................................................................................................... 37 
11 
REFERENCES ............................................................................................................................................. 38 
 

 
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STATEMENT OF COMPLIANCE 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good Clinical Practice (ICH 
GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR Part 50, 21 
CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are responsible for the conduct, 
management, or oversight of NIH-funded clinical trials have completed Human Subjects Protection and ICH GCP 
Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be submitted to the 
Institutional Review Board (IRB) for review and approval.  Approval of both the protocol and the consent form must be 
obtained before any participant is enrolled.  Any amendment to the protocol will require review and approval by the IRB 
before the changes are implemented to the study.  In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from participants who provided 
consent, using a previously approved consent form. 
 
1 
 
PROTOCOL SUMMARY 
1.1 
SYNOPSIS  
Title: 
The Practical Anemia Bundle for SusTained Blood Recovery (PABST-BR) in Critical Illness 
Randomized Clinical Trial 
Study Description: 
The goal of this investigation is to test a multi-faceted anemia prevention and targeted 
treatment bundle (optimized phlebotomy, decision support, targeted pharmacologic 
treatment) to attenuate anemia development and promote hemoglobin and functional 
recovery in adults with critical illness.  We hypothesize that the bundle will improve 
hemoglobin recovery and functional outcomes through 3 months post-hospitalization.   
Objectives: 
 
Primary Objective:  To assess the efficacy of the intervention on mean difference in 
hemoglobin concentrations at 1 month after hospitalization. 
 
Secondary Objectives:  
To assess the impact of the intervention on:  
• 
hemoglobin concentrations through 3-months post hospitalization 
• 
functional outcomes (Core Outcome Measurement Set [COMS], PROMIS-FATIGUE) 
at 1 and 3 months post-hospitalization 
• 
RBC transfusions through 3 months post-hospitalization 
• 
hospital readmissions through 12 months post-hospitalization  
• 
mortality through 12 months post-hospitalization 
Endpoints: 
Primary Endpoint: Hemoglobin concentrations (mean difference in hemoglobin 
concentrations at 1-month post-hospitalization) 
Secondary Endpoints:  
• 
Hemoglobin concentrations (through 3 months post-hospitalization)  
• 
Functional outcomes (EQ-5D, PROMIS-FATIGUE, 6-minute walk distance, daily step 
counts and energy expenditure, activities of daily living survey, MOCA-BLIND, HADS, 
IES-R) at 1 and 3-months postop-hospitalization 
• 
RBC transfusions through 3-months post-hospitalization  

 
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• 
Readmissions in first 12-months post-hospitalization  
• 
All-cause mortality through 12 months post-hospitalization 
Study Population: 
100 patients, male and females, age > 18 years, moderate-to-severe comorbid illness 
burden, moderate-to-severe acute illness burden, in ICUs at Mayo Clinic Rochester  
Phase: 
2   
Description of 
Sites/Facilities Enrolling 
Participants: 
ICUs at Mayo Clinic Rochester, MN; a large tertiary care academic medical center   
Description of Study 
Intervention: 
Participants will be randomized 1:1 to active intervention vs. standard of care using a 
stratified permuted block design by anemia type (iron-responsive vs. inflammatory) and ICU 
admission indication (surgical vs. non-surgical).   
 
The intervention arm is multi-faceted with 3 primary components: 
1) Optimized phlebotomy, defined by: 
• 
minimal volume draws 
• 
closed-loop blood sampling 
• 
bundling of similarly timed labs, all performed by a dedicated phlebotomy team 
independent from the treatment team 
 
2) Decision support aids, including: 
• 
visual and electronic alerts reminding the care team to minimize non-essential 
laboratory testing, mitigate patient-specific bleeding risk 
• 
daily communication with the ICU care team during clinical rounds to reiterate the 
purpose of the study 
 
3) Pharmacologic anemia treatment (given immediately following randomization) targeted 
to 2 broad groups:  
1) Anemia responsive to iron supplementation (i.e. 1000 mg IV low molecular 
weight iron dextran), and  
2) Anemia of inflammation requiring erythropoietic stimulation (i.e. 40,000 units of 
subcutaneous erythropoietin +/- iron supplementation as needed to augment iron 
stores prior to EPO dosing)  
Study Duration: 
2 years 
Participant Duration: 
3 months post-hospitalization, EMR review by study staff at 12 months post-hospitalization 
 
 

 
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1.2 SCHEMA 
 
Prior to  
Enrollment 
 
 
 
 
 
 
 
 
 
 
Visit 1 
Time Point  
 
 
 
 
 
Daily visits 
 
 
 
Hospital  
discharge 
 
 
 
1 month  
post-discharge 
 
 
 
 
3 months  
post-discharge 
 
 
 
12 months  
post-discharge 
 
 
Screen potential participants by inclusion/exclusion criteria.  
Obtain informed consent of 100 participants.  
Administer initial study intervention: 
• 
Optimized phlebotomy. Place card on patient door. 
• 
Clinical Support/Rounding checklist to ICU care team 
• 
1000 mg IV iron or 40,000 units subcutaneous EPO or both 
• 
Perform baseline assessments (refer to Section 1.3 SOA) 
Follow-up assessments of study endpoints and safety 
(refer to Section 1.3 SOA) 
• 
Hemoglobin and iron studies 
• 
Functional outcome assessments 
• Review Clinical Support Card/Rounding Checklist with ICU team. 
• Ensure Optimized Phlebotomy card in place 
• Document AE’s, labs, daily RBC transfusions, daily fluid balance 
Final Assessments 
(refer to Section 1.3 SOA) 
Intervention Arm 
50 participants 
Control Arm 
50 participants 
Randomize 
• 
Schedule follow-up appointments 
• 
Complete EQ-5D, PROMIS FATIGUE, and Fatigue Assessment 
• 
Record hemoglobin, iron study results 
Perform baseline 
assessments 
(refer to Section 
1.3 SOA) 
Document AE’s, labs, 
daily RBC transfusions, 
daily fluid balance 
EMR review only 
• 
All cause mortality 
•
Hospital readmissions

 
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1.3 
SCHEDULE OF ACTIVITIES (SOA) 
Procedures 
Enrollment/
Baseline 
Study day 1 
Daily visits 
throughout 
hospitalization  
Hospital 
Discharge 
1-month post-
hospitalization 
+/- 7 days 
3-months post-
hospitalization 
+/- 14 days 
 
12-months 
post-
hospitalization 
EMR review 
 
Informed consent 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
Administer study intervention 
X 
 
 
 
 
 
Vital signs- (BP, HR, RR, O2 sat) 
X 
 
 
 
 
 
Height 
X 
 
 
 
 
 
Weight 
X 
 
X 
 
 
 
Pregnancy test if needed 
X 
 
 
 
 
 
Anemia labsa 
X 
X 
X 
X 
X 
 
Platelet countd 
X 
 
X 
 
 
 
White blood cell countd 
X 
 
X 
 
 
 
Creatinined 
X 
 
X 
 
 
 
Functional outcome assessment b 
X 
 
X 
X 
X 
 
Con medication review c 
X 
X 
 
 
 
 
Fluid balance 
X 
 
X 
 
 
 
RBC transfusions documented 
X 
X 
X 
X 
X 
 
Daily phlebotomies for labs 
(excluding RMGs) 
 
X 
X 
 
 
 
Fatigue assessment 
 
 
X 
X 
X 
 
AE review and evaluation 
X 
X 
X 
X 
X 
 
Research Samplese 
X 
 
 
X 
X 
 
Hospital readmissions 
documentation 
 
 
 
X 
X 
X 
All cause mortality status 
 
 
 
 
 
X 
Complete Case Report Forms  
X 
X 
X 
X 
X 
X 
a. Hemoglobin, ferritin, and transferrin saturation will be obtained for all patients at enrollment, hospital  discharge, 1-month, and 3-months post-hospitalization. 
Other anemia labs to be reported at these and other timepoints include, if available Hemoglobin, MCV, RDW, ferritin, iron, transferrin saturation, reticulocyte 
hemoglobin, absolute reticulocyte count; record all values available recognizing that not all non-hemoglobin values will be available at each interval.  
b. Functional outcomes according to the Core Outcome Measurement Set will be obtained in the following fashion:  Enrollment – ADL survey (by patient or proxy); 
at Hospital discharge – EQ-5D, PROMIS-FATIGUE; at 1-month and 3-months – EQ-5D, PROMIS-FATIGUE, 6MWD, ADL Survey, MoCA-BLIND, HADS, IES-R, activity 
monitoring (optional study component).  
c. Concomitant meds review to include y/n for antiplatelet agents (i.e. aspirin, clopidogrel), anticoagulants (i.e. heparin, warfarin, direct oral anticoagulants, low 
molecular weight heparins), iron, and erythropoiesis stimulating agent use (i.e. darbepoetin, EPO). Daily visits only need to report if they received iron or 
EPO/darbepoetin. 
d. Platelets, WBC and Creatinine will be collected if done as standard of care. Baseline results used should be from within 24 hrs prior to enrollment. Hospital 
discharge results used should be the closest to discharge up to 72 hours prior. 
e. Research samples (10 ml phlebotomy) will be obtained at enrollment, 1-month, and 3-months and stored for potential biomarker assessment (i.e. hepcidin, IL-6, 
C-reactive protein) for future mechanistic studies on anemia development and recovery in critical illness survivors. 
 
2 
 
INTRODUCTION 
 
2.1 
STUDY RATIONALE  

 
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Anemia is common in the critically ill and is associated with poor patient outcomes both during and after hospitalization.  
Recent data suggests that anemia may also represent a potentially modifiable risk factor for impaired post-
hospitalization physical function.  The goal of this investigation is to test a multi-faceted anemia prevention and targeted 
treatment bundle (optimized phlebotomy practice, decision support, targeted pharmacologic anemia treatment) to 
attenuate anemia development and promote hemoglobin and functional recovery in the setting of critical illness. 
Specifically, we aim to assess the impact of the intervention on hemoglobin concentrations and functional outcomes (i.e. 
physical, cognitive, mental health) through 3-months after hospitalization.   
 
2.2 
BACKGROUND  
Anemia is remarkably common in the critically ill.1–3 Over the last 20 years, clinicians have become more tolerant of 
anemia during hospitalization and critical illness, a phenomenon driven in large part by the landmark Transfusion 
Requirements in Critical Care (TRICC) trial,4 which revealed similar 30-day mortality with restrictive versus liberal red 
blood cell (RBC) transfusion strategies. However, we now realize that survival of critical illness does not guarantee the 
quality of the life preserved. Up to 50% of survivors have substantial functional deficits in one or multiple domains 
related to physical function, cognition, mental health, and quality of life.5 This is increasingly relevant given the growing 
number of survivors of COVID-19-related critical illness.6 It is therefore paramount that we identify modifiable risk 
factors for impaired functional recovery in ICU survivors, of which anemia may be one potential target.7 Importantly, 
anemia has consistently been linked with impaired functional outcomes in non-critically ill populations, including the 
elderly,8–11 post-surgical patients,12–14 and those with hematologic disease15,16 and menstrual bleeding.17 However, our 
knowledge of post-hospitalization recovery from anemia in survivors of critical illness and its relationship with patient 
outcomes is limited, despite increasing anemia prevalence at the time of hospital discharge.3,18,19  
Regarding post-hospitalization hemoglobin recovery, a prospective investigation of 19 critically ill patients with 
anemia discovered that approximately 50% remained anemic 6-months later.20 In our data from 6460 survivors of critical 
illness enrolled in large population-based health study,21,22 80% of subjects were discharged from the hospital with 
anemia.3 At 12 months post-hospitalization, only half of those alive with available hemoglobin assessments had 
recovered to non-anemic status, with recovery varying in accordance with anemia severity at hospital discharge. These 
data confirm that for many patient’s anemia persists long after the resolution of critical illness. Additionally, higher 
hemoglobin concentrations at hospital discharge were associated with reduced post-hospitalization mortality in 
adjusted analyses (HR 0.95 [95% CI 0.90-0.99], per 1 g/dL increase; p=0.020), suggesting that anemia may have 
important implications for downstream clinical outcomes. Preliminary data from this cohort also shows that hemoglobin 
concentrations are strongly associated with unplanned hospital readmissions in the first 30-days after hospital 
discharge, with each 1 g/dL increase in hemoglobin associated with a 15% reduction in the instantaneous hazard for 
readmission after multivariable adjustment (HR 0.85, 95% CI 0.78, 0.93; p< 0.001; unpublished). Patient readmission 
status over time by the severity of anemia at hospital discharge for critical illness survivors is shown in Figure 1.   

 
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While the relationships between anemia and functional recovery after critical illness remain incompletely defined, 
our recent data from a multi-center prospective cohort of 195 survivors of acute respiratory distress syndrome 
discovered that anemia after critical illness was associated with impaired physical function 3-months later,7 including 
reductions in ambulatory capacity (i.e. 6-minute walk distance [6MWD]) and activities of daily living (ADLs). This suggests 
that anemia may represent a modifiable risk factor for improved physical outcomes after critical illness. However, 
relationships with other functional outcomes (cognition, mental health, quality of life) remain unknown, and it is unclear 
what effect the extent and timing of recovery from anemia after critical illness may have on outcomes. These 
multidimensional functional outcomes have been deemed of the highest importance for contemporary critical illness 
research.23  
Anemia management strategies include prevention, attenuation, and treatment.  Prevention and attenuation 
strategies are largely related to minimizing iatrogenic anemia development or progression secondary to phlebotomy and 
hemodilution.  Most prominently, this includes the use of low-volume blood sampling strategies.  Observational suggests 
that these low-volume blood draw strategies may decrease iatrogenic blood loss and transfusions,24 though clinical trial 
data is limited.25,26 In addition to low-volume phlebotomy, the use of clinical decision support is another method to 
promote appropriate lab utilization and to minimize excessive blood draws, though this has not been formally studied in 
critically ill patients. Regarding non-transfusion-based anemia treatment options, iron and erythropoietin (EPO) have 
been used in numerous clinical trials in the setting of critical illness.27–32  While these therapies have consistently 
augmented hemoglobin recovery during hospitalization, they have had inconsistent results on RBC reductions and 
mortality, for which reason they have not been widely adopted into clinical practice.  However, we now recognize that 
survival of hospitalization is not the final hurdle for critical illness survivors, and there is increasing recognition that 
anemia may contribute to persistent post-hospitalization impairments in daily functioning.7  As such, strategies to 
augment hemoglobin recovery during critical illness may favorably influence post-hospitalization outcomes, though this 
remains incompletely studied.  In one recent randomized clinical trial of intravenous iron with or without EPO therapy 
administered at the time of ICU discharge versus standard care, there was no difference between groups in the primary 
outcome of post-hospitalization length of stay.  However, patients receiving the treatment had a significant reduction in 
90-day mortality (17% vs. 8%). Additionally, there is growing evidence in surgical patients that anemia treatment can 
have positive consequences for patients that extend beyond hospitalization.33  Hence, future research is clearly 
warranted.   
Briefly, this is a randomized clinical trial of a multifaceted anemia prevention and treatment bundle versus standard 
of care to assess the impact of the intervention on hemoglobin recovery and post-hospitalization functional outcomes.  
Each patient randomized to the intervention will receive 3 treatment components: 1) optimized phlebotomy practice; 2) 
clinical decision support; and 3) pharmacologic anemia treatment.  With regards to pharmacologic anemia treatment, 
patients may receive either a single dose of intravenous (IV) iron therapy in isolation if they have an iron-responsive 
anemia or a single dose of EPO if they have an anemia of inflammation requiring erythropoietic stimulation.  Further, 
some patients receiving EPO may also receive a single dose of IV iron to replenish iron stores prior to EPO administration 
Figure 1. The percentage of patients 
still alive and not readmitted to the 
hospital (y-axis) over time (x-axis) is 
shown for critical illness survivors 
without anemia (hemoglobin >12 g/dL 
females, >13 g/dL males) and with 
mild (hemoglobin 10-12 g/dL female, 
10-13 g/dL male), moderate 
(hemoglobin 8-10 g/dL), and severe 
anemia (hemoglobin < 8 g/dl) at 
hospital discharge. 

 
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(i.e. if serum ferritin is < 1000 ng/ml at the time of randomization).  Patients randomized to the standard of care arm will 
receive usual ICU cares.   
 
2.3 
RISK/BENEFIT ASSESSMENT   
 
2.3.1 KNOWN POTENTIAL RISKS  
There is minimal patient risk associated with the employment of 1) optimized phlebotomy practices, or 2) decision-
support aids.  Changes to phlebotomy practice include: default low-volume blood sampling (e.g. 0.1-2 ml for most lab 
draws rather than 3-10 ml), which exposes the patient to no direct risk, and utilization of closed-loop blood sampling 
systems in order to minimize blood draw waste, again with no direct risk to the patient.  Low-volume blood sampling is 
already used clinically in our ICU environments for patients with severe anemia. In rare circumstances (<1%), a low-
volume sample may be insufficient for laboratory testing and additional phlebotomy may be required. Closed-loop blood 
sampling for those with pre-existing arterial or central venous catheters provides a method of returning “waste blood” 
directly to the patient rather than disposing of this “waste” volume, which typically is 10 ml per sample. It is routinely 
used throughout our pediatric ICU practices with no harm to patients, including no increased risk of infection. It has not 
been adopted into adult ICU practice given higher cost. At 1 and 3-month follow-up, patients will again undergo 
phlebotomy testing. There is a risk of patient discomfort with the additional blood draws at these follow-up 
assessments, which will be disclosed at the time of enrollment. Patients will retain the right to refuse these blood draws 
or any other follow-up measures. Additionally, a total of 5cc of blood will be removed for laboratory sampling at each 
follow-up assessment; this is not expected to have any substantial negative clinical consequence.  
 
The third component of the clinical intervention is the utilization of EPO and/or iron for the treatment of anemia, which 
does carry tangible patient risks. Iron will be administered as a single 1000 mg dose of IV low molecular-weight iron 
dextran. This is an approved therapy for patients with iron-deficiency anemia that is utilized in current clinical practice 
for critically ill patients with anemia and contraindications to transfusion therapies (i.e. Jehovah’s witness patients) and 
post-surgical patients after large volume blood loss. The estimated incidence of SAEs with newer IV iron formulations, 
such as low molecular weight iron dextran, is less than 1 in 250,000 administrations.34 Nevertheless, immediate risks of 
IV iron are real and include allergic reactions (<1%) and non-allergic infusions reactions (e.g. myalgias, arthralgias, 
dizziness, <1%). Additionally, as a long-term risk, repeated doses of iron administration, particularly to patients with iron 
storage disorders (i.e. hemochromatosis) or those requiring frequent and recurrent RBC transfusions, can culminate in 
iron overload. Patients with hemochromatosis or elevated iron stores (i.e. ferritin > 1000 ng/ml) will not be eligible to 
receive iron therapies in this study.  
 
EPO (i.e. Epoetin alpha), the erythropoiesis stimulating agent utilized in this trial, will be administered as a single 40,000 
unit subcutaneous injection after iron supplementation, though iron supplementation will be withheld for those with 
ferritin > 1000 ng/ml.  It has been used in previous clinical trials of anemia management in critical illness, and it is 
utilized in our current clinical practice for critically ill anemic and post-surgical patients with contraindications to 
transfusion therapies (i.e. Jehovah’s witness patients). There are short-term risks associated with this therapy, including 
minor non-allergic adverse reactions (nausea, dizziness, high blood pressure, pruritis; estimated <10%) and major rare 
adverse reactions (e.g. deep venous thrombosis, uncontrolled hypertension, myocardial infarction; estimated <1%). 
There is a black box warning for myocardial infarction, stroke, venous thromboembolism, vascular access thrombosis, 
and mortality when targeting hemoglobin levels >11 g/dL, data which is derived from repeated use of EPO to achieve 
near-normal hemoglobin levels for patients with chronic kidney disease. In a recent systematic review and meta-analysis 
of 21 trials in critical illness, the relative risk (RR) for mortality with EPO was 0.82 (95% CI 0.71-0.94).35 There were no 
significant differences in serious adverse events (RR 1.11, 95% CI 0.94-1.31) or VTE (RR 1.17, 95% CI 0.87-1.58), though 
these data do not exclude the potential for a clinically significant increase in the risk for adverse events with EPO 
therapy. As a longer-term risk, EPO may theoretically increase the risk of tumor progression or recurrence in patients 
with cancer. However, these concerns are derived from trials in non-surgical oncologic patients utilizing large doses of 
ESAs for extended periods of time, particularly when targeting normal hemoglobin levels.36–38 However, the 

 
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alone; hence, the potential benefits of IV iron in this group are high while the potential harms of EPO administration 
(e.g. thrombosis) likely outweigh any incremental benefit on hemoglobin recovery. Further, IV iron will be given as a 
single total dose infusion, which provides complete restoration of usable iron for >4 weeks.45,46 For anemias requiring 
erythropoietic stimulation, EPO will be given as a single 40,000 unit dose after ensuring restoration of iron stores, a 
strategy that has resulted in sustained hemoglobin improvement and is widely used in anemia clinics.46,47 Patients with 
laboratory evidence (i.e. ferritin > 1000 ng/mL) or clinical conditions (i.e. hemochromatosis) indicating states of iron 
overload will not receive iron supplementation prior to EPO therapy.  A single EPO dose carries a lower risk for 
thrombotic complications than repeat dosing, which is particularly relevant in the critically ill. 
Regarding the safety of IV iron (i.e. low molecular weight iron dextran), this medication is used extensively in modern 
medical practice.  The estimated incidence of serious adverse events (SAEs) is less than 1 in 250,000 administrations.34  
The medication will be administered by critical care nurses who have received training in iron administration in 
accordance with institutional medication administration protocols. A small test dose of 25 mg will be given over 5 
minutes to ensure no symptoms of adverse reaction with continuous assessment by the bedside nurse, including 
continuous monitoring of pulse oximetry, heart rate, and blood pressure (continuously for those with an invasive arterial 
catheter, and every 5 minutes for those without) and visual inspection of the patient for rashes or signs of physical 
and/or respiratory distress. At the discretion of the clinical team, patients deemed to be at high-risk for infusion 
reactions (e.g. inflammatory arthritis) may be given steroid premedication (e.g. 125 mg methylprednisolone). If a patient 
develops or is suspected of developing an infusion reaction, therapy will be immediately halted. All infusion reactions 
will be immediately reported to study personnel for accurate characterization and reporting. Those deemed to have a 
minor infusion reaction (i.e. rash in absence of hemodynamic or respiratory compromise) will be observed for 15 
minutes for signs of clinical progression.  If symptoms abate within 15 minutes, the infusion will be restarted at a lower 
rate.  If the patient has persistent mild symptoms, recurrent symptoms, and/or urticaria, they will be treated with an H2-
blocker antihistamine (e.g. ranitidine 50 mg), in accordance with institutional policy, prior to restarting the infusion at a 
lower rate. If there is concern for a moderate infusion reaction or further symptom progression (e.g. hypotension, 
worsening rash), patients may also receive IV steroids (e.g. methylprednisolone 1-2 mg/kg) +/- a 1L bolus of intravenous 
isotonic crystalloid (at discretion of ICU team) in addition to H2 blockers. Symptoms should abate completely prior to re-
challenging with IV iron, and an alternative iron formulation with comparable dosing should be considered (e.g. iron 
sucrose).  Should a severe reaction be observed (i.e. respiratory distress, anaphylaxis), the patient will receive immediate 
treatment with IV epinephrine (e.g. 0.1 mg) and additional cardiopulmonary support as dictated by the ICU treatment 
team.  Patients without any apparent reaction to IV iron will be observed clinically for 1 hour post-infusion for the 
development of delayed reactions with blood pressure measurements at least every 15 minutes, continuous pulse 
oximetry, and telemetry. Those experiencing infusion reactions will be observed for longer times as dictated by the 
severity of the reaction.  It is commonly thought that iron may predispose patients to bacterial infections;44 however, 
this has not been shown in multiple clinical trials in the critically ill.32,48,49 Out of an abundance of caution, we will exclude 
patients with uncontrolled sepsis, defined as <48 hours of appropriate antimicrobial therapy and/or lack of definitive 
source control.  
Regarding EPO, several actions are being taken to mitigate risk: 1) excluding patients with relative contraindications to 
EPO therapy (e.g. pregnancy, active thrombosis, an inability to receive VTE pharmacoprophylaxis, active myocardial 
ischemia, poorly controlled hypertension, recent stroke); 2) tailoring pharmacotherapy to anemia etiology, such that 
EPO is not administered to patients that are likely to mount an appropriate erythropoietic response with iron therapy 
alone; and 3) providing only a single dose of EPO therapy for those receiving this therapy. Of note, the optimal dosing of 
EPO is unknown in the critically ill, though clinical trials in surgical patients have shown that a single dose of EPO results 
in sustained hemoglobin improvement.47  All adverse events will be closely evaluated by study personnel as outlined in 
the data safety monitoring plan.  Similar to iron, EPO will be administered by critical care nurses in accordance with 
institutional medical administration protocols. Iron will be co-administered immediately prior to EPO to ensure 
adequate iron stores for EPO-induced augmentation of bone marrow erythropoiesis.   Patients will be continuously 
monitored at the time of administration for immediate adverse effects (e.g. cutaneous reactions, hypertension, 
dizziness, nausea).  Those without immediate reaction will be observed clinically for 1 hour post-infusion for the 

 
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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
frame: 1 and 3-months post-
hospitalization] 
To assess the impact of the intervention 
on cognitive function after critical illness 
MoCA-BLIND [Time frame: 1 and 3-
months post-hospitalization] 
Recommended as part of Core 
Outcome Measurement Set (COMS) 
for ICU survivors 
To assess the impact of the intervention 
on mental health after critical illness 
HADS, IES-R [Time frame: 1 and 3-
months post-hospitalization] 
Recommended as part of Core 
Outcome Measurement Set (COMS) 
for ICU survivors 
To assess the impact of the intervention 
on RBC transfusions  
Allogeneic RBC transfusions (units) 
[Time frame: hospitalization, through 
3-months post-hospitalization] 
Anemia management may directly 
result in reductions in RBC 
transfusions 
To assess the impact of the intervention 
on unplanned hospital readmissions 
through 12-months post-hospitalization. 
Unplanned hospital readmissions 
[Time frame: 12 months] 
Previous data suggests that anemia 
treatment with iron therapies may 
reduce hospital readmissions 
To assess the impact of the intervention 
on mortality through 12-months post-
hospitalization 
All-cause mortality [Time frame: 12 
months] 
Previous data suggests that IRON 
and EPO may reduce mortality 
during and after critical illness 
 
 
 
4 
STUDY DESIGN  
 
4.1 
OVERALL DESIGN 
 
This is a pragmatic, open-label, single-center, randomized phase 2 pilot clinical trial for superiority of a multi-faceted 
anemia prevention and treatment strategy assessing the impact of the intervention on hemoglobin concentrations and 
functional outcomes after hospitalization. We hypothesize that the multifaceted anemia intervention will increase 
hemoglobin concentrations and will improve multi-faceted functional recovery after hospitalization when compared to 
standard care.  
Patients satisfying inclusion/exclusion criteria, or their legal proxies, will be approached by trained study coordinators 
for written informed consent. Participants will be randomized 1:1 to active intervention vs. standard care using a 
stratified permuted block design by anemia etiology (iron-responsive or not) and ICU admission indication (surgical vs. 
non-surgical).  The intervention arm is multi-faceted with 3 primary components: 1) Optimized phlebotomy, defined by 
minimal volume draws (i.e. 0.1-2 ml vs. standard 3-10 ml per laboratory order) and closed-loop blood sampling 
(eliminates 10 ml waste volume per draw), all performed by a dedicated phlebotomy team independent from the 
treatment team; 2) Decision support aids, including visual and electronic alerts reminding the care team to minimize 
non-essential laboratory testing and mitigate patient-specific bleeding risk (e.g. stress ulcer prophylaxis in high-risk 
patients); and 3) Pharmacologic anemia treatment (given immediately following enrollment when hemoglobin first 
observed <10 g/dL) targeted to 2 broad groups: 1) anemias responsive to iron supplementation alone (i.e. acute blood 
loss, true iron deficiency [i.e. ferritin <100 ng/ml, transferrin saturation < 20%]), and 2) anemias requiring erythropoietic 
stimulation (e.g. anemia of inflammation, anemia of renal disease). Etiology of anemia will be determined immediately 
prior to randomization upon review of laboratory values (i.e. iron studies) and clinical history (i.e. admission diagnoses, 
surgery/acute blood loss) with treatment decisions adjudicated pre-randomization by the PI or Co-I’s. Subjects then 
randomized to the intervention arm will receive pharmacologic anemia treatment in accordance with their anemia 
etiology.  Patients with anemias responsive to iron supplementation will receive a single total dose infusion (1000 mg) of 
intravenous (IV) iron dextran. Patients with anemias requiring erythropoietic stimulation will receive a single dose of 
40,000 units of subcutaneous EPO, which will be immediately preceded by 1000 mg of IV iron dextran to replenish 
usable iron stores if the ferritin level is < 1000 ng/ml.  All patients randomized to the intervention group will receive 

 
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either IV iron, EPO, or both.  Targeted pharmacologic anemia therapies are being employed given that anemia in acute 
blood loss/post-surgery and true iron deficiency is iron-restricted and responds to iron supplementation alone; hence, 
the potential harms of EPO (e.g. thrombosis) likely outweigh benefits.  
 
Outcome assessment:  
In-person outcome assessments will occur at 1 month and 3 months post-hospitalization, with investigators and 
outcome assessors blinded to treatment allocation. The primary outcome will be the mean difference in hemoglobin 
between groups at 1 month. Differences in hemoglobin concentrations will also be assessed at ICU discharge, hospital 
discharge, and 3 month follow-up. Secondary outcomes will include changes in phlebotomy practice (i.e. number of 
draws, total volume of draws) during hospitalization and functional outcomes at 1 and 3 months, employing the NHLBI-
funded Core Outcome Measurement Set (COMS) for survivors of critical illness (aim 2b).23,50 This includes validated 
measures of physical function (6MWD, ADL survey), cognition (Montreal Cognitive Assessment Blind), mental health 
(Hospital Anxiety and Depression Scale, Impact of Events Scale-Revised), and quality of life (EQ-5D).  Additionally, as an 
optional study component, we will solicit patients to wear an activity monitor (Actigraph) on their wrist for 4 consecutive 
days at 1 and 3-months, from which we will capture daily step counts and energy expenditure measurements.  We will 
also assess several Epic-embedded patient-reported outcomes (i.e. PROMIS) with multidimensional computerized 
adaptive testing (i.e. PROMIS CAT), laying the groundwork for validation in critical illness research.  Differences in RBC 
transfusion rates will be assessed through 3 month follow-up. We will also assess hospital readmissions and mortality 
through 12-months post-hospitalization.  Research samples obtained will be stored for potential biomarker assessment 
(i.e. hepcidin, IL-6, C-reactive protein) for future mechanistic studies on anemia development and recovery in critical 
illness survivors.  
 
Sample size estimation:  
Power/sample size are calculated to detect a difference in the primary endpoint of hemoglobin at 1 month follow-up. 
Preliminary data show mean (standard deviation) hemoglobin levels of 10.8 (1.5) g/dL at 1 month among 636 patients 
with similar inclusion/exclusion criteria receiving standard care. A total sample size of 74 (37 per group) provides 80% 
power to detect 1.0 g/dL improvement using a two-sample unequal variances t-test with 2-sided alpha of 0.05 to 
compare 1 month hemoglobin between randomized arms.  Actual power is expected to be higher under the analysis 
approach, adjusting for pre-randomization prognostic variables to reduce residual variation. If adjustment variables 
account for 25% of the variation in 1 month hemoglobin (R2 for relationship between pre-randomization adjustment 
variables and outcome = 0.25), the sample size of 37 per group provides 90% power to detect a 1.0 g/dL improvement 
using analysis of covariance with 2-sided alpha of 0.05. While the analysis uses a linear mixed-effects model (LMM), 
power is not appreciably different for the LMM as compared to the unequal variances t-test or ANCOVA described here. 
Given expected dropout of up to 25% (death, loss to follow-up) resulting in loss of information, 100 subjects will be 
enrolled. 
 
Statistical considerations:  
The primary outcome is hemoglobin measured repeatedly on subjects at ICU discharge, hospital discharge, and 1 month 
and 3 months. The longitudinal trajectory of hemoglobin will be analyzed with a LMM. The primary parameter of 
interest is a treatment group by time interaction to estimate the effect of treatment at each follow up time-point. The 
treatment effect on 1 month hemoglobin is the primary outcome; other time-points will reflect secondary outcomes. As 
the functional form of hemoglobin over time is unknown, a discrete time representation will be used. The model will 
adjust for pre-randomization hemoglobin, age, sex, anemia etiology, and medical vs surgical ICU setting to reduce 
residual variation and improve precision of the estimated treatment effect.  
Dropout or non-response including skipped study visit and death represent two forms of missing data.  Dropout or non-
response unrelated to death at ICU discharge and hospital discharge is expected to be negligible but could occur with 

 
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withdrawal of consent.  We assume dropout (unrelated to death) while in the ICU is missing completely at random 
(MCAR); patients withdrawing consent prior to observation of hemoglobin outcome at ICU discharge will be excluded 
from the analysis.  Those dropping out after ICU discharge are assumed missing at random (MAR) with missingness 
possibly related to adjustment covariates, arm, or prior observed hemoglobin values.  Analyses using LMM assume 
dropout, nonresponse, or skipped visits are MAR. 
We anticipate up to 10% ICU mortality (despite exclusion of those not expected to survive hospitalization); such subjects 
will not have observed hemoglobin outcomes. We also anticipate additional post-ICU discharge mortality. In the primary 
analysis, we assume missing data due to death is MAR.  Those with ICU mortality will have ICU discharge hemoglobin 
multiply imputed under the MAR assumption.  Thereafter, LMMs assume additional missing data at other times are 
MAR.  In secondary approaches to the analysis of hemoglobin, we use a worst-case imputation approach, to impute 
hemoglobins as the worst possible outcome following death.  After imputation, if residuals are not reasonably normally 
distributed, a generalized linear mixed effects proportional odds model will be used or individual timepoints may be 
assessed by Wilcoxon rank-sum test without covariate adjustment.  A similar approach using proportional odds models 
or Wilcoxon rank-sum test will apply to functional outcomes which are not expected to satisfy regression assumptions 
including normality of residuals. Similar approaches assuming MAR and MNAR will be applied to missing functional 
outcome data. 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
This is a randomized parallel arm clinical trial comparing the multifaceted anemia intervention against control (standard 
care).  The control group will receive standard care without an active placebo for several reasons: 1) the multifaceted 
nature of the study intervention makes it difficult to design a placebo for each unique intervention element, particularly 
clinical decision support and optimized phlebotomy); 2) the expenses associated with administering a placebo for 
pharmacologic agents (i.e. iron, EPO) are considerable and would not be possible through the NIH K-23 funding 
mechanism; and 3) this is a pilot trial which will inform a larger, multi-center definitive clinical trial in which we would 
have the resources available for placebo administration of pharmacologic therapies.  Superiority will be assessed as the 
goal is to improve anemia in the critically ill, given that the problem of anemia is extremely prevalent in the ICU, rather 
than to prove non-inferiority against standard care.   
 
4.3 
JUSTIFICATION FOR DOSE 
 
IV iron given as a single total dose infusion of 1000 mg of IV low molecular weight iron dextran, which provides complete 
restoration of usable iron for >4 weeks and is the most commonly used dose in clinical practice for patients with iron 
deficiency.45,46 For anemias requiring erythropoietic stimulation, EPO will be given as a single 40,000 unit dose after 
ensuring restoration of iron stores, a strategy that has resulted in sustained hemoglobin improvement and is widely 
used in anemia clinics.46,47 A single EPO dose carries a lower risk for thrombotic complications than repeat dosing, which 
is particularly relevant in the critically ill. Defining optimal treatment dosing and duration remains a priority for future 
research.  
 
4.4 
END OF STUDY DEFINITION 
A participant is considered to have completed the study if they have completed all phases of the study including the last 
visit shown in the Schedule of Activities (SoA), Section 1.3.  Data on mortality and hospital readmission will be extracted 
at 12-months post-hospitalization for each patient by review of the electronic medical record.   
 
 
5 
STUDY POPULATION 
 
5.1 
INCLUSION CRITERIA 

 
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To be eligible to participate in this study, an individual must meet all the following criteria: 
1. Provision of signed and dated informed consent form (may be completed by legal proxies for those patients 
unable to provide consent, i.e. sedation/intubation) 
2. Stated willingness to comply with all study procedures and availability for the duration of the study, including 
follow-up assessments 
3. Male or female, age > 18 years 
4. Current ICU admission at Mayo Clinic Rochester  
5. Current ICU duration < 7 days   
6. Patients embedded in the local or regional Mayo Clinic Health System to facilitate post-hospitalization outcome 
assessment 
7. Moderate-to-severe anemia (i.e. hemoglobin concentration < 10 g/dL) at the time of enrollment, with the 
hemoglobin concentration assessed no more than 24 hours prior to enrollment.  If RBC transfusion has been 
administered between the qualifying hemoglobin assessment and enrollment, a repeat hemoglobin will be 
required prior to enrollment to ensure that it remains < 10 g/dL.   
 
5.2 
EXCLUSION CRITERIA 
 
An individual who meets any of the following criteria will be excluded from participation in this study: 
1. IV iron or any ESA use (i.e. darbepoetin, Aranesp, erythropoietin, Epogen, Procrit, Retacrit) within 30 days of 
enrollment. Oral iron is permitted (e.g. oral iron supplements, multivitamin with iron) 
2. Severe anemia prior to hospitalization (i.e. hemoglobin consistently <9 g/dL in the 90 days prior to  admission). If 
hemoglobin is not available or if hemoglobin is ≥9 g/dL at any time within 90 days prior to enrollment, then this 
criterion is not met, and the patient may be enrolled  
3. Known allergic reactions to IV iron or any EPO agent 
4. Inability to complete outcome assessments (i.e. not expected to survive hospitalization, unable to make follow-
up appointments, non-ambulatory status preceding hospitalization, dementia or other severe cognitive 
impairment, visual impairment i.e. blind or legally blind, non-English speaking) 
5. Pregnancy or breastfeeding at time of enrollment given unclear safety of EPO  
6. Inability to receive pharmacologic venous thromboembolic prophylaxis except in patients with acute blood loss 
anemia (i.e. recent surgery or gastrointestinal bleeding, extracranial bleeding) 
7. Active or suspected thrombosis (i.e. DVT, pulmonary embolism, acute arterial thrombus) within 3 months except 
in patients with acute blood loss anemia (i.e. recent surgery, gastrointestinal bleeding, extracranial bleeding) 
8. Uncontrolled sepsis (i.e. lack of definitive source control and/or <48 hours of appropriate antimicrobial therapy) 
9. Having received ≥10 units of allogeneic RBCs in the 48 hours before enrollment 
10. Acute coronary syndrome (STEMI or NSTEMI) or ischemic stroke within 3 months except in patients with acute 
blood loss anemia (i.e. recent surgery, gastrointestinal bleeding, extracranial bleeding) 
11. Weight less than 40 kg  
12. Concerns with study enrollment expressed by the clinical team 
 
5.3 
LIFESTYLE CONSIDERATIONS 
 
Not applicable 
 
5.4 
SCREEN FAILURES 
 
Screen failures are defined as participants who consent to participate in the clinical trial but are not subsequently 
randomly assigned to the study intervention or entered in the study. A minimal set of screen failure information is 

 
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required to ensure transparent reporting of screen failure participants, to meet the Consolidated Standards of Reporting 
Trials (CONSORT) publishing requirements and to respond to queries from regulatory authorities. Minimal information 
includes demography, screen failure details, and eligibility criteria. 
 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of subsequent hemoglobin 
assessments which prove exclusionary (i.e. hemoglobin > 10 g/dL) may be rescreened as long as they remain in the ICU 
with a duration not to exceed 7 days at the time of enrollment. Rescreened participants should be assigned the same 
participant number as for the initial screening.  
 
5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
Recruitment: Trained study coordinators from the Anesthesia Clinical Research Unit will receive daily electronic alerts 
notifying them of Mayo Clinic Rochester ICU patients > 18 years of age with a most recent hemoglobin value <10 g/dL 
(infrastructure for these near real-time electronic alerts [2-5 minute delay] are already in place through the ICU 
DataMart).  Patients may be present in any adult ICU.  These patients will then be screened through Electronic Health 
Record (EHR) review by study staff to ascertain eligibility in accordance with inclusion/exclusion criteria. Patients 
meeting inclusion/exclusion criteria will be approached by study coordinators in their patient room, or by telephone if 
indicated based on current clinical and/or IRB policies in the setting of COVID-19-related clinical practice/research 
modifications. Study coordinators will meet with patient or their legal proxies in the case of a patient’s inability to 
directly communicate with study personnel (i.e. deep sedation). The study coordinator will review the research study in 
detail, explaining the purpose of the study including iron and erythropoietin administration, additional necessary 
phlebotomy and needed follow up post hospital dismissal.  It will be made clear that all participants will receive routine 
clinical care regardless of whether they 1) agree to participate in the trial, or 2) are randomized to the active treatment 
arm. The informed consent discussion will occur between the patient and a member of the study team at the patient’s 
bedside during ICU admission as soon as the patient meets eligibility criteria (i.e. within 24 hours). The patient/proxy will 
be allowed time to have all their questions answered questions answered and assure no exclusions to enrollment are 
identified.  Written informed consent will be obtained by study staff with specific training in this procedure. Signed 
consent forms will be scanned into the patient’s HER and a copy will be provided to the study participant. No 
information will be used from patients that have not given consent to use their medical information.  In the event the 
LAR consents on behalf of the subject, the study coordinator will make sure and visit with the subject once functional 
status is reestablished to assure the subject wants to continue with participation. By this time, the subject may/may not 
have already received study drug, so all they would be affirming is their willingness to continue with the follow up 
visits/labs/questionnaires. 
Retention: A high-level of patient follow-up (>75%) is necessary for success, including in-person evaluations for 
hemoglobin laboratory draws. To achieve this, we have limited the study to residents residing locally (i.e. patients that 
receive routine medical cares in Mayo Clinic Rochester or the regional Mayo Clinic Health System), a unique population 
with a high-level of community engagement in clinical research and a high-level of post-hospitalization medical cares 
obtained primarily at the Mayo Clinic and its affiliated regional sites. Similar studies of Olmsted County residents, 
including those with laboratory draws, have achieved >90% retention.51 Additionally, we are partnering with the Mayo 
Clinic ICU Rehabilitation Program (MCIRP).  The MCIRP is a post-ICU clinic staffed by a physician, advanced ICU care 
nurse practitioner, ICU pharmacist, and occupational therapist, with the recent addition of a nurse coordinator. In the 
current care model, survivors of critical illness, identified through real-time electronic data “sniffers”, and their family 
members are approached by MCIRP team members for recruitment prior to hospital discharge. Patients are evaluated 
within 6 months of hospital discharge with a less than 5% no-show rate for enrolled participants and greater than 90% 
retention for additional visits. Multi-domain functional outcomes (physical, cognitive, mental health, quality of life) are 
assessed at each study visit in accordance with the NHLBI-funded improveLTO Core Outcome Measure Set 
(http://improvelto.com). Of note, with COVID-19 precautions, most MCIRP visits have been moved to virtual visitations. 
We will work with the MCIRP to ensure appropriate follow-up of all enrolled patients. Our goal remains in-person 
evaluations for all study participants in an outpatient setting. Of note, all core functional outcomes can be assessed over 

 
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the phone with exception of 6MWD. Additional retention in this clinical trial will be facilitated through employment of 
published cohort retention tools for longitudinal post-hospitalization critical care outcomes research 
 which have resulted in >90% cohort retention through 12 months.21 This includes utilization of 
a defined cohort retention protocol, careful collection of multiple unique sources of patient contact including proxies, 
frequent patient engagement, reminder notifications (e.g. reminder phone calls starting 2 weeks before each follow-up 
appointment and subsequently a phone call 1 week and 1 day before the appointment), remuneration (i.e. $25 per 
follow-up visit – 1 month and 3 months post-hospitalization), and vouchers for parking (4-hour parking passes, given at 
each follow-up visit). Recognizing that some patients may die or be lost to contact prior to outcome assessment (~25%), 
we have increased our study sample size from 74 to 100 participants.   
  
6 
STUDY INTERVENTION 
 
6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
 
6.1.1 STUDY INTERVENTION DESCRIPTION 
 
The intervention arm is multi-faceted with 3 primary components:  
1) Optimized phlebotomy, defined by minimal volume draws (i.e. 0.1-2 ml vs. standard 3-10 ml per laboratory 
order) and closed-loop blood sampling, all performed by a dedicated phlebotomy team independent from the 
treatment team. This intervention simply requires communication with the phlebotomy team rather than any 
direct change to patient care.   
2) Decision support.  This includes: 
a. A visual clinical support tool (appendix) urging the clinical team to minimize laboratory assessments and 
optimize patient bleeding risk.  This will be available by the clinical workstations for the ICU team and at 
the patient’s bedside.   
b. A daily rounding checklist (appendix) accompanied by brief daily discussion (2-minutes) between trained 
study coordinators and the ICU care team during clinical rounds to reiterate the purpose of the study.  
The checklist will be available at the clinical workstations for the ICU team. 
c. Epic direct messages sent twice per day (targeting day and night providers) with the information from 
the visual support tool to retitrate the purpose of the study. 
3) Pharmacologic anemia treatment.  These therapies will be given immediately following enrollment and targeted 
to 2 broad groups: 
a. Anemias responsive to iron supplementation alone.  This includes patients with anemia secondary to 
acute blood loss > 500 ml and patients with iron deficiency anemia (i.e. ferritin <100 ng/ml or transferrin 
saturation < 20%).   
• Patients with iron-responsive anemias will receive a single total dose infusion (1000 mg) of 
intravenous (IV) low molecular weight iron dextran (INFeD)  
• This medication is diluted in 500 ml of 0.9% saline. A 25 mg test dose (12.5) ml is administered 
over 5 minutes to ensure no immediate hypersensitivity reaction, followed by the completion of 
the infusion over 1-2 hours (not to exceed 1000 mg/hr). This medication will be given in 
accordance with Mayo Clinic administration guidelines. 
b. Anemias requiring erythropoietic stimulation. This includes anemia not secondary to acute blood loss or 
iron deficiency (e.g. anemia of inflammation, anemia of renal disease). Etiology will be determined 
immediately prior to randomization upon review of laboratory values (i.e. iron studies) and clinical 
history (i.e. admission diagnoses, surgery/acute blood loss) with treatment decisions adjudicated pre-
randomization by the PI and trial Co-I’s should the PI be unavailable.  
• Patients without iron-responsive anemias will receive a single dose of 40,000 units of 
subcutaneous EPO (Retacrit).  For those with ferritin less than 1000 ng/ml they will also receive 
1000 mg IV iron prior to EPO administration to replenish usable iron, given that iron will 

 
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invariably be mobilized secondary to EPO stimulation.  EPO will be given in accordance with 
Mayo Clinic administration guidelines.   
 
 
6.1.2 DOSING AND ADMINISTRATION 
 
Iron dextran shall be administered intravenously as a single dose of 1000 mg (25 mg test dose followed by 975 mg 
completion dose). EPO shall be administered as a single dose of 40,000 units subcutaneously. There is no patient-specific 
dose selection. Doses do not need to be modified in relation to meals.  
 
6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
 
This is a multifaceted intervention.  Optimized phlebotomy will be coordinated by direct communication to the 
phlebotomy team by trained study personnel.  Clinical decision support will be similarly coordinated by study 
coordinators.  If a patient is randomized to the intervention arm, study coordinators will contact the research pharmacy 
regarding the need for IV iron +/- EPO.  This will be distributed form the research pharmacy to the patient’s bedside 
followed by administration by the bedside critical care nurse. Study coordinators will be available to ensure appropriate 
administration.  Any unused and untampered agents will be immediately returned to the pharmacy.  
 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
 
Low molecular weight iron dextran (INFeD®, AbbVie, Inc.), details from package insert:  INFeD (iron dextran injection 
USP) is a dark brown, slightly viscous sterile liquid complex of ferric hydroxide and dextran for intravenous or 
intramuscular use. Each mL contains the equivalent of 50 mg of elemental iron (as an iron dextran complex), 
approximately 0.9% sodium chloride, in water for injection. Sodium hydroxide and/or hydrochloric acid may have been 
used to adjust pH. The pH of the solution is between 5.2 and 6.5.  
 
EPO (Retacrit®, Hospira, Inc), details from package insert: Epoetin alfa-epbx is a 165-amino acid erythropoiesis-
stimulating glycoprotein manufactured by recombinant DNA technology. It has a molecular weight of approximately 
30,400 daltons and is produced in Chinese Hamster Ovary (CHO) cell line. The product contains the identical amino acid 
sequence of isolated natural erythropoietin. RETACRIT (epoetin alfa-epbx) injection for intravenous or subcutaneous 
administration is a sterile, clear, colorless solution in single-dose vials, formulated with an isotonic sodium 
chloride/sodium phosphate buffered solution. Each 1 mL single-dose vial of 2,000, 3,000, 4,000, and 10,000 Units of 
epoetin alfa-epbx contains calcium chloride dihydrate (0.01 mg), glycine (7.5 mg), isoleucine (1 mg), leucine (1 mg), L-
glutamic acid (0.25 mg), phenylalanine (0.5 mg), polysorbate 20 (0.1 mg), sodium chloride (2.4 mg), sodium phosphate 
dibasic anhydrous (4.9 mg), sodium phosphate monobasic monohydrate (1.3 mg), and threonine (0.25 mg), in Water for 
Injection, USP. Each 1 mL vial of 40,000 Units of epoetin alfa-epbx contains calcium chloride dihydrate (0.01 mg), glycine 
(7.5 mg), isoleucine (1 mg), leucine (1 mg), L-glutamic acid (0.25 mg), phenylalanine (0.5 mg), polysorbate 20 (0.1 mg), 
sodium chloride (2.2 mg), sodium phosphate dibasic anhydrous (5.7 mg), Reference ID: 4263015 sodium phosphate 
monobasic monohydrate (1.5 mg), and threonine (0.25 mg), in Water  
 
6.2.3 PRODUCT STORAGE AND STABILITY 
 
Iron (INFeD®): Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).  
 
EPO (Retacrit®): Store at 36°F to 46°F (2°C to 8°C). Do not freeze. Do not shake. Do not use RETACRIT that has been 
shaken or frozen. Store RETACRIT vials in the original carton until use to protect from light. 

 
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6.2.4 PREPARATION 
 
No preparation (thawing, diluting, mixing, reconstitution) is required.  
 
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
 
Participants will be randomized 1:1 to active intervention vs. standard of care using a stratified permuted block design 
by anemia etiology (iron responsive vs. not) and ICU admission indication (surgical vs. non-surgical). Randomization will 
occur electronically using the REDCap randomization module.  Randomization lists will be developed by the study 
statisticians and uploaded directly to REDCap.  Study staff involved in patient care are unable to access randomization 
lists in advance and therefore are unlikely to predict future randomization/assignment. Clinicians and subjects will not 
be blinded to study interventions. However, all data analysts will be blinded to treatment allocation while the study is 
ongoing.  
 
6.4 
STUDY INTERVENTION COMPLIANCE 
Compliance will be assessed by the subject’s receipt of pharmacologic therapy (iron +/- EPO).  This will be assessed on 
study day 1 by research personnel. The proportion of subjects successfully receiving the intervention will be reported 
(number, %).  Similarly, the proportion of subjects seen for 1-month and 3-month follow-up assessments will be 
reported.  
 
6.5 
CONCOMITANT THERAPY 
 
For this protocol, a prescription medication is defined as a medication that can be prescribed only by a properly 
authorized/licensed clinician. Medications to be reported at baseline are all concomitant prescription medications, over-
the-counter medications and supplements.  Medications to be reported at daily visits are only to include if the subject 
has received iron or EPO/darbepoetin on these days. 
 
Subjects who received iron therapies (exclusive or multivitamins with iron) or erythropoiesis stimulating agents (i.e. 
darbepoetin , erythropoietin) within 30 days will be excluded, as these subjects have already been receiving anemia 
treatment prior to enrollment.    
 
 
6.5.1 RESCUE MEDICINE 
 
Not applicable 
 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT DISCONTINUATION/WITHDRAWAL.  
 
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
 
Discontinuation from the pharmacologic therapies (i.e. iron, EPO) does not mean discontinuation from the study, and 
remaining study procedures should be completed as indicated by the study protocol.  If a clinically significant finding is 
identified (including, but not limited to severe allergic reactions during medication administration) after enrollment, the 
investigator or qualified designee will determine if any change in participant management is needed. Any new clinically 
relevant finding will be reported as an adverse event (AE). 
 

 
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The data to be collected at the time of study intervention discontinuation will include the following: 
- 
Reason for discontinuation 
- 
Date and time of discontinuation 
- 
Subject-initiated or investigator-initiated discontinuation 
- 
Changes in vital signs or clinical status that prompted discontinuation 
- 
Adverse events 
 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
 
Participants are free to withdraw from participation in the study at any time upon request. 
An investigator may discontinue or withdraw a participant from the study for the following reasons: 
 
• 
Significant study intervention non-compliance  
• 
If any clinical adverse event (AE), laboratory abnormality, or other medical condition or situation occurs such 
that continued participation in the study would not be in the best interest of the participant 
• 
If the participant meets an exclusion criterion (either newly developed or not previously recognized) that 
precludes further study participation 
The reason for participant discontinuation or withdrawal from the study will be recorded on the appropriate Case 
Report Form (CRF). Subjects who sign the informed consent form and are randomized but do not receive the study 
intervention may be replaced.  Subjects who sign the informed consent form, and are randomized and receive the study 
intervention, and subsequently withdraw, or are withdrawn or discontinued from the study, will not be replaced. 
7.3 
LOST TO FOLLOW-UP 
 
A participant will be considered lost to follow-up if they fail to return for 2 scheduled post-hospitalization visits and is 
unable to be contacted by the study site staff.  
 
The following actions must be taken if a participant fails to return to the clinic for a required study visit: 
• 
The site will attempt to contact the participant and reschedule the missed visit within 1 week and counsel the 
participant on the importance of maintaining the assigned visit schedule and ascertain if the participant wishes 
to and/or should continue in the study. 
• 
Before a participant is deemed lost to follow-up, the investigator or designee will make every effort to regain 
contact with the participant (where possible, 3 telephone calls and, if necessary, a certified letter to the 
participant’s last known mailing address or local equivalent methods). These contact attempts should be 
documented in the participant’s medical record or study file.  
• 
Should the participant continue to be unreachable, they will be considered to have withdrawn from the study 
with a primary reason of lost to follow-up. 
 
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 
EFFICACY ASSESSMENTS  
 
Study subjects will undergo the following procedures/evaluations: 
• 
Baseline assessments. Medical history, surgical history, demographic features, height, weight, concomitant 
medication review and cumulative fluid balance, including previous exposure to blood transfusions, ADL survey.   

 
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• 
Biological specimen collection and laboratory evaluations. Following enrollment, study labs will be obtained 
according to table 1.3.  CBC and creatinine is often done daily as standard of care. If the subject has a CBC and 
creatinine value obtained within the prior 24 hrs, this result may be used. However, if they received a unit of 
blood after that timepoint, the CBC would need to be repeated.  All subjects will return for followup 
assessments and blood draws as noted in table 1.3.  The research blood samples for storage and future research 
will be obtained (10 ml per subject) at enrollment and post-hospitalization assessments for future mechanistic 
studies.  These samples will be cold-stored.  
• 
Administration of questionnaires or other instruments.  Subjects will undergo functional outcome assessments 
in accordance with the NHLBI-supported COMS of critical illness.  These measures, either comprehensively or in 
part (as outlined in 1.3), will be obtained at enrollment, hospital discharge, and 1-month and 3-months post-
hospitalization.  
 
8.2 
SAFETY AND OTHER ASSESSMENTS 
 
Subjects will undergo the following procedures/evaluations: 
• 
Vital signs. Temperature, pulse, respirations, blood pressure, continuous telemetry, oxygen saturations will be 
monitored during administration of iron and EPO for those in the intervention group as outlined in section 2.3.  
All subjects will receive standard ICU monitoring throughout their stay in the ICU.  
  
• 
Weight. Subjects < 40 kg will be excluded due to unclear safety of 40,000 unit of EPO in persons with low 
weights 
 
• 
Assessment of adverse events. Medical records will be reviewed daily for evaluation of adverse events.  Adverse 
events will be indicated on the data forms for the study and on the specific adverse event report forms and all 
serious adverse events will be reported to the IRB within 24 hours of the research team learning about the event 
followed by a more detailed written report to the IRB.  The following information about adverse events will be 
collected:  1) the onset and resolution of the event, 2) an assessment of the severity or intensity of the event, 3) 
an assessment of the relationship of the event to the intervention, and 4) any action taken because of 
event. The PI will report all potentially related SAEs to the DSMB and to NHLBI within 7 days of discovery.  
 
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
 
Adverse event means any untoward medical occurrence associated with the use of an intervention in humans, whether 
or not considered intervention-related (21 CFR 312.32 (a)). 
As our subject population is by definition ‘critically ill’, it is expected that they will have many unrelated adverse health 
events during their hospital stay. Therefore, we will limit the scope of our adverse event monitoring and recording to 
focus on the following conditions:  
➢ Study drug infusion reactions  
➢ Venous thromboembolic disease   
➢ Myocardial infarction 
➢ Non-hemorrhagic stroke 
➢ Bloodstream infections  
➢ Hypertensive urgency or emergency in the 1 hour after study drug administration (i.e. SBP > 200 or SBP 
increase by > 40 mmHg from the time of infusion start) 
 

 
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8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
 
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of either the investigator or 
sponsor, it results in any of the following outcomes: death, a life-threatening adverse event, inpatient hospitalization or 
prolongation of existing hospitalization, or a persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions.  
Serious adverse events (SAEs) will be defined as:  
➢ Death, believed to be related to the study procedures, or a death that is unexpected considering the 
acuity of a subject. 
➢ A life-threatening experience, including severe infusion reactions, believed to be related to the study 
procedures.  
➢ Persistent or significant disability or incapacity that is of greater frequency or severity than what would 
be normally expected in the course of critical illness. 
➢ An event that jeopardizes the human subject and may require medical or surgical treatment to prevent 
one of the preceding outcomes and is not expected in the subject’s ICU course. 
 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
 
8.3.3.1 SEVERITY OF EVENT 
 
For adverse events (AEs), the following guidelines will be used to describe severity.  
 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s clinical course.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic measures. Moderate 
events may cause some interference with the subject’s clinical course. 
• 
Severe – Events interrupt a participant’s clinical course and may require systemic drug therapy or other 
treatment. Severe events are usually potentially life-threatening or incapacitating. 
 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
 
All adverse events (AEs) must have their relationship to study intervention assessed by the clinician who examines and 
evaluates the participant based on temporal relationship and his/her clinical judgment.  The degree of certainty about 
causality will be graded using the categories below. In a clinical trial, the study product must always be suspect.  
 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible contributing 
factors can be ruled out. The clinical event occurs in a plausible time relationship to study intervention 
administration and cannot be explained by concurrent disease or other drugs or chemicals. The response to 
withdrawal of the study intervention (dechallenge) should be clinically plausible. The event must be 
pharmacologically or phenomenologically definitive, with use of a satisfactory rechallenge procedure if 
necessary. 
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence of other factors is 
unlikely. The clinical event occurs within a reasonable time after administration of the study intervention, is 
unlikely to be attributed to concurrent disease or other drugs or chemicals, and follows a clinically reasonable 
response on withdrawal (dechallenge). Rechallenge information is not required to fulfill this definition. 

 
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• 
Potentially Related – There is some evidence to suggest a causal relationship (e.g., the event occurred within a 
reasonable time after administration of the trial medication). However, other factors may have contributed to 
the event (e.g., the participant’s clinical condition, other concomitant events). Although an AE may rate only as 
“possibly related” soon after discovery, it can be flagged as requiring more information and later be upgraded to 
“probably related” or “definitely related”, as appropriate. 
• 
Unlikely to be related – A clinical event whose temporal relationship to study intervention administration makes 
a causal relationship improbable (e.g., the event did not occur within a reasonable time after administration of 
the study intervention) and in which other drugs or chemicals or underlying disease provides plausible 
explanations (e.g., the participant’s clinical condition, other concomitant treatments). 
• 
Not Related – The AE is completely independent of study intervention administration, and/or evidence exists 
that the event is definitely related to another etiology. There must be an alternative, definitive etiology 
documented by the clinician. 
 
8.3.3.3 EXPECTEDNESS  
 
The PI will be responsible for determining whether an adverse event (AE) is expected or unexpected.  An AE will be 
considered unexpected if the nature, severity, or frequency of the event is not consistent with the risk information 
previously described for the study intervention. 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention of study personnel 
during study visits and interviews of a study participant presenting for medical care, or upon review by a study monitor. 
 
As noted earlier, for this study we plan to observe for a specific set of AEs and this information will be captured on the 
appropriate case report form (CRF). Information to be collected includes event description, time of onset, clinician’s 
assessment of severity, relationship to study product (assessed only by those with the training and authority to make a 
diagnosis), and time of resolution/stabilization of the event. All AEs will be followed to adequate resolution. 
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event at each level of 
severity to be performed.  
 
Study coordinators will record all listed reportable events with start dates occurring any time after informed consent is 
obtained through 3-months after hospitalization.  At each study visit, the investigator will inquire about the occurrence 
of AE/SAEs since the last visit.  Events will be followed for outcome information until resolution or stabilization. 
 
 
8.3.5 ADVERSE EVENT REPORTING  
 
All adverse events will be indicated on the data forms for the study and on the specific adverse event report forms and 
all serious adverse events will be reported to the IRB within 24 hours of the research team learning about the event 
followed by a more detailed written report to the IRB.  The following information about adverse events will be 
collected:  1) the onset and resolution of the event, 2) an assessment of the severity or intensity of the event, 3) an 
assessment of the relationship of the event to the intervention, and 4) any action taken because of event. The PI will 
report all potentially related SAEs to the NHLBI immediately after discovery (within 7 days).  
 
8.3.6 SERIOUS ADVERSE EVENT REPORTING  
 

 
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The study clinician will immediately report to the IRB any serious adverse event, whether or not considered study 
intervention related, including those listed in the protocol or investigator brochure and must include an assessment of 
whether there is a reasonable possibility that the study intervention caused the event. Study endpoints that are serious 
adverse events (e.g., all-cause mortality) must be reported in accordance with the protocol unless there is evidence 
suggesting a causal relationship between the study intervention and the event (e.g., death from anaphylaxis). In that 
case, the investigator must immediately report the event to the sponsor. All serious adverse events (SAEs) will be 
followed until satisfactory resolution or until the site investigator deems the event to be chronic or the participant is 
stable.  
 
8.3.7 REPORTING EVENTS TO PARTICIPANTS  
 
Study coordinators will disclose any adverse events that are probably or definitively-related to the enrolled subject after 
review by the PI.  
  
8.3.8 EVENTS OF SPECIAL INTEREST  
 
Not applicable 
 
8.3.9 REPORTING OF PREGNANCY  
 
Not applicable 
 
8.4 
UNANTICIPATED PROBLEMS 
 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to participants or 
others to include, in general, any incident, experience, or outcome that meets all the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are described in 
the protocol-related documents, such as the Institutional Review Board (IRB)-approved research protocol and 
informed consent document; and (b) the characteristics of the participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a reasonable 
possibility that the incident, experience, or outcome may have been caused by the procedures involved in the 
research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or recognized. 
 
 
8.4.2  UNANTICIPATED PROBLEM REPORTING  
 
The investigator will report unanticipated problems (UPs) to the reviewing Institutional Review Board (IRB) and to the 
principal investigator (PI). The UP report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project number; 
• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome represents an UP;  
• 
A description of any changes to the protocol or other corrective actions that have been taken or are proposed in 
response to the UP. 

 
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To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB within 7-days of the investigator becoming 
aware of the event.  
• 
Any other UP will be reported to the IRB and to the DCC/study sponsor within 10-days of the investigator 
becoming aware of the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s written reporting 
procedures), the supporting agency head (or designee), and the Office for Human Research Protections (OHRP) 
within 10 days of the IRB’s receipt of the report of the problem from the investigator. 
 
 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS  
 
Study coordinators will disclose UPs that are probably or definitively-related to the enrolled subject. 
 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 
STATISTICAL HYPOTHESES 
In this study, we will perform a pilot pragmatic clinical trial testing a multi-faceted anemia intervention (optimized 
phlebotomy practice, decision support, targeted pharmacologic anemia treatment) to attenuate anemia development 
and promote functional recovery in the setting of critical illness  
Primary endpoint: To assess the impact of the intervention on 1 month post-hospitalization hemoglobin concentrations. 
Secondary endpoint: To assess the impact of the intervention on post-hospitalization functional outcomes and 
hemoglobin concentrations measured at 3 months. 
Hypotheses: A multifaceted anemia intervention will increase hemoglobin concentrations and will improve functional 
recovery through 3 months after hospitalization.  
 
9.2 
SAMPLE SIZE DETERMINATION 
Power/sample size are calculated to detect a difference in the primary endpoint of hemoglobin at 1 month follow-up. 
Preliminary data show mean (standard deviation) hemoglobin levels of 10.8 (1.5) g/dL at 1 month among 636 subjects 
with similar inclusion/exclusion criteria receiving standard care. A total sample size of 74 (37 per group) provides 80% 
power to detect 1.0 g/dL improvement using a two-sample unequal variances t-test with 2-sided alpha of 0.05 to 
compare 1 month hemoglobin between randomized arms.  Actual power is expected to be higher under the analysis 
approach, adjusting for pre-randomization prognostic variables to reduce residual variation. If adjustment variables 
account for 25% of the variation in 1 month hemoglobin (R2 for relationship between pre-randomization adjustment 
variables and outcome = 0.25), the sample size of 37 per group provides 90% power to detect a 1.0 g/dL improvement 
using analysis of covariance with 2-sided alpha of 0.05. While the analysis uses a linear mixed-effects model (LMM), 
power is not appreciably different for the LMM as compared to the unequal variances t-test or ANCOVA described here. 
Given expected dropout of up to 25% (death, loss to follow-up) resulting in loss of information, 100 subjects will be 
enrolled. 
The study has not been powered for exploratory outcomes such as RBC transfusion, mortality, and readmissions, but 
this data will serve for hypothesis-generation for future, larger clinical trials. 
 
9.3 
POPULATIONS FOR ANALYSES 

 
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As the primary approach, subjects will be analyzed using an intention-to-treat (ITT) approach. Secondarily, analysis will 
be performed using modified intention-to-treat.  
 
9.4 
STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
Baseline demographic and clinical characteristics will be presented using descriptive statistics, as applicable. Unadjusted 
outcome summary statistics will be described for each randomized group.  Continuous variables will be summarized by 
mean (standard deviation), median (25th, 75th) percentiles, and range.  Categorical variables will be summarized by 
percentage. 
 
The primary analysis dataset consists of all randomized participants and will be analyzed using intention-to-treat (ITT) 
principles such that each subject is analyzed based on their allocated arm.  Mortality and dropout may occur, and 
subjects will be analyzed as described in 9.4.2 and 9.4.3. 
A secondary analysis approach may consider a per-protocol analysis, analyzing those participants who completed study 
procedures without major protocol violations.  The per-protocol analysis definition will be finalized prior to database 
lock and data analysis.  The ITT analysis will be considered primary. 
 
9.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
The primary outcome is hemoglobin measured repeatedly on subjects at ICU discharge, hospital discharge, and 1 month 
and 3 months. The longitudinal trajectory of hemoglobin will be analyzed with a LMM. The primary parameter of 
interest is a treatment group by time interaction to estimate the effect of treatment at each follow up time-point. The 
treatment effect on 1 month hemoglobin is the primary outcome; other time-points will reflect secondary outcomes. As 
the functional form of hemoglobin over time is unknown, a discrete time representation will be used. The model will 
adjust for pre-randomization hemoglobin, age, sex, anemia etiology, and medical vs surgical ICU setting to reduce 
residual variation and improve precision of the estimated treatment effect.  
Dropout or non-response including skipped study visit and death represent two forms of missing data.  Dropout or non-
response unrelated to death at ICU discharge and hospital discharge is expected to be negligible but could occur with 
withdrawal of consent.  We assume dropout (unrelated to death) while in the ICU is missing completely at random 
(MCAR); subjects withdrawing consent prior to observation of hemoglobin outcome at ICU discharge will be excluded 
from the analysis.  Those dropping out after ICU discharge are assumed missing at random (MAR) with missingness 
possibly related to adjustment covariates, arm, or prior observed hemoglobin values.  Analyses using LMM assume 
dropout, nonresponse, or skipped visits are MAR. 
We anticipate up to 10% ICU mortality (despite exclusion of those not expected to survive hospitalization); such subjects 
will not have observed hemoglobin outcomes. We also anticipate additional post-ICU discharge mortality. In the primary 
analysis, we assume missing data due to death is MAR.  Those with ICU mortality will have ICU discharge hemoglobin 
multiply imputed under the MAR assumption.  Thereafter, LMMs assume additional missing data at other times are 
MAR.  In secondary approaches to the analysis of hemoglobin, we use a worst-case imputation approach, to impute 
hemoglobins as the worst possible outcome following death.  After imputation, if residuals are not reasonably normally 
distributed, a generalized linear mixed effects proportional odds model will be used or individual timepoints may be 
assessed by Wilcoxon rank-sum test without covariate adjustment.   
In the primary analysis, the point estimate, 95% confidence interval, and p-value will be reported from the LMM for the 
1 month hemoglobin comparison.  A point estimate in the direction favoring higher hemoglobin for the intervention arm 

 
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and two-sided p-value<0.05 will reject the null hypothesis of no treatment benefit in favor of the conclusion that 
intervention improves 1 month hemoglobin. 
 
9.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
 
Secondary and exploratory endpoints (besides hemoglobin at 3 months) include EQ-5D [Time frame: hospital discharge, 
1 month, and 3 months post-hospitalization], PROMIS-Fatigue [Time frame: hospital discharge, 1 month, and 3 months 
post-hospitalization], 6-minute walk distance, activity monitoring (i.e. daily step counts, daily energy expenditure), and 
activities of daily living survey [Time frame: 1 and 3-months post-hospitalization], MoCA-BLIND [Time frame: 1 and 3-
months post-hospitalization], HADS and IES-R [Time frame: 1 and 3-months post-hospitalization].   
Activity Monitoring: During the initial consent process for the study, subjects will be given the option to also consent for 
activity monitoring at 1- and 3-months post-hospitalization.  Activity monitors (AMs) are wearable devices (Actigraph) 
that will be provided to participants by mail. Participants will be asked to wear these monitors to measure physical 
activity and sedentary behavior in the free-living environment. The monitors will be worn over 4 consecutive days, which 
will occur during the 1- and 3-month assessment intervals.  Devices will be distributed to patients either in-person 
during their 1- and 3-month appointments or delivered via mail.  Participants will be given a pre-paid envelope to mail 
the activity monitors back after 4 consecutive days of wear. A valid AM hour is defined as ≤30 minutes of consecutive 
‘zero’ values (no activity) and a valid AM day is defined as ≥10 wear hours per day. Subjects will be asked to repeat 
wearing the AM if a data collection contains ≤2 valid days across 4 days, or if the AM has malfunctioned. AMs are 
attached with straps worn on the non-dominant wrist. All activity monitors can be worn comfortably under or over 
clothing. The activity monitors are to be put on in the morning upon waking and removed at night before bed.  The 
sensors are not waterproof and will be removed for bathing and swimming. The risks from wearing an AM are no 
different than those normally encountered in the free-living environment.  Instructions for participants are provided in 
Appendix 3.  
Analyses will use Wilcoxon rank-sum tests to compare the distribution of each outcome between groups at each 
timepoint since assumptions including normality of residuals are not expected to be satisfied for these outcomes.  
Additional, when applicable, a cutpoint defining a clinically actionable adverse outcome may be defined, for example, 
defining depression by HADS-Depression ≥8.  Binary outcomes will be summarized as proportion and compared by 
randomized arm using a Chi-square test.  Death and dropout will be assumed MAR in the primary approach and multiple 
imputation will be used to impute missing values.  Analyses will be conducted on each imputed dataset and results 
combined to reflect uncertainty due to missing data.  An additional analysis will consider a worst-value imputation for 
mortality, assigning death the worst possible outcome. 
Mortality and readmission through 1 year post-discharge will be described by randomized arm using cumulative 
incidence estimates, censoring subjects at last known contact with the Mayo medical system when status is unknown at 
1 year.  Inferential analyses will use log-rank tests and Gray’s test for mortality and readmission outcomes, respectively. 
 
Since the goal is to provide robust data for further clinical trial evaluation, secondary and exploratory outcomes will be 
assessed without adjustment for multiplicity, with conclusions from each based on a two-sided alpha level 0.05 
statistical test.   
 
9.4.4 SAFETY ANALYSES 
 
All AEs and SAEs will be presented and compared between groups.  Mortality and hospital readmission rates will also be 
presented and compared between groups.   
 

 
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9.4.5 BASELINE DESCRIPTIVE STATISTICS 
 
Descriptive statistics will be utilized to present baseline demographic, clinical, and laboratory features for both groups. 
No inferential statistics will be utilized.  
 
9.4.6 PLANNED INTERIM ANALYSES  
 
Not applicable 
 
9.4.7 SUB-GROUP ANALYSES 
 
We do not expect treatment effect heterogeneity of this intervention.  However, exploratory analyses will assess 
potential for heterogeneity of treatment effect using interaction analyses in LMM models for the primary endpoint.  An 
interaction term between randomized arm and each of sex, age, anemic etiology, and surgical vs. medical admissions, 
will be evaluated separately.  The estimate of the treatment effect will be reported in subgroups using linear contrasts of 
with the interaction analysis when evidence supports a statistically significant interaction.  
 
9.4.8 TABULATION OF INDIVIDUAL PARTICIPANT DATA 
 
Not applicable. 
 
9.4.9 EXPLORATORY ANALYSES 
 
Multiple exploratory analyses have been planned as outlined throughout the protocol.  These will be utilized to inform a 
definitive multicenter phase III clinical trial.  
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
10.1.1 INFORMED CONSENT PROCESS 
 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO PARTICIPANTS 
 
Consent forms describing in detail the study intervention, study procedures, and risks are given to the participant and 
written documentation of informed consent is required prior to starting intervention/administering study intervention.  
The following consent materials are submitted with this protocol: Consent form. 
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the study and continues 
throughout the individual’s study participation. Consent forms will be Institutional Review Board (IRB)-approved and the 
participant/LAR will be asked to read and review the document. The study coordinator will explain the research study to 
the participant &/or LAR and answer any questions that may arise. A verbal explanation will be provided in terms suited 
to the participant’s comprehension of the purposes, procedures, and potential risks of the study and of their rights as 
research participants.  Participants/LAR will have the opportunity to carefully review the written consent form and ask 
questions prior to signing. The participants should have the opportunity to discuss the study with their family or 

 
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surrogates or think about it prior to agreeing to participate. The participant/LAR will sign the informed consent 
document prior to any procedures being done specifically for the study. Participants must be informed that participation 
is voluntary and that they may withdraw from the study at any time, without prejudice. A copy of the informed consent 
document will be given to the participants for their records. The informed consent process will be conducted and 
documented in the source document (including the date), and the form signed, before the participant undergoes any 
study-specific procedures. The rights and welfare of the participants will be protected by emphasizing to them that the 
quality of their medical care will not be adversely affected if they decline to participate in this study. 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause.  Written 
notification, documenting the reason for study suspension or termination, will be provided by the suspending or 
terminating party to study participants, investigator, funding agency, and regulatory authorities.  If the study is 
prematurely terminated or suspended, the PI will promptly inform study participants, IRB, and sponsor and will provide 
the reason(s) for the termination or suspension.  Study participants will be contacted, as applicable, and be informed of 
changes to study visit schedule. 
  
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping    
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and satisfy the 
sponsor, IRB and/or Food and Drug Administration (FDA). 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
 
Participant confidentiality and privacy are strictly held in trust by the participating investigators, their staff, and the 
sponsor(s) and their interventions. This confidentiality is extended to cover testing of biological samples and genetic 
tests in addition to the clinical information relating to participants. Therefore, the study protocol, documentation, data, 
and all other information generated will be held in strict confidence. No information concerning the study or the data 
will be released to any unauthorized third party without prior written approval of the sponsor.  
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB, regulatory agencies or 
pharmaceutical company supplying study product may inspect all documents and records required to be maintained by 
the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for the 
participants in this study. The clinical study site will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal use during the study. 
At the end of the study, all records will continue to be kept in a secure location for as long a period as dictated by the 
reviewing IRB, Institutional policies, or sponsor requirements. 
 

 
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Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be transmitted 
to and stored at the Mayo Clinic. This will not include the participant’s contact or identifying information. Rather, 
individual participants and their research data will be identified by a unique study identification number. The study data 
entry and study management systems will be secured, and password protected. At the end of the study, all study 
databases will be de-identified and archived at the Mayo Clinic. 
 
Certificate of Confidentiality 
To further protect the privacy of study participants, a Certificate of Confidentiality will be issued by the National 
Institutes of Health (NIH).  This certificate protects identifiable research information from forced disclosure. It allows the 
investigator and others who have access to research records to refuse to disclose identifying information on research 
participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that would identify 
research participants, Certificates of Confidentiality help achieve the research objectives and promote participation in 
studies by helping assure confidentiality and privacy to participants. 
 
 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA  
 
With the participant’s approval and as approved by local IRBs, de-identified biological samples will be stored at the 
Mayo Clinic with the same goal as the sharing of data with the Mayo Clinic. These samples could be used to research the 
causes of anemia, its complications and other conditions for which individuals with anemia are at increased risk, and to 
improve treatment. The PI and study team will keep a record that will allow linking the biological specimens with the 
phenotypic data from each participant, maintaining the blinding of the identity of the participant. 
 
During the conduct of the study, an individual participant can choose to withdraw consent to have biological specimens 
stored for future research. However, withdrawal of consent with regard to biosample storage may not be possible after 
the study is completed.  
 
When the study is completed, access to study data and/or samples will be provided through the PI and Mayo Clinic. 
 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
 
Principal Investigator 
Matthew A. Warner, MD, Associate Professor of Anesthesiology 
Mayo Clinic 
 
 
 
 
10.1.6 SAFETY OVERSIGHT 
 
Safety oversight will be conducted in accordance with the Data and Safety Monitoring Plan (DSMP).  
 
10.1.7 CLINICAL MONITORING 
 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants are protected, that the 
reported trial data are accurate, complete, and verifiable, and that the conduct of the trial is in compliance with the 

 
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currently approved protocol/amendment(s), with International Conference on Harmonisation Good Clinical Practice (ICH 
GCP), and with applicable regulatory requirement(s).  
 
It is the responsibility of the Principal Investigator to oversee the safety of the study.  This safety monitoring will include 
careful assessment and appropriate reporting of adverse events as noted above, as well as the construction and 
implementation of a site data and safety-monitoring plan.  Medical monitoring will include a regular assessment of the 
number and type of serious adverse events 
 
10.1.8 QUALITY ASSURANCE AND QUALITY CONTROL 
 
The clinical site will perform internal quality management of study conduct, data and biological specimen collection, 
documentation and completion.  An individualized quality management plan will be developed to describe a site’s 
quality management. 
 
Quality control (QC) procedures will be implemented beginning with the data entry system and data QC checks that will 
be run on the database will be generated. Any missing data or data anomalies will be communicated to the site(s) for 
clarification/resolution. 
 
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is conducted and 
data are generated and biological specimens are collected, documented (recorded), and reported in compliance with 
the protocol, International Conference on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory 
requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)).  
 
The investigational site will provide direct access to all trial related sites, source data/documents, and reports for the 
purpose of monitoring and auditing by the sponsor, and inspection by local and regulatory authorities. 
 
 
10.1.9 DATA HANDLING AND RECORD KEEPING  
 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the site investigator. The 
investigator is responsible for ensuring the accuracy, completeness, legibility, and timeliness of the data reported.  All 
source documents should be completed in a neat, legible manner to ensure accurate interpretation of data.  Hardcopies 
of the study visit worksheets will be provided for use as source document worksheets for recording data for each 
participant enrolled in the study.  Data collected and entered into electronic case report form (eCRF) derived from 
source documents should be consistent with the data recorded on the source documents. Clinical data (including 
adverse events (AEs), concomitant medications, and expected adverse reactions data) and clinical laboratory data will be 
entered into REDCap electronic data capture. REDCap is HIPAA-compliant with built-in user right controls and audit trails 
for data security and tracking. The data system includes password protection and internal quality checks, such as 
automatic range checks, to identify data that appear inconsistent, incomplete, or inaccurate. Clinical data will be 
entered directly from the source documents. 
 
10.1.9.2 STUDY RECORDS RETENTION  
 
Study documents should be retained for a minimum of 2 years. These documents should be retained for a longer period, 
however, if required by local regulations. No records will be destroyed without the written consent of the sponsor, if 
applicable. It is the responsibility of the sponsor to inform the investigator when these documents no longer need to be 
retained. 

 
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10.1.10 
PROTOCOL DEVIATIONS  
 
A protocol deviation is any noncompliance with the clinical trial protocol, International Conference on Harmonisation 
Good Clinical Practice (ICH GCP), or Manual of Procedures (MOP) requirements. The noncompliance may be either on 
the part of the participant, the investigator, or the study site staff. As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly.  
 
These practices are consistent with ICH GCP:  
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of the site investigator to use continuous vigilance to identify and report deviations.  All deviations 
must be addressed in study source documents, reported to the NHLBI Program Official. Protocol deviations must be sent 
to the reviewing Institutional Review Board (IRB) per their policies. The site investigator is responsible for knowing and 
adhering to the reviewing IRB requirements.  
 
10.1.11 
PUBLICATION AND DATA SHARING POLICY 
 
This study will be conducted in accordance with the following publication and data sharing policies and regulations: 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the published results 
of NIH funded research. It requires scientists to submit final peer-reviewed journal manuscripts that arise from NIH 
funds to the digital archive PubMed Central upon acceptance for publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial 
Information and the Clinical Trials Registration and Results Information Submission rule. As such, this trial will be 
registered at ClinicalTrials.gov, and results information from this trial will be submitted to ClinicalTrials.gov. In addition, 
every attempt will be made to publish results in peer-reviewed journals.  Data from this study may be requested from 
other researchers within 5 years after the completion of the primary endpoint by contacting the PI.  
 
10.1.12 
CONFLICT OF INTEREST POLICY 
 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical industry, is 
critical.  Therefore, any actual conflict of interest of persons who have a role in the design, conduct, analysis, publication, 
or any aspect of this trial will be disclosed and managed. Furthermore, persons who have a perceived conflict of interest 
will be required to have such conflicts managed in a way that is appropriate to their participation in the design and 
conduct of this trial.  The study leadership in conjunction with NHLBI has established policies and procedures for all 
study group members to disclose all conflicts of interest and will establish a mechanism for the management of all 
reported dualities of interest. 
 
 
 
10.2 ADDITIONAL CONSIDERATIONS 
 
Appendix 1: Visual Aid 
 

 
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 Appendix 2: Daily Rounding 

 
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10.3 ABBREVIATIONS 
 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
COC 
Certificate of Confidentiality 
COMS 
Core Outcome Measurement Set 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DHHS 
Department of Health and Human Services 
DSMP 
Data Safety Monitoring Plan 
DRE 
Disease-Related Event 
EC 
Ethics Committee 
eCRF 
Electronic Case Report Forms 
EHR 
Electronic health record 
EPO 
Erythropoietin  
ESA 
Erythropoiesis-stimulating agents 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FFR 
Federal Financial Report 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
HIPAA 
Health Insurance Portability and Accountability Act  
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation  
ICMJE 
International Committee of Medical Journal Editors 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
IV 
Intravenous 
MedDRA 
Medical Dictionary for Regulatory Activities 
MOP 
Manual of Procedures 
MSDS 
Material Safety Data Sheet 
NCT 
National Clinical Trial 
NIH  
National Institutes of Health 
NIH IC 
NIH Institute or Center 
OHRP 
Office for Human Research Protections 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SMC 
Safety Monitoring Committee 
SOA 
Schedule of Activities 
SOC 
System Organ Class 

 
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SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 
6MWD 
6-minute walk distance 
 
 
 

 
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10.4 PROTOCOL AMENDMENT HISTORY 
The table below is intended to capture changes of IRB-approved versions of the protocol, including a description of the 
change and rationale. A Summary of Changes table for the current amendment is located in the Protocol Title Page.  
 
Version 
Date 
Description of Change  
Brief Rationale 
2 
March 28, 
2022 
Revision of inclusion/exclusion 
criteria 
Improve clarity of inclusion and exclusion items. 
3 
May 11, 
2022 
Revision to indicate subjects may be 
approached telephonically vs 
virtually for recruitment and follow-
up. 
To aid in recruitment and enrollment 
4 
July 26, 
2022 
Revision to protocol to allow for use 
of activity monitor in subjects who 
opt in for this component. 
Allows the ability to gather additional outcome 
data pertaining to activity changes. 
5 
October 11, 
2022 
Revision to correlate information in 
section 2.3.3 Assessment of Risks 
with actual Exclusion Criteria in 
section 5.2  
Needed for clarity and consistency.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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