A Prospective, Randomized, Single Center Pilot Study Comparing Patient and Graft Survival, Adverse Events and Tolerability of Zortress® (Everolimus) Versus Rapamune® (Sirolimus) in Combination With Low Dose Neoral® (Cyclosporine) Dosed by C2 Monitoring, in Deceased and Living Donor Renal Transplant Recipients Under a Thymoglobulin® (Antithymocyte Globulin) and Rapid Steroid Induction Protocol.
Phase: NA
Conditions: Renal Failure
Sponsor: Ohio State University

 [INVESTIGATIONAL DRUG CODE/everolimus] 
Clinical Study Protocol IIRP-1426 
A prospective, randomized, single center pilot study 
comparing patient and graft survival, adverse events and 
tolerability of Zortress® (everolimus) versus Rapamune® 
(sirolimus) in combination with low dose Neoral® 
(cyclosporine) dosed by C2 monitoring, in deceased and 
living donor renal transplant recipients under a 
Thymoglobulin® (antithymocyte globulin) and rapid steroid 
induction protocol. 
Authors: 
Pelletier R 
Principle or Coordinating 
Investigator 
Rajab A 
Document type: 
Clinical Study Protocol 
Version number: 
1.1  
Release date: 
16-May-2013 
 
 
Template Version June 2008 

2 
 
Table of contents 
Table of contents ................................................................................................................. 2 
List of tables ........................................................................................................................ 3 
List of abbreviations ............................................................................................................ 4 
Glossary of terms ................................................................................................................. 5 
Protocol synopsis ................................................................................................................. 6 
1 
Background ........................................................................................................................ 10 
2 
Purpose and rationale......................................................................................................... 10 
3 
Objectives .......................................................................................................................... 10 
3.1 
Primary objectives ................................................................................................. 10 
3.2 
Secondary objectives ............................................................................................. 11 
3.3 
Exploratory objectives ........................................................................................... 11 
4 
Study design ...................................................................................................................... 11 
5 
Population .......................................................................................................................... 12 
5.1 
Inclusion criteria .................................................................................................... 12 
5.2 
Exclusion criteria ................................................................................................... 12 
6 
Treatment ........................................................................................................................... 13 
6.1 
Investigational and control drugs ........................................................................... 13 
6.2 
Treatment arms ...................................................................................................... 14 
6.3 
Treatment assignment ............................................................................................ 14 
6.4 
Treatment blinding ................................................................................................. 14 
6.5 
Treating the patient ................................................................................................ 14 
6.5.1 
Patient numbering ................................................................................. 14 
6.5.2 
Dispensing the study drug ..................................................................... 14 
6.5.3 
Study drug supply, storage and tracking ............................................... 14 
6.5.4 
Permitted study drug dose adjustments and interruptions ..................... 14 
6.5.5 
Study drug discontinuation and premature patient withdrawal ............. 15 
6.5.6 
Early study termination ......................................................................... 15 
7 
Visit schedule and assessments ......................................................................................... 16 
7.1 
Table 7-1 
7.2 
Information to be collected on screening failures .................................................. 17 
7.3 
Patient demographics/other baseline characteristics.............................................. 18 
7.4 
Treatment exposure and compliance ..................................................................... 18 
7.5 
Efficacy .................................................................................................................. 18 
7.5.1 
Efficacy assessment 1............................................................................ 18 
8 
Safety monitoring .............................................................................................................. 19 

3 
 
8.1 
Adverse events ....................................................................................................... 19 
8.2 
Serious adverse event reporting ............................................................................. 19 
8.3 
Pregnancies ............................................................................................................ 19 
9 
Data review and database management ............................................................................. 20 
9.1 
Data collection ....................................................................................................... 20 
9.2 
Database management and quality control ............................................................ 20 
10 Data analysis (Any or all sections may be included based on type of study) .................... 20 
10.1 
Analysis of the primary objective(s) ...................................................................... 20 
10.1.1 
Variable ................................................................................................. 20 
10.1.2 
Statistical hypothesis, model, and method of analysis .......................... 20 
10.1.3 
Handling of missing values/censoring/discontinuations ....................... 21 
10.2 
Analysis of secondary objectives ........................................................................... 21 
10.2.1 
Efficacy (secondary) ............................................................................. 21 
10.2.2 
Safety ..................................................................................................... 21 
 
10.3 
Sample size calculation .......................................................................................... 21 
10.4 
Power for analysis of critical secondary variables................................................. 21 
10.5 
Interim analysis ...................................................................................................... 22 
11 Ethical considerations ........................................................................................................ 22 
11.1 
Regulatory and ethical compliance ........................................................................ 22 
11.2 
Informed consent procedures ................................................................................. 22 
11.3 
Responsibilities of the investigator and IRB/IEC/REB ......................................... 22 
11.4 
Publication of study protocol and results ............................................................... 22 
12 Protocol adherence ............................................................................................................ 23 
12.1 
Protocol Amendments............................................................................................ 23 
13 References ......................................................................................................................... 23 
 
List of tables 
Table 7-1 
Assessment schedule ............................................................................. 17 
 
 

4 
 
List of abbreviations 
AE 
adverse event 
ALT 
alanine aminotransferase 
AST 
aspartate aminotransferase 
b.i.d. 
twice a day 
CRF 
Case Report/Record Form 
CRD 
Clinical Research and Development 
CPO 
Country Pharma Organization 
CRO 
Contract Research Organization 
CSR 
Clinical Study Report 
ECG 
Electrocardiogram 
ICH 
International Conference on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
IEC 
Independent Ethics Committee 
IMS 
Integrated Medical Safety 
i.v. 
intravenous(ly) 
IRB 
Institutional Review Board 
IVRS 
Interactive Voice Response System  
o.d. 
once a day 
p.o. 
oral(ly) 
REB 
Research Ethics Board 
SAE 
serious adverse event 

5 
 
Glossary of terms 
 
Assessment 
A procedure used to generate data required by the study 
Control drug 
A study drug used as a comparator to reduce assessment bias, 
preserve blinding of investigational drug, assess internal study 
validity, and/or evaluate comparative effects of the investigational 
drug 
Enrollment 
Point/time of patient entry into the study; the point at which 
informed consent must be obtained (i.e. prior to starting any of the 
procedures described in the protocol) 
Investigational drug 
The study drug whose properties are being tested in the study; this 
definition is consistent with US CFR 21 Section 312.3 and is 
synonymous with “investigational new drug.” 
Medication number 
A unique identifier on the label of each medication package in 
studies that dispense medication using an IVR system 
Patient number 
A number assigned to each patient who enrolls in the study. When 
combined with the center number, a unique identifier is created for 
each patient in the study. 
Stage 
A major subdivision of the study timeline; begins and ends with 
major study milestones such as enrollment, randomization, 
completion of treatment, etc. 
Period 
A minor subdivision of the study timeline; divides phases into 
smaller functional segments such as screening, baseline, titration, 
washout, etc. 
Premature patient withdrawal 
Point/time when the patient exits from the study prior to the 
planned completion of all study drug administration and 
assessments; at this time all study drug administration is 
discontinued and no further assessments are planned 
Randomization number 
A unique identifier assigned to each randomized patient, 
corresponding to a specific treatment arm assignment 
Stop study participation 
Point/time at which the patient came in for a final evaluation visit or 
when study drug was discontinued whichever is later 
Study drug 
Any drug administered to the patient as part of the required study 
procedures; includes investigational drug and any control drugs 
Study drug discontinuation 
Point/time when patient permanently stops taking study drug for 
any reason; may or may not also be the point/time of premature 
patient withdrawal 
Variable 
Information used in the data analysis; derived directly or indirectly 
from data collected using specified assessments at specified 
timepoints 
 

6 
 
Protocol synopsis 
Title of study: A prospective, randomized, single center pilot study comparing patient and graft 
survival, adverse events and tolerability of Zortress® (everolimus) versus Rapamune® (sirolimus) in 
combination with low dose Neoral® (cyclosporine) dosed by C2 monitoring, in deceased and living 
donor renal transplant recipients under a Thymoglobulin® (antithymocyte globulin) and rapid steroid 
induction protocol. 
Purpose and rationale: Our center’s renal transplant immunosuppression protocol has consisted of 
Thymoglobulin and steroid induction for 5 doses only, with early initiation of Rapamune® (sirolimus) 
and then Neoral for nearly a decade now.  We do observe a significant amount of adverse events in 
our patient population, with many of these potentially related to the sirolimus.  The combination of 
“half-dose” cyclosporine (early C2 levels around 800 to 1000 ng/ml) allows us to minimize calcineurin 
inhibitor toxicity and its combination with the mTOR drug sirolimus provides excellent protection 
against acute rejection in our renal transplant recipients.  Our earlier experience with everolimus and 
the recent publications describing renal recipients’ outcomes with this drug, suggest to us that our 
patients may do better on everolimus than sirolimus.  For our center, this pilot study would be very 
straightforward as the only difference in medication from our current well established protocol would be 
the randomization to either Rapamune®, our current standard of care, or Zortress®, the study drug. 
Objectives: The primary objective of this pilot study will be to determine equivalency of Zortress® as 
compared to Rapamune® when used in our de novo immunosuppression regimen following renal 
transplantation. The primary endpoint will be a composite endpoint of graft survival (non-death 
censored) and biopsy proven acute rejection at 1 year. The primary outcome of immunosuppressive 
protection would be studied in our Thymoglobulin and rapid steroid discontinuation protocol, with “half-
dose” Neoral as described above. 
Secondary outcomes would include factors involved with adverse events and tolerability and would 
include: renal graft survival (non-death censored) and biopsy proven acute rejection at 6 months, 2 
and 3 years, as well as the number and grade of acute rejection episodes and responsiveness to 
treatment, serum creatinine and estimated GFR, results of renal biopsies at 12 months post-transplant 
to look for histological evidence of graft injury, early and late wound complications, infections including 
CMV, EBV and BK infections as monitored by serum PCR testing, lipid panel testing, particularly 
triglycerides, cardiac events such as acute myocardial infarctions or Congestive Heart Failure 
episodes, and tolerability of the Neoral and mTOR combination as determined by the patients who 
required conversion off of the intended randomized drug combination, with attempt to document why 
the patient did not tolerate the drug combination.   
Exploratory objectives would include molecular markers indicative of kidney and vascular endothelial 
function.  
Population: The patient population will be all adults (18-75 years of age) who receive a living donor or 
deceased donor renal transplant as a first or subsequent renal transplant procedure only (no extra-
renal organ transplant recipients).  We will invite any patient who would normally be considered for our 
current Sirolimus®/ Neoral® protocol with Thymoglobulin® and steroid induction to consent for this pilot 
study and then undergo randomization post-operatively if the transplant surgeon anticipates normal 
early graft function.  We would propose to enroll a total of 60 patients. 
Inclusion/Exclusion criteria:  
 
Inclusion Criteria 
 
Primary renal transplant recipients between ages 18 and 75 years of age. 
 
Females capable of becoming pregnant must have a negative pregnancy test prior to 
transplantation and practice an effective form of birth control for the duration of the study.  
 

7 
 
 
Exclusion Criteria 
 
Total cholesterol > 300 mg/dl or triglycerides > 400 mg/dl despite lipid lowering therapy 
 
Pre-existing bone marrow suppression (WBC < 3000, platelets < 100,000)  
 
Positive crossmatch or ABO incompatible 
 
Pregnant or nursing (lactating) women, where pregnancy is defined as the state of a female 
after conception and until the termination of gestation, confirmed by a positive serum human 
chorionic gonadotrophin laboratory test (>5 mIU/mL) 
 
Women of child-bearing potential, defined as all women physiologically capable of becoming 
pregnant, including women whose career, lifestyle, or sexual orientation precludes intercourse 
with a male partner and women whose partners have been sterilized by vasectomy or other 
means, UNLESS they are using two birth control methods. The two methods can be a double 
barrier method or a barrier method plus a hormonal method. 
 
Adequate barrier methods of contraception include: diaphragm, condom (by the 
partner), intrauterine device (copper or hormonal), sponge or spermicide. Hormonal 
contraceptives include any marketed contraceptive agent that includes an estrogen 
and/or a progestational agent. 
 
Reliable contraception should be maintained throughout the study and for 12 weeks 
after study drug discontinuation. 
 
Women are considered post-menopausal and not of child bearing potential if they 
have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical 
profile (e.g. age appropriate, history of vasomotor symptoms) or six months of 
spontaneous amenorrhea with serum FSH levels > 40 mIU/mL and estradiol 
< 20 pg/mL] or have had surgical bilateral oophorectomy (with or without 
hysterectomy) at least six weeks ago. In the case of oophorectomy alone, only when 
the reproductive status of the woman has been confirmed by follow up hormone level 
assessment is she considered not of child bearing potential. 
 
Active infection (HBV, HIV) 
 
Malignancy (except for adequately treated squamous or basal cell skin carcinoma) unless 
patient has written clearance from an Oncologist or if patient has had no malignancy for at 
least 2 years prior to the transplant 
 
Allergy or intolerance to sirolimus, everolimus, cyclosporine, or ATG 
Investigational and reference therapy: Zortress® bid for goal levels of 3 to 8 ng/ml by approved 
testing methods;  Rapamune® goal levels of 10 to 18 ng/ml by Architect assay, or 8 to 12 by LC-MS 
methodology;  Neoral® goal levels of 800 to 1000 ng/ml by immunoassay until 3 months Post-
transplant, 600-800 ng/ml 3-6 months post-transplant, 400-600 ng/ml 6-12 months post-transplant, and 
400 ng/ml > 12 months post-transplant.  Induction agents: Thymoglobulin 1.25 mg/kg for 4 to 5 doses 
adjusted for white blood count and platelet count, as well as appropriate levels of the two maintenance 
immunosuppressive agents, and steroids given as methylprednisone IV for two doses, then oral 
prednisone at: 500 mg, 200 mg, 125 mg, 50 mg, and 25 mg.   
Study design: Randomized, single center parallel-group, open-label study. 
Pilot study with exploratory objectives. 
Eligibility:  All primary or retransplant recipients of deceased donor or living donor grafts with negative 
crossmatch who are felt to have good expectations for renal function recovery after surgery will be 
offered entry into the study. 
Treatment scheme is as described above, with Solumedrol 500 mg IV in OR as induction, then 5 
doses of Thymoglobulin starting morning of POD 1 at 1.25 mg/dose (rounded to nearest 25 mg) with 

8 
 
rapid steroid taper over five doses.  The mTOR inhibitor drug will be started on POD 0 and Neoral 
introduced as renal function recovers, usually starting on POD 2. 
Measurement/Assessments: as described above, graft and patient survival per standard definitions, 
clinically indicated biopsies for determination of acute cellular or antibody mediated rejection, renal 
function as estimated from serum Cr based on MDRD, clinic visits for wound assessment, standard of 
care labs for renal function, bone marrow function (WBC and platelet count), liver function, lipid panel, 
donor specific antibody determination during any significant increase in serum Cr, drug levels routinely 
monitored for need of number of dose adjustments and compliance, Emergency Room and 
hospitalizations, as well as unscheduled clinic and other physician visits.  For the pilot study, we would 
perform scheduled CMV, EBV and serum BK PCRs monthly for the first year, then quarterly or with 
any viral symptoms. 
Potential study participants will be approached for consent immediately prior to transplantation by the 
transplant surgeon or appointed representative if they meet the inclusion criteria above and do not fit 
the exclusion criteria above. If the transplant candidate agrees to participate he/she will be categorized 
as a living or deceased donor kidney recipient category and as primary or subsequent kidney 
transplant recipient. The candidate will then be randomized, in a 2:1 fashion, to either the Zortress or 
Rapamune study arm. Following transplantation all recipients will receive daily Thymoglobulin doses of 
1.25 mg/kg starting on POD #1 for 4 to 5 doses adjusted for white blood count and platelet count. All 
recipients will be administered steroids as methylprednisone IV for two doses, then oral prednisone at: 
500 mg, 200 mg, 125 mg, 50 mg, and 25 mg and will receive delayed Neoral® on POD #2-3 dosed to 
achieve serum levels of 800 to 1000 ng/ml by immunoassay until 3 months post-transplant, 600-800 
ng/ml 3-6 months post-transplant, 400-600 ng/ml 6-12 months post-transplant, and 400 ng/ml > 12 
months post-transplant. Zortress® will be started on POD #0 for Zortress study arm recipients, 
administered bid and dosed to achieve target levels of 3 to 8 ng/ml by approved testing methods;  
Rapamune® study arm recipients will receive Rapamune once daily, dosed to achieve target levels of 
10 to 18 ng/ml by Architect assay, or 8 to 12 by LC-MS methodology. Neoral and Rapamune/Zortress 
levels will be monitored twice weekly for the first 3 months, once weekly for months 3-6, every other 
week months 6-12, and monthly thereafter. This pilot study is estimated to take one year for enrollment 
and three years from the date of last patient enrollment for completion of last patient visit, then several 
months for completion of paper work.  This will be about 4.5 to 5 years. 
Efficacy assessments:  
 
Incidence of graft loss in the first post-transplant year 
 
Incidence of patient death in the first post-transplant year 
 
Incidence of acute rejection at 1 year post-transplant 
 
Other assessments:  
 
Incidence of non-death censored graft loss at 6 months, 2 and 3 years after transplantation 
 
Number and grade of acute rejection episodes at 6 months, 1, 2, and 3 years after 
transplantation 
 
Tolerability of Zortress at 1 year post-transplant 
 
Estimated GFR at 6 months, 1, 2, and 3 years after transplantation 
 
Incidence of CMV, EBV and BK infections 1 year after transplantation 
 
Results of 12 month surveillance biopsies 
 
Lipid panels and use of lipid lowering medications at 1 year after transplant 
 
Incidence of MI and CHF at 1 and 3 years after transplant  

9 
 
 
Incidence of wound infection at 1 year after transplantation 
 
Incidence of lymphocele at 1 year after transplantation 
 
Plasma concentrations of S-adenosyl homocysteine (SAH) and S-adenosyl methionine 
(SAM)Plasma concentrations of endothelial dysfunction markers (symmetric and asymmetric 
dimethyl arginine (SDMA, ADMA), L-arginine, L-citrulline, L-ornithine cysteine, and 
homocysteine over the observation period 
 
Plasma concentrations of bioactive lipids (HODEs, HEPEs, HETEs, and prostaglandins) over the 
observation period 
 
Plasma protein patterns 
Data analysis: The incidence of graft loss, patient death, and acute rejection will be compared by chi 
squared analyses. Patient and graft Kaplan-Meier survival curves will be compared by log rank test. 
We hypothesize there will be no statistically significant difference between the treatment arms. As this 
is a pilot study, it was not statistically powered to detect subtle differences in outcome. All continuous 
variables such as serum creatinine, cGFR, serum lipids, WBC, platelets, etcetera will be compared by 
student’s t test. Any other dichotomous variables will be compared by chi squared analysis. 

10 
 
1 
Background 
Two prospective randomized trials (A2306 and A2307) have demonstrated that everolimus 
combined with steroids and low dose Neoral with (A2307) or without (A2306) basiliximab 
induction result in excellent 1 year outcomes (1). In 2002 we adopted an immunosuppressive 
regimen using Rapamune and reduced dose Neoral without steroids using induction therapy 
with Thymoglobulin. Since employing this regimen our acute rejection rate within the first 
year post-transplant has been between 7% and 10% for any given calendar year. However, 
many patients need to have their Rapamune discontinued due to drug related side effects or 
compliance difficulties related to the noon dosing (when most other medications are taken at 8 
am and 4 pm). We feel strongly that use of an alternative drug to Rapamune in such cases is 
necessary. Use of Zortress in this setting would be ideal, however, no data currently exists 
concerning the use of Zortress with Neoral in a steroid free maintenance immunosuppression 
regimen following Thymoglobulin induction. Thus we propose this pilot study primarily to 
verify Zortress efficacy using our established immunosuppressive protocol. Secondarily we 
are interested in characterizing the Zortress drug related side effect profile to enable us in the 
future to exploit any favorable differences between Zortress and Rapamune. 
2 
Purpose and rationale 
Our center’s renal transplant immunosuppression protocol has consisted of Thymoglobulin 
and steroid induction for 5 doses only, with early initiation of Rapamune® (Sirolimus) and 
then Neoral for nearly a decade now.  We do observe a significant amount of adverse events 
in our patient population, with many of these potentially related to the Sirolimus.  The 
combination of “half-dose” cyclosporine (early C2 levels around 800 to 1000 ng/ml) allows us 
to minimize calcineurin inhibitor toxicity and its combination with the mTOR drug Sirolimus 
provides excellent protection against acute rejection in our renal transplant recipients.  Our 
earlier experience with Everolimus and the recent publications describing renal recipients’ 
outcomes with this drug, suggest to us that our patients may do better on Everolimus than 
Sirolimus (1,2).  For our center, this pilot study would be very straightforward as the only 
difference in medication from our current well established protocol would be the 
randomization to either Rapamune®, our current standard of care, or Zortress®, the study drug. 
3 
Objectives 
3.1 
Primary objectives 
The primary objective of this pilot study will be to determine equivalency of Zortress® as 
compared to Rapamune® when used in our de novo immunosuppression regimen following 
renal transplantation. The primary endpoint will be a composite endpoint of graft survival 
(non-death censored) and biopsy proven acute rejection at 1 year. The primary outcome of 
immunosuppressive protection would be studied in our Thymoglobulin and rapid steroid 
discontinuation protocol, with “half-dose” Neoral as described above. 

11 
 
3.2 
Secondary objectives 
Secondary outcomes would include factors involved with adverse events and tolerability and 
would include: renal graft survival (non-death censored) and biopsy proven acute rejection at 
6 months, 2 and 3 years, as well as the number and grade of acute rejection episodes and 
responsiveness to treatment, serum creatinine and estimated GFR, results of renal biopsies at 
12 months post-transplant to look for histological evidence of graft injury, early and late 
wound complications, infections including CMV, EBV and BK infections as monitored by 
serum PCR testing, lipid panel testing, particularly triglycerides, cardiac events such as acute 
myocardial infarctions or Congestive Heart Failure episodes, and tolerability of the Neoral 
and mTOR combination as determined by the patients who required conversion off of the 
intended randomized drug combination, with attempt to document why the patient did not 
tolerate the drug combination.  All objectives are exploratory in nature as this is a pilot study. 
3.3 
Exploratory objectives 
4 
 To explore the kidney and vascular endothelial function 
assessed by a panel of molecular markers over the 
observation period. Study design 
Randomized, single center parallel-group, open-label study. 
Pilot study with exploratory objectives. 
Eligibility:  All primary or retransplant recipients of deceased donor or living donor grafts 
with negative crossmatch who are felt to have good expectations for renal function recovery 
after surgery will be offered entry into the study. 
Treatment scheme is as described above, with Solumedrol 500 mg IV in OR as induction, then 
5 doses of Thymoglobulin starting morning of POD 1 at 1.25 mg/dose (rounded to nearest 25 
mg) with rapid steroid taper over five doses.  The mTOR inhibitor drug will be started on 
POD 0 and Neoral introduced as renal function recovers, usually starting on POD 2. 
Measurement/Assessments: as described above, graft and patient survival per standard 
definitions, clinically indicated biopsies for determination of acute cellular or antibody 
mediated rejection, renal function as estimated from serum Cr based on MDRD, clinic visits 
for wound assessment, standard of care labs for renal function, bone marrow function (WBC 
and platelet count), liver function, lipid panel, donor specific antibody determination during 
any significant increase in serum Cr, drug levels routinely monitored for need of number of 
dose adjustments and compliance, Emergency Room and hospitalizations, as well as 
unscheduled clinic and other physician visits.  For the pilot study, we would perform 
scheduled CMV, EBV and serum BK PCRs monthly for the first year, then quarterly or with 
any viral symptoms. 
A subset of patients will have coded plasma samples sent to clinical research and development 
at the University of Colorado. These biomarker samples will be used to assess vascular 
endothelial dysfunction and inflammation markers as well as kidney dysfunction markers. 

12 
 
Plasma samples are collected and stored at The Ohio State University Wexner Medical Center 
tissue typing lab per standard of care.   
5 
Population 
The patient population will be all adults (18-75 years of age) who receive a living donor or 
deceased donor renal transplant as a first or subsequent renal transplant procedure only (no 
extra-renal organ transplant recipients).  We will invite any patient who would normally be 
considered for our current Sirolimus®/ Neoral® protocol with Thymoglobulin® and steroid 
induction to consent for this pilot study and then undergo randomization post-operatively if 
the transplant surgeon anticipates normal early graft function.  If there were significant 
concerns for prolonged graft dysfunction, then the patients will not be invited into the pilot 
study.  Invited patients would include anyone currently not on steroids prior to transplantation, 
and those with no known intolerance to any of the drugs mentioned.  Patients must also be 
willing to perform the expectations of the study protocol reliably. 
This will be a single center pilot study performed at The Ohio State University 
Comprehensive Transplant Center.  Our center performs approximately 100 to 110 living 
donor and 90 to 100 deceased donor renal transplants per year.  If we assume that at least 150 
patients per year qualify for the study, then a conservative estimate of 75 enrolled patients a 
year is possible.  We would propose to enroll a total of 60 patients over 12 months, and then 
follow these patients for a complete 3 years.  We will randomize 2:1 Zortress to Sirolimus 
using a random number generator. 
5.1 
Inclusion criteria 
Patients eligible for inclusion in this study have to fulfill all of the following criteria at the 
time of enrollment: 
1. 
Patients must give written informed consent before any assessment is performed. 
2. 
Primary renal transplant recipients between ages 18 and 75 years of age. 
3. 
Females capable of becoming pregnant must have a negative pregnancy test prior to 
transplantation and practice an effective form of birth control for the duration of the 
study and 12 weeks after discontinuation of the study drug if applicable.  
5.2 
Exclusion criteria 
 Exclusion Criteria at the time of enrollment: 
 Total cholesterol > 300 mg/dl or triglycerides > 400 mg/dl despite lipid lowering 
therapy 
 Pre-existing bone marrow suppression (WBC < 3000, platelets < 100,000)  
 Positive crossmatch or ABO incompatible 

13 
 
 Pregnant or nursing (lactating) women, where pregnancy is defined as the state of a 
female after conception and until the termination of gestation, confirmed by a positive 
serum human chorionic gonadotrophin laboratory test (>5 mIU/mL) 
 Women of child-bearing potential, defined as all women physiologically capable of 
becoming pregnant, including women whose career, lifestyle, or sexual orientation 
precludes intercourse with a male partner and women whose partners have been 
sterilized by vasectomy or other means, UNLESS they are using two birth control 
methods. The two methods can be a double barrier method or a barrier method plus a 
hormonal method. 
 Adequate barrier methods of contraception include: diaphragm, condom (by 
the partner), intrauterine device (copper or hormonal), sponge or spermicide. 
Hormonal contraceptives include any marketed contraceptive agent that 
includes an estrogen and/or a progestational agent. 
 Reliable contraception should be maintained throughout the study and for 12 
weeks after study drug discontinuation. 
 Women are considered post-menopausal and not of child bearing potential if 
they have had 12 months of natural (spontaneous) amenorrhea with an 
appropriate clinical profile (e.g. age appropriate, history of vasomotor 
symptoms) or six months of spontaneous amenorrhea with serum FSH levels > 
40 mIU/mL and estradiol < 20 pg/mL] or have had surgical bilateral 
oophorectomy (with or without hysterectomy) at least six weeks ago. In the 
case of oophorectomy alone, only when the reproductive status of the woman 
has been confirmed by follow up hormone level assessment is she considered 
not of child bearing potential. 
 Active infection (HBV, HIV) 
 Malignancy (except for adequately treated squamous or basal cell skin carcinoma) 
unless patient has written clearance from an Oncologist or if patient has had no 
malignancy for at least 2 years prior to the transplant 
 Allergy or intolerance to sirolimus, everolimus, cyclosporine, or ATG 
6 
Treatment 
6.1 
Investigational and control drugs 
Zortress will be started on POD #0 and initially dosed at 0.75 mg BID (12 hours apart) dosed 
simultaneously with Neoral and the dose adjusted thereafter to achieve a target trough serum 
level between 3 ng/ml and 8 ng/ml. Sirolimus will be dosed per our standard approach, 
specifically started on POD #0 at 5 mg/d, decreasing to 3 mg/d on POD #2, and adjusted 
thereafter at achieve a target trough serum level of 10 to 18 ng/ml by Architect assay, or 8 to 12 by 
LC-MS methodology. 

14 
 
6.2 
Treatment arms 
Patients will be assigned to one of the following “n” treatment arms in a ratio of 2:1; Zortress 
or Sirolimus started on POD 0, with Solumedrol 500 mg IV in OR as induction, then 5 doses 
of Thymoglobulin starting morning of POD 1 at 1.25 mg/dose (rounded to nearest 25 mg) 
with rapid steroid taper over five doses.  Neoral will be introduced as renal function recovers, 
usually starting on POD 2. We will enroll a total of 60 patients. 
 Zortress and Neoral, with Thymoglobulin induction and perioperative steroids 
 Rapamycin and Neoral, with Thymoglobulin induction and perioperative steroids 
6.3 
Treatment assignment 
Randomization will be stratified by type of donor kidney received (living or deceased donor 
kidney) and primary versus retransplant recipient. Randomization will be performed using a 
random number generator. 
6.4 
Treatment blinding 
This is an open-label study and thus there will be no blinding. 
6.5 
Treating the patient  
Patients enrolled in this study will receive our normal standard of post-transplant follow up 
care. 
6.5.1 
Patient numbering 
As this is an open-label study there will be no blinding and thus no need for patient 
identifying numbers as part of a blinding strategy. 
6.5.2 
Dispensing the study drug 
As this is an open-label study utilizing currently commercially available drugs, the drugs 
under study will be dispensed utilizing standard operating procedures.  
6.5.3 
Study drug supply, storage and tracking 
As this is an open-label study utilizing currently commercially available drugs, special 
arrangements for study drug supply, storage and tracking will not be necessary. 
6.5.4 
Permitted study drug dose adjustments and interruptions 
Zortress and Sirolimus dose adjustments and interruptions will be allowed and will be made at 
the discretion of the treating physician. All drug adjustments and interruptions will be 
recorded and monitored for this study, which requires little additional effort as this is already 
our current practice. 

15 
 
6.5.5 
Study drug discontinuation and premature patient withdrawal 
As we currently do for Sirolimus, Zortress dosing will be decreased or discontinued when the 
transplant physician deems appropriate due to deleterious side effects or the presence of 
infection or malignancy where a reduction in overall immunosuppression in desirable. 
 
6.5.6 
Early study termination  
Early study termination will be considered if there is a statistically significant difference in 
primary outcome between the 2 study arms and it is the opinion of the treating physicians that 
this 
is 
likely 
due 
to 
differences 
in 
efficacy

 
7 
Visit schedule and assessments 
Table 7-1 lists all of the assessments and indicates with an “x” the visits when they are performed. 

17 
 
7.1 
Table 7-1 
Assessment schedule:   
Visit number 
1 
Screening/
Baseline 
2 
 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
Time of Visit 
 
Day 
0 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
51 
Day 
61 
Day 
71 
Wk 
2 
Mo 
1 
Mo 
2 
Mo 
3 
Mo 
6 
Mo 
12 
Mo 
18 
Mo 
24 
Mo 
36 
Inclusion/Exclusion criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology 
 
X 
 
 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X  
Chemistry 
 
X 
 
 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X  
Lipid panel 
X 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X  
24 hour urine 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
Alloscreen 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Flow Crossmatch 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
HGB A1C 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
Kidney Biopsy 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Cyclosporine level3 
 
 
 
 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Everolimus level3 
Optional sub study: Plasma 
for Biomarkers4                         
 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 

 
 
 
 
 
Legend: 
1: If still inpatient 
2: Females capable of childbearing 
3: Cyclosporine and Zortress levels are monitored twice weekly for 0-3 months post-transplant, every 
two weeks for 3-12 months post-transplant, and monthly greater than 1 year post-transplant. 
4: Plasma for biomarkers will be assessed at the University of Colorado in a subset of patients using 
existing plasma samples.  
 
Patients will be followed as per the standard of care at this transplant center (The Ohio State 
University Medical Center, Division of Transplantation).  Additional study procedures include a protocol 
biopsy at month 12 and some additional laboratory work at screening/baseline and at months 6, 12, 
24, and 36. 
7.2 
Information to be collected on screening failures 
No information will be collected on patients failing the screening process. 
 
7.3 
Patient demographics/other baseline characteristics 
Patient demographics are routinely captured within our transplant database and as such will be 
available for analysis. Demographic data collection  includes, but is not limited to, name, age, 
gender, race, cause of renal failure, years on dialysis, sensitization status (PRA),  
7.4 
Treatment exposure and compliance 
Zortress serum trough levels will be monitored twice weekly for the first 3 months after 
transplant, once weekly between months 3 and 6, every other week between months 6 and 12, 
and monthly thereafter. Compliance with Zortress can be determined based on serum trough 
levels. 
7.5 
Efficacy  
7.5.1 
Efficacy assessment 1 
 
Incidence of graft loss in the first post-transplant year 
 
Incidence of patient death in the first post-transplant year 
 
Incidence of biopsy proven acute rejection at 1 year post-transplant 
 
Tolerability of Zortress at 1 year post-transplant 
 
Renal function at 1 year post-transplant 

 
19 
 
8 
Safety monitoring 
8.1 
Adverse events 
Adverse events that the investigators consider to be clinically significant and associated with the use of 
Zortress® or Rapamune® will be recorded at each study visit.  Serious adverse events will be reported 
to Novartis within 24 hours of discovery or notification.  An adverse event will be considered serious if 
it results in any of the following outcomes: 
 
Results in death, 
 
Is life threatening (an adverse event is considered “life-threatening: if, in the view of 
the investigator, its occurrence places the subject at immediate risk of 
death. It does not include an adverse event that, had it occurred in a more severe form, 
might have caused death), 
 
Results in persistent or significant disability/incapacity, or substantial disruption of the 
ability to conduct normal life functions, 
 
Results in congenital anomaly, or birth defect, 
 
Requires inpatient hospitalization or leads to prolongation of hospitalization 
(hospitalization for treatment/observation/examination caused by AE is to be considered 
as serious). 
 
Other medically important events 
Follow-up information for serious adverse events will be collected, recorded, and reported to Novartis.   
Adverse events that meet IRB reporting requirements will be submitted to the IRB for review. 
8.2 
Serious adverse event reporting 
To ensure patient safety, every SAE, regardless of suspected causality, occurring after the 
patient has provided informed consent and until 30 days after the patient has stopped study 
participation (defined as time of last dose of study drug taken or last visit whichever is later). 
Any SAEs experienced after this 30 day period should only be reported to Novartis if the 
investigator suspects a causal relationship to the study drug.  
8.3 
Pregnancies 
To ensure patient safety, each pregnancy in a patient on study drug must be reported to 
Novartis within 24 hours of learning of its occurrence. The pregnancy should be followed up 
to determine outcome, including spontaneous or voluntary termination, details of the birth, 
and the presence or absence of any birth defects, congenital abnormalities, or maternal and/or 
newborn complications. 

 
20 
 
9 
Data review and database management 
9.1 
Data collection 
Patient data will be collected/retained within our transplant patient database as per our normal 
operating procedure and thus immediately available and retrievable for subsequent analyses. 
The data is housed within the Ohio State University Medical Centers Transplant server 
located in a locked, secure facility. 
9.2 
Database management and quality control 
Permanent patient electronic records will be stored and maintained on the Transplant server 
housed in a locked, secure facility. Study patient data will be subject to the same quality 
controls already in place for all patients treated by the Ohio State University Medical Centers 
Transplant Program.  
10 
Data analysis (Any or all sections may be included based on 
type of study) 
10.1 
Analysis of the primary objective(s) 
10.1.1 
Variable 
The primary endpoint consists of non-death censored graft survival and biopsy proven acute 
rejection at 1 year post-transplant. These events will be directly measured and not calculated. 
10.1.2 
Statistical hypothesis, model, and method of analysis 
The primary endpoint will be a composite endpoint of graft survival (non-death censored) and 
biopsy proven acute rejection at 1 year. 
Secondary endpoints at 6 months, 1, 2 and 3 years will include: graft survival and patient 
survival/death at 2 and 3 years, rate and grade of acute cellular rejection, rate of acute 
antibody mediated rejection, rate of new donor specific antibody formation, estimated CrCl by 
MDRD, lipid control as determined by requirement for anti-lipid medications and average 
levels with and without medications, ability to maintain initial immunosuppressive 
medications and reason for switch if required, wound complications as determined by need for 
wound packing, infection treatment with antibiotics, presence of hernia on exam and 
requirement for hernia repair, as well as presence of symptomatic lymphocele, and New Onset 
Diabetes After Transplant as determined by need for new oral or sustained Insulin medication. 
Statistical analysis will be performed on SPSS or STATA software with dichotomous 
variables evaluated by Chi-Squared analysis, continuous variables by Student’s T-Test, non-
parametric outcomes will be assessed by Wilcoxon rank sum test (Mann-Whitney U test).  
Kaplan-Meier survival curves with log rank tests will be used to determine a difference in 
graft and patient survival over time. 
Safety data will include patient and graft survival, biopsy proven acute rejection, and hospital 
admissions. 

 
21 
 
10.1.3 
Handling of missing values/censoring/discontinuations 
Patients lost to follow-up or discontinued from the study will be censored from further 
analysis at the time of their withdrawal from the study. 
10.2 
Analysis of secondary objectives 
10.2.1 
Efficacy (secondary) 
Secondary endpoints at 6 months, 1, 2 and 3 years will include: graft survival and patient 
survival/death at 2 and 3 years, rate and grade of acute cellular rejection, rate of acute 
antibody mediated rejection, rate of new donor specific antibody formation, estimated CrCl by 
MDRD, lipid control as determined by requirement for anti-lipid medications and average 
levels with and without medications, ability to maintain initial immunosuppressive 
medications and reason for switch if required, wound complications as determined by need for 
wound packing, infection treatment with antibiotics, presence of hernia on exam and 
requirement for hernia repair, as well as presence of symptomatic lymphocele, and New Onset 
Diabetes After Transplant as determined by need for new oral or sustained Insulin medication. 
Statistical analysis will be performed on SPSS or STATA software with dichotomous 
variables evaluated by Chi-Squared analysis, continuous variables by Student’s T-Test, non-
parametric outcomes will be assessed by Wilcoxon rank sum test (Mann-Whitney U test).  
Kaplan-Meier survival curves with log rank tests will be used to determine a difference in 
graft and patient survival over time. 
 
10.2.2 
Safety 
Safety will be assessed by reviewing hospital admissions and graft and patient survival on a 
monthly basis as we currently do for our center’s quality assurance reviews.  Any apparent 
differences in outcome showing a disadvantage to the patient’s in the Zortress group will be 
reviewed by our Renal Transplant surgical and medical directors and they will decide if the 
study needs to be halted or amended. 
10.3 
Sample size calculation 
Due to the fact that the sample size is 60 patients, this will be a pilot study that is exploratory 
in nature, and therefore not powered to show statistical difference. 
 
10.4 
Power for analysis of critical secondary variables 
Due to the fact that the sample size is 60 patients, this will be a pilot study that is exploratory in nature, 
and therefore not powered to show statistical difference. 
 

 
22 
 
10.5 
Interim analysis 
Interim analyses will be performed at 6 months post-transplant to assure patient safety. We 
expect to demonstrate non-inferiority of the primary endpoint for patients in the Zortress 
study arm.  
11 
Ethical considerations 
11.1 
Regulatory and ethical compliance 
This clinical study was designed and shall be implemented and reported in accordance with 
the ICH Harmonized Tripartite Guidelines for Good Clinical Practice, with applicable local 
regulations (including European Directive 2001/20/EC, US Code of Federal Regulations Title 
21, and Japanese Ministry of Health, Labor, and Welfare), and with the ethical principles laid 
down in the Declaration of Helsinki. 
11.2 
Informed consent procedures 
Eligible patients may only be included in the study after providing written (witnessed, where 
required by law or regulation), IRB/IEC/REB-approved informed consent, or, if incapable of 
doing so, after such consent has been provided by a legally acceptable representative of the 
patient. In cases where the patient’s representative gives consent, the patient should be 
informed about the study to the extent possible given his/her understanding. If the patient is 
capable of doing so, he/she should indicate assent by personally signing and dating the written 
informed consent document or a separate assent form. Informed consent must be obtained 
before conducting any study-specific procedures (i.e. all of the procedures described in the 
protocol). The process of obtaining informed consent should be documented in the patient 
source documents.  
Women of child bearing potential should be informed that taking the study medication may 
involve unknown risks to the fetus if pregnancy were to occur during the study and agree that 
in order to participate in the study they must adhere to the contraception requirement for the 
duration of the study. If there is any question that the patient will not reliably comply, they 
should not be entered in the study. 
11.3 
Responsibilities of the investigator and IRB/IEC/REB 
The protocol and the proposed informed consent form must be reviewed and approved by a 
properly constituted Institutional Review Board/Independent Ethics Committee/Research 
Ethics Board (IRB/IEC/REB) before study start. A signed and dated statement that the 
protocol and informed consent have been approved by the IRB/IEC/REB must be given to 
Novartis before study initiation. 
11.4 
Publication of study protocol and results 
Study data in preparation for publication will be made available to Novartis for review prior 
to submission. 

 
23 
 
12 
Protocol adherence 
12.1 
Protocol Amendments 
Any change or addition to the protocol can only be made in a written protocol amendment that 
must be approved by Novartis, Health Authorities where required, and the IRB/IEC/REB. 
Only amendments that are required for patient safety may be implemented prior to 
IRB/IEC/REB approval. Notwithstanding the need for approval of formal protocol 
amendments, the investigator is expected to take any immediate action required for the safety 
of any patient included in this study, even if this action represents a deviation from the 
protocol. 
13 
References 
 
1. Vitko S, Tedesco H,  Eris J, Pascual J, Whelchel J, Magee J, et al. Everolimus with 
optimized cyclosporine dosing in renal transplant recipients: 6-month safety and 
efficacy results of two randomized studies. Am J Transplant 2004; 4: 626–635