Immunomodulatory Biomimetic Device to Treat Myocardial Stunning in End-stage Renal Disease Patients (ERSD)
Phase: NA
Conditions: End Stage Renal Disease, Acute Kidney Injury, Chronic Kidney Disease Stage 5
Sponsor: University of Michigan

Title: Immunomodulatory Biomimetic Device to Treat Myocardial Stunning in 
ESRD Patients 
 
NCT #: NCT03539861 
Date of IRB Approval: 10/26/2022 

 
SCD Myocardial Stunning Protocol 
 
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Clinical Study Protocol 
 
Title: Immunomodulatory Biomimetic Device to Treat Myocardial Stunning in ESRD Patients 
 
 
Drug/Device:  Selective cytopheretic device (SCD) 
 
 
Investigator(s): 
Lenar Yessayan, M.D. 
Associate Professor of Medicine, Department of Internal Medicine, Division of Nephrology 
Director, Acute Dialysis Program 
3914 Taubman Center 
1500 E. Medical Center Dr. 5364 
Ann Arbor, Michigan  48109-5364 
Phone: 734-647-9342  
Fax: 734-936-9621 
Email: lenar@umich.edu 
 
 
H. David Humes, M.D. 
Professor of Medicine Department of Internal Medicine, Division of Nephrology 
University of Michigan School of Medicine 
4520 MSRB I, 5651 
1150 W. Medical Center Dr. 
Ann Arbor, MI 48109 
Phone:734-647-8018,  
Fax 734-763-4851 
Email: dhumes@umich.edu 
 
Balazs Szamosfalvi, M.D. 
Associate Professor of Medicine, Department of Internal Medicine, Division of Nephrology 
3914 Taubman Center 
1500 E. Medical Center Dr. 5364 
Ann Arbor, Michigan  48109-5364 
Phone: 734-647-9342  
Fax: 734-936-9621 
Email: Bszamos@med.umich.edu 
 
Marty Tam, MD 
Co-Investigator 
Professor of Medicine,  
Department of Internal Medicine, Division of Cardiology 
Assistant Professor of Internal Medicine and Associate Fellowship Director - cardiovascular 
disease,  
University of Michigan School of Medicine 

 
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1500 E. Medical Center Dr.  
Ann Arbor, Michigan 48109 
 
Karthik Ramani, MD 
Co-Investigator 
Department of Internal Medicine, Division of Nephrology 
Associate Professor of Internal Medicine  
3914 Taubman Center 
1500 E. Medical Center Dr.  
Ann Arbor, Michigan 48109-5364 
 
 
 
Protocol Version Date(s):  v3.2:10/24/2022 

 
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Table of Contents 
 
Study Synopsis .................................................................................................................... 5 
1. 
Background and Rationale .......................................................................................... 8 
2. 
Potential Risks and Benefits ..................................................................................... 12 
3. 
Study Objectives ....................................................................................................... 13 
4. 
Study Design ............................................................................................................. 14 
5. 
Subject Selection ....................................................................................................... 15 
6. 
Study Materials ......................................................................................................... 17 
7. 
Concomitant Therapy................................................................................................ 25 
8. 
Study Methods .......................................................................................................... 25 
9. 
Statistical Considerations .......................................................................................... 34 
10. 
Adverse Events ..................................................................................................... 35 
11. 
Investigator Responsibilities and Statement ......................................................... 38 
References ......................................................................................................................... 39 
Appendix 1. Schedule of Events ....................................................................................... 43 
Appendix 2. Laboratory Analyses .................................................................................... 44 
 
List ofAbbreviations 
 
 
 
 
AKI 
Acute Kidney Injury 
AMI 
Acute Myocardial Infarction 
AV 
Arteriovenous 
BP 
Blood Pressure 
Cai 
Ionized Calcium 
CBC 
Complete Blood Count 
CHF 
Congestive Heart Failure 
CPB 
Cardiopulmonary Bypass 
CRF 
Case Report Form 
CRRT 
Continuous Renal Replacement Therapy 
CRP 
C-Reactive Protein 
CKD 
Chronic Kidney Disease 
CVD 
Cardiovascular Disease 
ESRD 
End-Stage Renal Disease 
HD 
Hemodialysis 
HgB 
Hemoglobin 
HR 
Heart Rate 

 
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IDWG 
Inter-Dialytic Weight Gain 
IL 
Interleukin 
IRB 
Institutional Review Board 
LE 
Leukocytes 
LVEF 
Left Ventricular Ejection Fraction 
M 
Marcophage 
MO 
Monocyte 
MOD 
Multi-Organ Dysfunction 
MS 
Myocardial Stunning 
NE 
Neutrophils 
NIH 
National Institute of Health 
PMN 
Polymorphonuclear 
RCA 
Regional Citrate Anti-Coagulation 
RR 
Respiratory Rate 
SAE 
Serious Adverse Event 
SCD 
Selective Cytopheretic Device 
SHH 
Standard Heparin Hemodialysis 
T2D 
Type II Diabetes 
TNF-α 
Tumor Necrosis Factor-alpha 
UF 
Ultrafiltration 
WBC  
White Blood Cell Count 

 
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Study Synopsis 
 
Study Objectives 
 
❖ To diminish the ischemia induced myocardial stunning 
events observed in ERSD patients on chronic hemodialysis 
requiring aggressive ultrafiltration 
Study Design 
❖ This is a Phase II trial.  
❖ Myocardial stunning events and biomarker measurements 
will be compared pre and post hemodialysis with standard 
heparin anticoagulated hemodialysis treatment and after one 
hemodialysis treatment with the regional citrate 
anticoagulated SCD device. 
Study Population 
❖ The subject population to be studied are those who have 
been on chronic hemodialysis for ≥ 3 months  
❖ It is estimated that up to 10 Subjects will be studied in this 
protocol. 
 
Entry Criteria 
❖ Inclusion Criteria  
1. End-stage renal disease (CKD Stage 5) 
2. Receiving chronic hemodialysis thrice weekly for ≥3 
months 
3. Current dialysis access is a well-functioning 
arteriovenous (AV) graft, AV fistula, or cuffed tunneled 
catheter 
4. Patient can safely receive chronic hemodialysis thrice 
weekly with heparin anticoagulation 
5. Patient has achieved Kt/V≥ 1.2 over the preceding 2 
months 
6. Patient has no contraindication for regional citrate 
anticoagulation 
7. Baseline blood pressure before hemodialysis has been 
≥100/50 over preceding 4 weeks 
8. Able to and have given informed consent 
9. Recurrent intradialytic weight gain >0.04 kg/kg body 
weight at the beginning of the week (i.e. Monday or 
Tuesday). Recurrent is defined as at least two of eight 
sessions the past 60 days or at least three of twelve 
sessions the past 90 days.  
OR 
Intradialytic hypotension (IDH) prone (IDH greater than 
30% of dialysis sessions in month before session) IDH 
defined as systolic blood pressure (SBP) less than 100 
mmHg or SBP decrease greater than >10% of predialysis 
with symptoms 
10. Age ≥ 18 years 
 
❖ Exclusion criteria: 

 
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1. Severe heart failure (NY Heart Association functional 
class greater than or equal to 3) 
2. Cardiac transplant recipient 
3. Mental incapacity to consent 
4. Human immunodeficiency virus (HIV) 1 or 2 Ab (+)  
5. Any active inflammatory condition (e.g., gout, systemic 
lupus erythematosus flare, hepatitis B or C infection, 
allograft rejection, subcutaneous injection of illicit drugs, 
“skin popping”) 
6. Treatment with immunosuppressive therapy (e.g anti-
neoplastic agents, glucocorticoids, calcineurin inhibitors) 
within 30 days of the treatment program 
7. Hemoglobin (HgB) <9 g/dL 
8. Platelet count <50,000/mm3 
9. WBC <4,000/mm3 
10. Acute coronary syndrome, including myocardial 
infarction within 90 days of the treatment period 
11. Ischemic cardiomyopathy 
12. Participation in an experimental drug or device study, 
within 30 days of the treatment period 
13. Woman who is pregnant, breast feeding a child, or try to 
become pregnant 
14. Inability to comply with Study Procedures  
15. Exposure to hemodialysis for less than 90 days 
16. Positive test for active infection with COVID-19 virus 
 
Treatment Plan 
Each Subject will receive one standard study hemodialysis 
treatment with heparin anticoagulation during which all 
procedures noted in Appendix 1 will be performed.  
Subsequently each subject will receive hemodialysis with the 
added SCD filter anticoagulated with regional citrate. 
Data Safety 
Monitoring  
This is a small feasibility study.  A safety analysis will be 
performed on each patient prior to their next hemodialysis 
treatment by the PI.  
Key Measurements 
❖ 
Adverse events 
❖ 
Regional wall abnormalities and myocardial strain on 
Echocardiogram 
 
Exploratory 
Measurements 
❖ 
Soluble Markers (Elastase, Hs CRP, IL-6, IL-10, IL-17, 
IL-23, G-CSF, TNF-α, MCP-1, L-selectin, neopterin, IL-
1β, IL-8) 
❖ 
Leukocyte flow cytometry (circulatory monocyte subsets 
and circulatory activated neutrophils) 
❖ 
WBC and platelet counts  
 

 
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Primary Analyses 
Descriptive analysis will be conducted on the following 
parameters in all Subjects exposed to any study hemodialysis 
treatment: 
❖ 
Adverse events 
❖ 
Regional wall abnormalities and myocardial strain 
❖ 
Clinical laboratory and physiological  measurements 
Secondary Analyses 
A number of secondary analyses will be conducted, including 
the following:  
❖ 
Mean change from baseline in cytokines at the end of each 
treatment 
❖ 
Mean change from baseline in markers of inflammation at 
the end each treatment 
 
Study Periods and 
Study Duration 
❖ 
The total duration of participation will be approximately 3 
weeks.  
 
 

 
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 1. 
Background and Rationale 
 
 
More than 400,000 people are currently treated by hemodialysis (HD) in the US end 
stage renal disease (ESRD) program. The mortality in this group of patients is unacceptably high 
with almost half of the deaths due to cardiovascular disease (CVD). Strategies to reduce the 
mortality of HD patients with directed interventions at cardiovascular risk factors have largely 
been ineffective. It is well recognized that HD patients suffer excess morbidity and mortality, 
mainly due to cardiac failure and sudden death rather than traditional thrombotic occlusion 
leading to acute myocardial infarction (AMI).1,2 The excess cardiovascular risk is not the result 
of the traditional factors associated with CVD but a combination of non-traditional factors 
unique to chronic kidney disease (CKD).  
There is a growing body of evidence to suggest that a combination of multiple 
hemodynamic and inflammatory factors contribute to this elevated risk. These factors operate 
simultaneously and sequentially, contributing to the poor outcomes. They include the repetitive 
hemodynamic insult precipitated by rapid volume removal with HD and the immune 
dysregulation accentuated by dialysis. It has been shown that dialysis is associated with a 
repetitive ischemic injury termed myocardial stunning (MS) 3. A subsequent observational study 
over 12 months has shown that MS is associated with 30% mortality and 10% reduction in left 
ventricular ejection fraction 4. Larger inter-dialytic weight gain (IDWG) with the requirement for 
larger ultrafiltration volume is strongly associated with MS and increased mortality 4-6, 
specifically for ultrafiltration (UF) requirements exceeding 12.37 ml/h/kg. It seems that HD itself 
may contribute to the development of heart failure and the risk of sudden death. In addition to the 
hemodynamic instability precipitated by HD, these patients are subject to substantive metabolic 
and inflammatory stress 7.  
Since treatment of traditional risk factors for CVD have been ineffective, focus on non-
traditional risk factors, especially acute and chronic inflammation, has become a focus of 
therapeutic interventions in dialysis patients. In this regard, inflammation and its cellular 
immunologic effector, the activated monocytes (MO), are central to the accelerated progression 
of CVD in patients with CKD and patients with ESRD on HD. Consequently, a focus on non-
traditional and non-modifiable risk factors has emerged with MO activation as a prime 
therapeutic target. A pivotal pathobiologic role of MO and macrophages (M) on development 
and progression of atherosclerosis has been clearly established 8-10. In this regard, heterogeneous 
subpopulations of MO have been identified in humans. Cell surface expression of CD14 and 
CD16 identifies 3 functionally distinct subsets of MO: classical (CD14hi, CD16-, pro-
inflammatory), intermediate (CD14hi, CD16+, pro-inflammatory) and non-classical (CD14low, 
CD16++, anti-inflammatory/reparative). Intermediate MO play an instrumental role in the 
development of atherosclerosis in the general and CKD populations 11-14. This subset of M has a 
greater degree of pro-inflammatory phenotype compared to the other subsets. Furthermore, 
epidemiologic studies have reported that the number of intermediate MO increases with 
worsening renal function and higher cell numbers predict adverse cardiovascular outcomes in 
ESRD patients undergoing chronic dialysis 14-17. This proposal plans to evaluate a novel 
immuno-modulatory device, the selective cytopheretic device (SCD), on the immune 
dysregulated state of ESRD and to assess the benefit of this innovative strategy to improve 
cardiac performance and reduce progressive congestive heart failure (CHF). 
The SCD has shown to has shown to improve clinical outcomes of critically ill patients 
with multiorgan dysfunction (MOD) by mitigating the inflammatory cascade. Benefit has also 

 
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been indicated with chronic inflammation, such as that observed in end stage renal disease 
(ESRD). This technology has proven to be effective in pre-clinical animal models of disease for 
which inflammation is present, such as cardiopulmonary bypass (CPB), septic shock and stroke. 
This proposal plans to further evaluate therapeutic impact of a novel device (SCD) specifically 
toward ischemic cardiac events during hemodialysis (HD) in ESRD patients. 
 
 
 
 
 
SCD Mechanism of Action 
 
 
 
The SCD is an immuno-regulating, extracorporeal fiber membrane device targeted to 
modulate the cardiac ischemic events occurring during HD. The platform of SCD technology is 
the ability of polysulfone fibers to selectively sequester activated systemic leukocytes (LE), 
primarily neutrophils (NE) and MO, as they flow through the fiber casing via an extracorporeal 
circuit. The bound LE are deactivated via exposure to a pharmacologic agent (citrate), resulting 
in lower ionized calcium (iCa) which resets the excessive/dysregulated activation kinetics of LE 
to a more normal state, while also providing regional anticoagulation. The reset LE are then 
released back to the systemic blood. The SCD has demonstrated to ameliorate acute MOD in 
four clinical trials resulting in a relative 50% reduction in mortality rates of ICU patients with 
MOD 18-20, as well as shifting the circulating MO pool to a less inflammatory phenotype in 
ESRD patients on chronic HD. The SCD has the potential to transform the therapeutic approach 
to a disorder that results in progressive cardiac failure in the ESRD population on chronic HD 21. 
 
 
Preliminary Clinical Observations 
 
Acute Renal Failure 
 
 
This approach has been initially evaluated in ICU patients with acute kidney injury (AKI) 
and multiorgan failure requiring CRRT. These trials were initiated after preclinical experiments 
in a porcine model demonstrated that SCD therapy had a significant ameliorative effect on sepsis 
induced organ dysfunction, including cardiac, pulmonary and renal parameters along with an 
immunomodulatory effect on circulating LE.  The clinical evaluation of SCD therapy has been 
completed in 3 exploratory clinical trials in ICU adult patients with AKI requiring continuous 
renal replacement therapy (CRRT) and multi organ dysfunction (MOD).  These trials have 
demonstrated an excellent safety profile and suggested efficacy impact.  Leukopenia and 
sustained thrombocytopenia were not observed; accelerated renal recovery with RRT 
discontinuation and an approximately 15-20 percent or greater improvement in survival rates has 
been observed compared to conventional RRT.  This device is added in series to the CRRT after 
the standard HD filter.  Of note, in all 3 trials SCD therapy was well tolerated, without 
significant effects on hematological parameters, including white blood counts (WBC) and 
platelet counts, and with no unanticipated serious adverse events related to SCD therapy.  Due to 
these favorable results in 3 trials, a Phase III controlled, randomized, multicenter clinical trial 
was undertaken.  The control group received standard CRRT with RCA and the SCD treated 
group received up to 7 days of device therapy.  An analysis of per protocol patients demonstrated 

 
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no device related serious adverse events.  The SCD therapy group had a 60-day mortality rate of 
16% compared to 41% in control.  The SCD therapy group had no patients with dialysis 
dependency at day 60 compared to 23% of control patients.  The composite end point of either 
death or dialysis dependency at day 60 was 16% for SCD therapy vs. 58% for control (p=0.01).   
 
Acute Heart Failure and CHF  
 
Over the past decade, a number of novel pharmacologic approaches have failed to prove 
clinical efficacy, accentuating the need to discover new, safe approaches to treat CHF. 
Inflammation is central to the development of a variety of acute organ failures, including heart, 
kidney, lung and brain, as well as chronic organ dysfunction, including heart, kidney and Type 2 
Diabetes. CHF and acute decompensated heart failure have been increasingly recognized as 
associated with chronic systemic inflammation 22. MO and tissue M have been identified as 
critical sources of systemic inflammation in CHF 23 and cause a decrease in cardiac myocyte 
contractility 24. In this regard, the SCD has been assessed in a preclinical model of CHF. SCD 
efficacy to dampen the cardio-depressant effects associated with the chronic pro-inflammatory 
state of CHF was evaluated in a preclinical canine CHF model 25 developed and fully 
characterized by Dr. Hani Sabbah. This model manifests many of the sequelae of CHF in 
humans, including profound systolic dysfunction, increased systemic vascular resistance and 
decreased cardiac output 26. It has been used to predict efficacy of new therapies for treatment of 
CHF 26-28. Five dogs with advanced CHF were used in the study set. The effect of SCD therapy 
on LVEF in this model, demonstrates that this therapy converts viable but non-contracting 
myocardium to contracting myocardium. The renal effects were also substantive with doubling 
of urine sodium excretion with SCD therapy compared to baseline. With respect to safety profile, 
no episodes of arrhythmias or hypotension were observed during the treatment period. Recent 
ongoing studies supported with NIH funding in this model has demonstrated that this SCD 
related improved myocardial performance lasts up to 4 weeks after treatment.  
 
Ischemia/Reperfusion Injury of Myocardium  
 
Inflammation with LE infiltration into injured myocardium 29 plays a critical role in the 
degree of myocardial ischemia reperfusion injury after AMI. To evaluate the ability of SCD 
therapy to reduce infarct size of AMI, dogs underwent complete occlusion of the circumflex 
coronary artery with a balloon catheter for 3h followed by 2h of reperfusion after balloon 
deflation. Control IRI dogs (n=4) received no treatment; SCD therapy was initiated 20-30 
minutes prior to reperfusion and continued for the entire 2h reperfusion period (n=3). As 
demonstrated in Figure 3, SCD therapy had a substantial effect to reduce infarct size reducing the 
percent of infarct area to total LV mass from control of 19 ± 1.35 to 10.2 ± 2.6 % (p<0.05) in 
SCD therapy animals. The degree of NE infiltration was markedly diminished in the area of 
injury. Serum troponin levels were 10x lower in SCD animals compared to controls (data not 
shown). 
 
Pilot Feasibility Trial of SCD Therapy in ESRD Patients  
 
A pilot safety trial was undertaken by Szamosfalvi et al. to evaluate SCD therapy in a 
more stable renal failure patient population. Fifteen ESRD patients with CRP levels above 

 
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5mg/L were enrolled to assess the safety and early efficacy signals on inflammatory biomarkers 
in these patients.  After a Non-Significant Risk designation by the Henry Ford Health System 
(HFHS) IRB, this study was performed 21. The clinical results demonstrated an excellent safety 
profile with no decline in total WBC, NE or platelet counts. To evaluate the effect of SCD 
therapy on M phenotypes in these patients, determination of CD14hi fluorescent intensity on 
peripheral blood M was analyzed utilizing flow cytometry. SCD therapy promoted a shift in MO 
phenotype from predominantly CD14hi expressing MO at baseline/pre-SCD therapy to CD14low 
expressing MO post-SCD therapy (Figure 4, A/B). In the 13 ESRD patients evaluated, a 
significant shift in MO population phenotype afforded by a single SCD therapy session was 
observed (p<0.013). In a subset of patients (n=7) presenting with T2D, indicative of an even 
greater chronic inflammatory state, this persistent decline in M CD14 expression was sustained 
as long as 2 weeks post therapy (Figure 4, C). The average number of cells bound to the SCD 
membrane following 4 hours of therapy showed 1.13x109, with 68% identified as NE, 23% M, 
7% eosinophils and 0% lymphocytes. The eluted M were almost all of CD14high phenotype; with 
the differential percentage being more than double the average 9% circulating M pool. Of note, 
two patients underwent SCD treatment with standard heparin HD (SHH), as opposed to RCA. 
No change in M phenotype was observed, but symptomatic and biochemical adverse events were 
seen after SHH+SCD treatment, including a greater than doubling of CRP levels. No further 
studies were undertaken with SHH+SCD treatment due to these adverse events.  
 
Myocardial stunning in ESRD patients undergoing chronic hemodialysis  
 
 
The mortality rate in ESRD patients requiring chronic hemodialysis treatment is 
unacceptably high with almost half of the deaths due to cardiovascular disease (CVD). This 
excessive CVD mortality is not due to classical atherosclerotic disease complications but mainly 
due to cardiac failure and sudden death, often during the dialysis procedure1,2. The pathogenesis 
of heart failure in this patient population appears to be due to intradialytic recurrent myocardial 
stunning (MS) as defined as ischemia mediated transient reduction in myocardial function. 
Overtime these recurrent ischemic insults results in irreversible fibrotic changes, chronic heart 
failure, arrhythmias, and sudden cardiac death3,30,31. In this regard, hemodialysis-induced 
myocardial ischemia and MS has been found to be common in these patients and is significantly 
associated with high rates of ultrafiltration and intradialytic hypotension4. Of note, pediatric 
patients devoid of atherosclerotic coronary artery disease also have had a high incidence of 
MS32. MS in HD patients promotes both ischemia induced areas of hypokinesis and akinesis. The 
majority of these areas of MS improve within 30 minutes post hemodialysis33,34 More frequent 
HD regimes are associated with lower UF volumes and reduction of intradialytic hypotension 
and MS events. This relationship may explain in part improved outcomes associated with more 
frequent HD, such as nocturnal or home HD, compared to the conventional 3 times a week HD 
treatment program35. MS may be the critical pathophysiologic factor promoting the CV related 
deaths predominated by heart failure and sudden death in ESRD patients on chronic 
hemodialysis. 
 
Immunomodulatory Biomimetic Device to Treat Myocardial Stunning in ESRD Patients 
 
 
This clinical protocol will evaluate the influence of the SCD on myocardial stunning 
events in ESRD patients in chronic hemodialysis patients. Regional citrate anticoagulation 

 
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protocols are routinely used during continuous renal replacement therapy for critically ill patients 
in intensive care units in many medical centers. A citrate protocol will be adapted for use in this 
research clinical study in patients with ESRD during one hemodialysis treatment with the added 
SCD cartridge. We have used this protocol with variations in blood flow/dialysate flow in 
previous research studies with SCD in both hemodialysis and CRRT treatments. With the 
currently available citrate intravenous solutions, blood flow through the dialysis system will be 
300 mL/min rate. The delivered dose of clearance will be measured online using conductivity 
dialysance measurements available on Fresenius 2008 T machine. Citrate infusion into the blood 
will lower the blood ionized calcium level, so that blood ionized calcium levels must be 
monitored closely. Possible differences may occur in ionized calcium levels in the blood from 
the extracorporeal circuit obtained at the pre-citrate infusion site compared to the systemic levels 
may occur. This difference would only occur due to recirculation of blood around the blood 
access site used for dialysis treatment. Accordingly, assessment of recirculation will be 
performed using online recirculation module available on Fresenius 2008 T machine. If citrate 
use results in hypocalcemia this may be associated with paresthesia, tetany, lethargy. If 
hypocalcemia is not corrected and continues to worsen it may result in severe laryngospasm, 
seizures, and in rare cases death. Due to these rare potential risks during citrate infusion, ionized 
calcium levels in the blood from the extracorporeal circuit obtained at the pre-citrate infusion 
will be carefully monitored, with rapid treatment for protocol subjects in the rare event of 
developing symptomatic hypocalcemia. Clinical use of regional citrate anticoagulation to prevent 
circuit clotting (see sections 6.3.4 and 6.3.5) is established and routinely used in clinical 
hemodialysis at many medical centers. The authors conducted a study of SCD in ESRD patients 
using citrate anticoagulation at Henry Ford Health System (HFHS) where HFHS IRB deemed 
the study Non-Significant Risk.  
 
2. 
Potential Risks and Benefits 
 
 
The hemodialysis treatment with SCD is comprised of two dialysis cartridges in series 
within an extracorporeal blood circuit and its associated blood pump systems and blood tubing. 
The first dialysis cartridge is a conventional high-flux, high surface area Fresenius polysulfone 
hemofilter (Optiflux 250NR) and the second cartridge is the SCD, which is identical to an FDA 
approved conventional Fresenius polysulfone F40 filter, Fresenius Medical Care North America, 
Waltham, MA, U.S.A. approved by the FDA for use in acute and chronic hemodialysis. The 
extracorporeal perfusion circuit uses standard dialysis arteriovenous blood tubing and is 
schematized in the Figure 1 with two hemodialysis cartridges in series. The cartridges and blood 
tubing are placed in a dialysate delivery pump system. 
 
 
The risks of this device system are similar to risks associated with hemodialysis 
treatments and include clotting of the perfusion circuit, air entry into the circuit, catheter or blood 
tubing kinking or disconnection, and temperature dysregulation. The dialysis machines and 
associated dialysis blood perfusion sets have been designed to identify these problems during 
treatment with alarm systems and to mitigate any clot or air embolism to the patient with clot 
filters and air bubble traps. These pump systems and blood tubing sets are FDA approved for this 
treatment indication. 
 

 
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The blood flow path is changed in the second cartridge compared to conventional use, 
with blood flowing outside the hollow fibers in the extracapillary space of the hemofiltration 
cartridge. The lumens of the hollow fibers of the second cartridge will be filled with normal 
saline, and the entry and exit ports will be capped. This formulation is a reversal of conventional 
fluid flow mechanics of the dialysis membrane. The risk of this change in flow geometry has 
proven to be minimal. The use of this second cartridge in this extracorporeal perfusion circuit has 
been evaluated in over 100 large animals in pre-clinical testing and in 123 patients in Phase I, II, 
and III clinical studies with no unanticipated adverse events related to the second cartridge and 
the perfusion circuit. These studies have used both systemic heparin and regional citrate 
anticoagulation treatments. In fact, in the clinical experience, if clotting occurs within the circuit, 
it has always been initiated in the first dialysis cartridge. The anticoagulation protocols, both 
systemic heparin and regional citrate in general (see sections 6.3.4 and 6.3.5), are currently 
established and routinely used in clinical hemodialysis at many medical centers. Potential 
benefits may be a short-term improvement of the chronic pro-inflammatory state of ESRD.  
 
 
For our intended use population the following risk are: cardiac arrhythmias, atrial 
fibrillation, atrial flutter, bradycardia, sinus tachycardia, ventricular fibrillation, ventricular 
tachycardia. these risks are all associated with myocardial ischemia. This risk is higher in the 
intended use population since the enrolled patients will have a tendency to myocardial 
stunning/ischemia promoting intradialytic hypotension. 
 
3. 
Study Objectives 
 
 
The objective of the study is to evaluate the efficacy and safety of SCD in diminishing 
ischemia induced myocardial stunning events observed in ERSD patients on chronic 
 
Fig. 1.  SCD device. 

 
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hemodialysis requiring aggressive ultrafiltration. Our aim is to decrease myocardial stunning 
events in hemodialysis patients.   
 
4. 
Study Design 
 
 
4.1 
Design 
This is an exploratory pilot trial. The subject population to be studied are those who have 
been on chronic hemodialysis for ≥ 3 months with recurrent intradialytic weight gain 
>0.04 kg/kg body weight.  
Regional myocardial wall abnormalities and biomarker measurements will be compared 
pre and post hemodialysis with standard heparin anticoagulated hemodialysis treatment 
and after one hemodialysis treatments with the regional citrate anticoagulated SCD 
device. 
 
Two different treatment regimens are planned for this clinical trial. 
 
Treatment 1 will be a 5 hour hemodialysis treatment session utilizing heparin 
anticoagulation. The first hour will utilize a blood flow rate (BFR) of 300 mL/min and a 
dialysate flow rate (DFR) of 600 mL/min with no ultrafiltration (UF). After the first hour, 
the blood flow rate will be adjusted to 200 mL/min with a dialysate flow rate of 400 
mL/min. This BFR and DFR will be maintained for the remaining 4 hours of the 5 hour 
session.  
 
Treatment 2 will be a 5 hour hemodialysis treatment session. The first hour will be 
undertaken with heparin anticoagulation utilizing a BFR of 300 mL/min and a dialysate 
flow rate of 600 mL/min with no UF. After the first hour, the SCD will be integrated into 
the circuit with regional citrate anticoagulation and BFR adjusted to 200 mL/min with a 
DFR of 400 mL/min. This BFR and DFR with RCA will be maintained for the last 4 
hours of the 5 hour session.  
Of importance, this 5 hour session is planned to ensure adequate solute clearance but with 
only 4 hour high UF to achieve the patients dry weight.  
 
Entry Criterial Met 
 
Treatment 1 
echocardiogram 
Heparin Hemodialysis 
All Assays in Hemodialysis Section 
echocardiogram 
 
24 hr echocardiogram 
Blood assay 
 
Treatment 2 
echocardiogram 
Single Treatment with SCD 
All Assays in SCD Section 
echocardiogram 

 
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24 hr echocardiogram 
Blood assay 
Concluding Safety Measurements 
 
 
The hemodialysis treatments will be performed at the Acute Dialysis Unit, University of 
Michigan. 
 
4.2 
Number of Subjects 
 
10 Subjects will be studied in this protocol. 
 
4.3 
Duration of Study 
 
The total duration of participation will be approximately 3 weeks. 
 
5. 
Subject Selection 
 
 
5.1 
Inclusion Criteria 
 
5.1.1 End-stage renal disease (CKD Stage 5) 
 
5.1.2 Receiving chronic hemodialysis thrice weekly for ≥3 months 
 
5.1.3 Current dialysis access is a well-functioning arteriovenous (AV) graft, AV 
fistula, or cuffed tunneled catheter (average blood flow >350 ml/min in the 
last 3 HD sessions)  
 
5.1.4 Patient can safely receive chronic hemodialysis thrice weekly with heparin 
anticoagulation 
 
5.1.5 Patient has achieved Kt/V≥ 1.2 over the preceding 2 months 
 
5.1.6 Patient has no contraindication for regional citrate anticoagulation 
 
5.1.7 Baseline blood pressure before hemodialysis has been ≥ 100/50 over 
preceding 4 weeks 
 
5.1.8 Recurrent intradialytic weight gain >0.04 kg/kg body weight at the 
beginning of the week (i.e.Monday or Tuesday). Recurrent is defined as at 
least two of eight sessions the past 60 days or at least three of twelve 
sessions the past 90 days. 
 
OR 
 
Intradialytic hypotension (IDH) prone (IDH greater than 30% of dialysis 
sessions in month before session) IDH defined as systolic blood pressure 

 
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(SBP) less than 100 mmHg or SBP decrease greater than >10% of 
predialysis with symptoms 
 
5.1.9 Able to and have given informed consent 
 
5.1.10 Age ≥ 18 years 
 
 
 
 
 
5.2 
Exclusion Criteria 
 
5.2.1. Human immunodeficiency virus (HIV) 1 or 2 Ab (+)  
 
5.2.2. Any active inflammatory condition (e.g., gout, systemic lupus 
erythematosus flare, hepatitis B or C infection, allograft rejection, 
subcutaneous injection of illicit drugs, “skin popping”) 
 
5.2.3. Treatment with immunosuppressive therapy (e.g., anti-neoplastic agents, 
glucocorticoids, calcineurin inhibitors) within 30 days of the treatment 
program 
 
5.2.4. Hemoglobin (Hgb) <9 g/dL 
 
5.2.5. Platelet count <50,000/mm3 
 
5.2.6 WBC <4,000/mm3 
 
5.2.7. Acute coronary syndrome, including myocardial infarction within 90 days 
of the treatment period 
 
5.2.8. Ischemic cardiomyopathy 
 
5.2.9 Participation in an experimental drug or device study, within 30 days of 
the treatment period 
 
5.2.10. Woman who is pregnant, breast feeding a child, or is trying to become 
pregnant 
 
5.2.11 Inability to comply with Study Procedures  
 
5.2.12  Exposure to hemodialysis for less than 90 days 
 
5.2.13  Severe heart failure (NY Heart Association functional class greater than or 
equal to 3) 

 
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5.2.14  Cardiac transplant recipient 
 
5.2.15  Mental incapacity to consent 
 
5.2.16 Positive test for active infection with COVID-19 virus 
 
 
6. 
Study Materials 
 
6.1 
Study Materials Packaging and Storage 
 
All non-routine supplies and components needed to administer SCD treatments will be 
stored in a secure, limited-access area.    
 
6.2 
Use of the SCD 
 
Personnel at the University of Michigan dialysis unit will be responsible for 
administering SCD treatments under the supervision and guidance of the clinical 
investigators.  
 
In this trial, “SCD treatment” using a two-cartridge system will be delivered using a type 
of dialysis equipment commonly used for conventional hemodialysis therapy. The SCD 
cartridge will be connected in line with the conventional hemodialysis system, and 
treatment will be delivered for the usual duration of patient treatment. Blood exchange 
will occur using the patient’s existing hemodialysis access (i.e., arteriovenous graft, 
arteriovenous fistula, or dialysis catheter). 
 
6.2.1 SCD Set-up 
 
Consult The Set Up Manual of Operations For Fresenius 2008T. 
6.2.2 Vascular Access 
 
The Subject’s current hemodialysis vascular access will be used for study 
hemodialysis treatments.  The vascular access will be cannulated or accessed only 
by persons who are trained and experienced in this procedure. 
 
6.2.3 Dialysate Fluid 
 
The dialysate fluid during SHH and during the first hour of SCD treatment arm 
will be chosen by the Principal Investigator based on the Subject’s laboratory tests 
and clinical status. The content of the dialysate fluid may be adjusted as needed. 
For the next four hours of SCD treatment with citrate anticoagulation, 0 mM 
calcium dialysate will be used. 
  
6.3 
Selective Cytopheresis System Procedures 

 
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6.3.1  Description of SCD System 
Dr. H. David Humes, Professor of Internal Medicine, and his group have 
developed a biomimetic membrane cell processing device, named the Selective 
Cytopheretic Device (SCD).  This developing commercial product licensed to 
CytoPherx, Inc. (a University of Michigan spinoff) is identical to hemodialysis 
cartridges (F series) manufactured by Fresenius, AG except for a cartridge casing 
with closed end caps (U.S. patent 9,341,626). This device, when incorporated into 
an extracorporeal blood circuit, preferentially binds activated leukocytes (LE), 
and in the low calcium environment afforded by regional citrate anticoagulation 
(RCA), the bound LE are deactivated and released back to the systemic 
circulation.  This device is identical to a polysulphone membrane dialyzer but 
with the blood flow path directed to the outside of the hollow fiber membrane 
rather than the inside of the membrane. The blood flow path results in low shear 
forces similar to capillary shear so the membrane has selectivity to bind activated 
LE. This continuous cell processing activity results in measurable diminution of 
excessive inflammatory responses in a variety of preclinical and clinical 
disorders. 
  
The Selective Cytopheretic Device (SCD) investigational device to be used in the 
execution of this clinical trial protocol consists of two (2) devices packaged 
separately: 1) SCD Blood Tubing Set (Product Code 8X64R1) 2) SCD-F40 
(Fresenius F40S). These two devices are connected in series to a Renal 
Replacement pump (a Fresenius 2008T ® RRT device). Blood from the Renal 
Replacement pump circuit is diverted after the hemodialysis dialyzer through the 
extra capillary space (ECS) of the SCD-F40. Blood circulates through this space 
and it is returned to the patient via the venous return line of the renal replacement 
therapy circuit. Regional citrate anticoagulation is used for the entire 
hemodialysis circuit and SCD blood circuits. When utilized with this flow 
pathway and in the presence of regional citrate anticoagulation, the SCD 
membrane binds activated leukocytes and modulates inflammation. Thus, the 
F40-SCD, and blood tubing are investigational- not FDA approved or cleared for 
marketing. The remainder of the system is commercially available, FDA cleared. 
 
 
6.3.2  Intended Use 
 
 
The SCD is intended to be used in conjunction with FDA-approved dialysis 
systems on ESRD patients who are already receiving chronic dialysis in the 
dialysis unit of the University of Michigan. 
 
  
 
6.3.3  SCD System Perfusion Initiation Protocol 
 
Procedural Overview 
 
The preparation for hemodialysis with SCD integration is similar to that of the 
conventional dialysis blood lines by adding the SCD in series with the initial 
hemodialysis cartridge. 

 
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Aseptic technique must be used throughout the entire integration procedure. The 
SCD cartridge will be brought to the patient's bedside where the SCD blood line 
will be connected in series to the existing dialysis circuit. After one hour of 
hemodialysis the SCD will be integrated into the extracorporeal circuit, the 
dialysate pump system will be initiated and maintained by the trained personnel of 
the dialysis unit.  
 
6.3.4 Citrate Anticoagulation Therapy  
       
❖ Citrate acts as an anticoagulation agent by binding with calcium. The 
bound calcium is then unavailable to trigger clotting factors. A fixed blood 
flow to citrate flow ratio will be used to ensure strong anticoagulant 
activity (circuit ionized Ca < 0.4 mM) throughout the entire circuit 
 
❖ The specific clinical protocol developed at Henry Ford Hospital by Balazs 
Szamosfalvi (co-investigator) for citrate anticoagulation will be used. 
About 90-95 % of the free [citrate- and complex [citrate-calcium]- ions are 
cleared on the high flux and high efficiency OF250NR dialyzer using a 
commercial Fresenius calcium-free dialysis fluid at 400 ml/min dialysate 
flow rate. The remaining clinically negligible citrate enters the patient 
with the venous blood return and is metabolized in the liver. The very high 
citrate removal on the dialyzer is a unique feature of the IHD-RCA 
protocol and will prevent citrate accumulation in the patient even in the 
absence of body metabolism of citrate. 
 
❖ The filter performance in removing citrate is indirectly monitored by 
online measurements of conductivity dialysance and by visual filter 
inspections for clotting. 
 
❖ Anticoagulation is only reversed when calcium is added to the circuit 
venous bloodstream just before it is returned to the patient in order to 
restore systemic ionized calcium levels that will allow adequate systemic 
blot clotting and cardiac function. 
 
❖ The initial calcium rate is selected from a table based on patient online 
hemoglobin (Crit-Line III) and last measured albumin level. The calcium 
infusion is adjusted hourly based on online hemoglobin values and every 
time a systemic ionized calcium measurement is performed. 

 
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❖ IHD-RCA Protocol at QB=200: Ca-infusion (200 ml 10% CaCl2 + 0.8 
L 0.9% saline) dosing 
 
1. Select the base Calcium-infusionTable l Rate at QB=200: The 
amount of calcium removed from the circuit blood by the dialyzer is 
altered by the hemoglobin (Hb) and albumin level. The initial calcium 
infusion rate is prescribed by the PI based on the last laboratory 
hemoglobin and serum albumin using Table 1. At start the nurse adjusts 
the initial Ca-infusion Table l Rate using the Crit-Line online optical 
hemoglobin value and the last serum albumin and confirms any change 
with the PI. The systemic ionized calcium at 1 hour is charted but not used 
to alter the initial rate. An offset is always applied to the Table l Rate 
based on the hourly net ultrafiltration rate (see below).   
 
 
 
 
 
Table 1 ACD-A (Citrate) Infusion Fixed Rate, Blood flow = 200 ml/min, ACD-A flow = 400 
ml/hour 
Figure 2.  
Diagram of the first filter circuit for the HFH citrate protocol 
Patient Access 
Calcium 
Infusion 
Concentrated 
Citrate Infusion 
Infusion Pumps 
Input Dialysis Fluid 
Output Dialysate 
Sample Port 
SCD Citrate Dialysis Circuit on First Filter 
Hematocrit Sensor 
Crit-Line III) 
Hct 30 % 
Kecn 190 ml 
Online Clearance 

 
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Rate in ml/hour of the Ca-infuson (20 gm CaCl2 + 0.8 L 0.9% saline). The rate is defined by 
the systemic albumin and hemoglobin at a blood flow of 200 ml/min.  
Hb 
6-6.9 
g/dL 
7-7.9 
g/dL 
8-8.9 
g/dL 
9-9.9 
g/dL 
10-10.9 
g/dL 
11-11.9 
g/dL 
12-12.9 
g/dL 
13-13.9 
g/dL 
14-14.9 
g/dL 
15-15.9 
g/dL 
Albumin 
 
 
 
 
 
 
 
 
 
 
0.0-0.7 
g/dL 
110 
106 
102 
98 
93 
90 
86 
82 
78 
73 
0.8-1.2 
g/dL 
116 
112 
108 
103 
99 
95 
91 
87 
82 
78 
1.3-1.7 
g/dL 
122 
118 
113 
109 
105 
100 
96 
91 
87 
82 
1.8-2.2 
g/dL 
129 
125 
120 
115 
110 
106 
101 
96 
91 
87 
2.3-2.7 
g/dL 
136 
131 
126 
121 
116 
111 
106 
101 
96 
91 
2.8-3.2 
g/dL 
142 
137 
132 
127 
121 
116 
111 
106 
101 
96 
3.3-3.7 
g/dL 
149 
143 
138 
132 
127 
121 
116 
111 
105 
100 
3.8-4.2 
g/dL 
155 
149 
144 
138 
132 
127 
121 
116 
110 
104 
4.3-4.7 
g/dL 
162 
156 
150 
144 
138 
132 
126 
120 
115 
108 
4.8-5.2 
g/dL 
168 
162 
156 
150 
144 
137 
131 
125 
119 
113 
 
2. Adjust the base Ca-infusion Table l Rate at QB=200 using systemic 
hemoglobin changes The systemic hemoglobin (Hb) level in the 
arterial limb of the blood circuit will be continuously measured and 
displayed by an optical sensor (Crit-Line III).  
The Hb level may decrease due to bleeding and increase due to blood 
transfusions or hemoconcentration due to excessive ultrafiltration. If the 
Hb increases, the circuit plasma flow will decrease and the dialyzer 
calcium losses will decrease, therefore the calcium infusion rate must be 
decreased. If the Hb decreases, the circuit plasma flow will increase and 
the dialyzer calcium losses will increase, therefore the calcium infusion 
rate must be increased.  
The Hb based adjustments are done when a Hb-range change is observed 
or at least every 20 minutes independent of other adjustments. Select the 
new base Ca-infusion rate for the hemoglobin range (column) 
corresponding to the last optical Hb value from Table 1. Use the most 
recent albumin level to find the appropriate row. Apply the Total Current 
Offset to the base Ca-infusion Table l Rate to get the final Ca-infusion rate 
(see below). 
 
3. Offset the base Ca-infusion Table l Rate at QB=200 using the 
hourly net ultrafiltration rate:  Circuit Ca losses due to net ultrafiltration 
need not be replaced. Calculate the hourly net ultrafiltration rate: [Pre-

 
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dialysis weight (kg) — estimated dry weight (kg)] * 1000 / 4 (hours) = 
Net ultrafiltration rate (ml/hour).   The base Ca-infusion Table l Rate is 
always decreased by 1 ml/each 100 ml/hour net ultrafiltration rate, e.g in 
table 2:  
 
Table 2 QB=200: Use the net ultrafiltration rate to adjust the base Table l Rate of the Ca-
infusion (200 ml 10% CaCl2 + 0.8 L 0.9% saline) at a blood flow of 200 ml/min 
 
The Patient's Hourly  
Net Ultrafiltration Rate 
Calcium Infusion Table l Rate 
Offset for Hourly Net Ultrafiltration 
Net UF 100 ml/hour 
Offset Table l Rate DOWN by 1 ml/hr 
Net UF 700 ml/hour 
Offset Table l Rate DOWN by 7 ml/hr 
Net UF 1300 ml/hour 
Offset Table l Rate DOWN by 13 ml/hr 
 
 
 
 
6.3.5 Heparin Anticoagulation therapy 
 
❖ Heparin is a naturally occurring anticoagulant that binds to the enzyme 
inhibitor antithrombin III (AT-III) causing a conformational change which 
results in its active site being exposed. The activated AT-III then 
inactivates thrombin and other proteases involved in blood clotting, most 
notably factor Xa. 
 
❖ 1000 units of heparin will be used as a loading dose with a maintenance 
dose of 1000U heparin/hr via the heparin infusion port, with the syringe 
on the 2008T machine. 
 
❖ The heparin dose may be adjusted to the patient’s stable dialysis regimen. 
 
6.3.6 Sampling  
 
Blood samples will be drawn from sampling sites along the extracorporeal blood 
circuit. Ionized calcium samples will be drawn from extracorporeal blood circuit 
before citrate infusion site.  
 
6.3.7 Required Support Equipment for SCD Treatment 
 
(Refer to individual equipment manual for proper operating instructions.) 
  
6.3.8 Operating SCD Circuit During Normal Treatment Period  
 
Observe pressure monitors for any consistent, large pressure fluctuations (this 
could indicate a clotting problem or line occlusion). If the problem persists, call 
the Principal Investigator. If pressure build up is such that Circuit lines could fail, 
SCD therapy will be discontinued immediately.  

 
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6.3.9 Conclusion of Normal SCD Perfusion  
 
At the conclusion of SCD therapy the patient's blood in the SCD system will be 
returned to the patient under conventional dialysis and hemodialysis treatment 
procedures.  
 
6.3.10 Removal of the SCD 
 
After the conclusion of SCD therapy the SCD circuit system will be flushed by 
research personnel with normal saline to clear the SCD cartridge of residual 
blood. Elution buffer will be infused into the cartridge and all ports capped. 
 
6.3.11 Discontinuation of SCD Therapy Due to Adverse Event  
 
If the Principal Investigator or Principal Investigator delegate determines that 
SCD therapy should be discontinued prior to the scheduled end of treatment, the 
following procedure should be followed:  
 
A. 
The dialysate pump system is turned off.  
 
B. 
A decision to return the blood in the extracorporeal blood circuit to the 
patient is made.  
 
C. 
The SCD and its circuit are removed from the dialysis system.  
 
D. 
The PI decides to reinstate hemodialysis. 
 
If there is clotting of the cartridge per se unaccompanied by any clinical 
prohibitions, the clotted cartridge is to be removed and replaced with a new 
device.  See section 6.3.14 below. 
 
6.3.12 Warnings and Precautions 
 
The following warning and precautionary signs could indicate potential system 
failures: 
 
A. 
Changes in patient status should be referred to the clinical investigator.  
 
B. 
Any leakage of blood from system lines.  
 
C. 
Any sudden large (>40%), persistent (>2 minutes) change in monitored 
pressures.  
 
D. 
Air observed in lines.  
 

 
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E. 
Development of clots in bubble traps or SCD cartridge extracapillary 
space. 
 
6.3.13 Required Documentation 
 
The following items need to be recorded: 
 
A. 
Time of SCD cartridge hook-up.  
 
B. 
Time of SCD system integration with hemodialysis system.  
 
C. 
Visual inspection of SCD system upon initiation of perfusion.  
 
D. 
Calcium levels in blood samples and other parameters as required during 
Citrate anticoagulation therapy per University of Michigan protocol. 
 
E.  
System pump speeds every hour.  
 
F. 
Adjustments in IV pump infusion rates.  
 
J.  
Time of cessation of SCD therapy.  
 
K.  
Any unanticipated occurrences should be recorded in hourly comment 
sections.  
 
 
6.3.14 Hemodialysis Cartridges 
 
A new SCD cartridge will be used for each treatment. 
 
In the event that either hemodialysis cartridge is not usable for the entire 
treatment for any reason, a new cartridge will be placed within the perfusion 
circuit using procedures similar to replacing cartridges during standard 
hemodialysis. 
 
6.3.15 Dialysis Prescription  
  
❖ Subjects will have their routine hemodialysis treatment with the added 
SCD filter.  
 
❖ All “chronic hemodialysis treatments” will be conducted according to 
usual clinical practice, using standard hemodialysis machines. 
 
❖ The schedule of chronic dialysis will be consistent with the research 
subjects’ routine treatment day. 
 

 
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❖ The Principal Investigator will adjust net ultrafiltration to achieve the 
patient’s established stable dry weight. 
 
6.3.16 Duration of Treatment 
 
Each Subject will receive one SCD treatment.  
 
6.3.17 Disconnecting From the SCD Cartridge 
 
❖ All blood in the Study Hemofiltration Circuit will be returned to the 
Subject (unless contraindicated due to presence of clot, Subject’s volume 
status, etc.). 
 
❖ If the access being used is a tunneled catheter, flush each lumen with 10 
mL of 0.9% NaCl solution USP and then instill a heparin flush (5,000 
units/mL) into the ports. 
 
❖ If the access being used is an AV fistula or AV graft, remove the dialysis 
needles or vascular catheters (i.e. angiocaths) used to cannulate the access 
according to the hospital’s dialysis unit protocol. 
 
7. 
Concomitant Therapy 
 
7.1 
Permitted Medications and Therapies 
 
The Subject should continue receiving his usual chronic medications during the Study 
without limitation in addition to any other needed medications. Routine medications will 
be given after SCD treatment. 
 
8. 
Study Methods 
 
8.11 
Key Study Measurements 
 
❖ Adverse events, vital signs, and laboratory data 
❖ Regional wall abnormalities and myocardial strain on spectral tracking on 
echocardiogram (see section 8.4.1) 
8.12 
Exploratory Measurements 
 
❖ Soluble Markers (Elastase, Hs CRP, IL-6, IL-10, TNF-α, L-Selectin, MCP-1, IL-
17, IL-23, IL-8. G-CSF, IL-1β, WBC, platelet count, Neopterin) 
❖ Leukocyte flow cytometry (circulatory monocyte subsets) 
❖ SCD integrity monitoring during treatment will include visual inspection for 
clotting and hemolysis, and additional testing following return of hemofilter to the 
research laboratory. 
 
8.2 
Screening Procedures (See also Appendix 1) 

 
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Initial screening of Subjects for eligibility may be performed within 4 weeks prior to the 
start of treatment. Informed consent should be obtained prior to initiation of any study-
specific procedures. 
 
❖ Obtain informed consent. 
 
❖ Review CBC with Differential and Platelet Count that would fall into the 
Screening Period window. 
 
❖ Review Entry Criteria, including Medical History and Concomitant Medications. 
If the subject meets the entry criteria, including Concomitant Medications, contact 
the study monitor to confirm admission to the study. 
 
❖ Perform a pregnancy test on women of child bearing potential (serum 
quantitative bHCG) 
 
8.3 
Hemodialysis Procedures – (See also Appendix 1) 
 
Subjects will enter the Hemodialysis Period within 4 weeks of completing the screening 
process.  
 
8.3.1 Study Treatment 
 
Each Subject will have the treatments described below, during which identical 
study procedures will be performed during each study treatment.  
   
Treatment 1:  Initial standard hemodialysis treatment with heparin (SHH) 
anticoagulation. 
 
Treatment 2:   A single hemodialysis treatment with SCD treatment and regional 
citrate anticoagulation one week after Treatment 1. 
 
   
 
Each subject’s safety data will be monitored by the PI on an ongoing basis.     
 
Prior to start of Study Treatment (SHH or SCD Treatment) 
 
8.3.1.1 Perform 2 D echo 
 
 
8.3.1.2 Prepare a heparin or citrate intravenous infusion per hospital 
routine to use with a standard volumetric programmable pump 
and Crit-Line III online hematocrit measurement device if 
required by the citrate protocol. 

 
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8.3.1.3  Assemble blood drawing supplies, including ice bucket, and 
label tubes. 
 
8.3.1.4 Assemble and set-up Study Circuit. 
 
8.3.1.5 For Subjects with AV fistula or graft, access with needles or 
venous cannula (i.e., angiocatheters) according to Investigator 
orders or per hospital routine. 
 
8.3.1.6 For Subjects with tunneled catheters, aspirate heparin flush 
according to Investigator orders or per hospital routine.   
 
8.3.1.7 Review medical history. 
 
8.3.1.8 Review concomitant medications. 
 
8.3.1.9 Obtain BP, RR, and HR, weight without shoes or over clothes, 
and oral temperature. Perform physical exam.  
 
8.3.1.10 Obtain blood for albumin according to instructions in Appendix 
2. 
 
8.3.1.11 Obtain blood for basic metabolic panel according to instructions 
in Appendix 2. 
 
8.3.1.12 Obtain blood for CBC with differential and platelets according to 
instructions in Appendix 2. 
 
8.3.1.13 Obtain blood for systemic soluble markers according to 
instructions in Appendix 2. 
 
8.3.1.14 Obtain blood for flow cytometry according to instructions in 
Appendix 2. 
 
Initiate the Study Hemodialysis Treatment (SHH or SCD Treatment) 
 
8.3.1.15 Begin intravenous heparin infusion as prescribed by standard 
protocol (for SHH treatment, heparin will be used for the entire 
duration of the procedure. For the SCD treatment, heparin will 
be used only during the first hour of the SCD treatment.)  
 
8.3.1.16 Turn on blood pump at the speed prescribed by the Principal 
Investigator. Turn on the calcium infusion per protocol. 
 
8.3.1.17 Obtain BP, HR, and RR. 

 
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Repeated Procedures During Entire Study Hemodialysis Treatment 
(SHH or SCD Treatment) 
 
8.3.1.18 Record Adverse Events. 
 
8.3.1.19 Record concomitant medications. 
 
8.3.1.20 Adjust heparin flow rate as needed for SHH or calcium chloride 
administration rate for SCD treatment protocol to maintain 
systemic iCa level between 1-1.3 mM during the citrate 
anticoagulant therapy. Document the pre-SCD filter ionized Ca 
as required. 
 
8.3.1.21 Observe cartridges for evidence of hemolysis, clotting, and 
leakage hourly. 
 
At 1 Hour into Study Treatment Protocol (For SCD Treatment Only) 
 
8.3.1.22 Obtain blood for iCa with i-STAT, a bedside diagnostic device 
(Abbott Labs). 
 
8.3.1.23 At 1 hour, stop heparin, change dialysate to zero calcium and 
start citrate and calcium infusion. After 3 minutes of citrate and 
calcium infusion, stop the blood pump, clamp the venous return 
line. Please refer to Fresenius Operator’s Manual on how to 
integrate the SCD to circuit. Within the first 10 minutes of 
initiating citrate with the integrated SCD obtain blood from 
sampling port of arterial segment of extracorporeal circuit (pre-
citrate infusion) and send for iCa using a bedside i-STAT 
Analyzer (Appendix 2).  
 
At 2 Hour Into Study Treatment (For SCD Treatment Only) 
 
8.3.1.24 For SCD treatment protocol, obtain blood for iCa from 
extracorporeal blood circuit (pre-citrate infusion) arm using the 
bedside i-STAT Analyzer.  
 
At 3 Hours Into Study Treatment (For SCD Treatment Only) 
 
8.3.1.25 For SCD treatment protocol, obtain blood for iCa from 
extracorporeal blood circuit (pre-citrate infusion) using the 
bedside i-STAT Analyzer.   
 
At 4 Hours Into Study Treatment (For SCD Treatment Only) 
 

 
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8.3.1.26 For SCD treatment protocol, obtain blood for iCa from 
extracorporeal blood circuit (pre-citrate infusion) using a bedside 
i-STAT Analyzer.   
 
 
At 5 Hours Into Study Treatment (SHH and SCD Treatment except if 
indicated otherwise) 
 
8.3.1.27 Obtain blood for basic metabolic panel according to instructions 
in Appendix 2. 
 
8.3.1.28 Obtain blood for CBC with differential and platelets according to 
instructions in Appendix 2. 
 
8.3.1.29 Obtain blood for systemic soluble markers according to 
instructions in Appendix 2. 
 
8.3.1.30 Obtain blood for flow cytometry according to instructions in 
Appendix 2. 
 
8.3.1.31 For SCD treatment protocol, obtain blood for iCa with i-STAT 
Analyzer. 
 
 
End the Study Treatment Period 
 
8.3.1.32 Discontinue heparin infusion in heparin anticoagulant treatment 
or citrate infusion in citrate anticoagulant treatment. 
 
8.3.1.33 Remove any peripheral intravenous catheter(s). 
 
8.3.1.34 For Subjects with AV fistula or graft, remove needles or venous 
cannula (i.e. angiocatheters) and obtain hemostasis according to 
Investigator orders or per hospital routine. 
 
8.3.1.35 For Subjects with tunneled catheters, disconnect tubing and 
instill heparin flush according to Investigator orders or per 
hospital routine. 
 
8.3.1.36 Obtain oral temperature, BP, pulse, and weight without shoes or 
overclothes. 
 
8.3.1.37 Disassemble the Study Circuit.  
 
8.3.1.38 Perform 2 D echo 
 

 
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8.3.1.39 The Subject may be discharged after at least 1 hour of 
observation following completion of his/her last study treatment. 
At the Investigator’s discretion, the Subject may be kept for 
observation beyond 1 hours, if needed. During this 1 hour 
observation period, additional iCa may be obtained post SCD 
treatment session, upon PI’s determination.  
 
24 hours after Treatment (SHH or SCD Treatment) 
 
8.3.1.40  Perform 2 D echo 
 
8.3.1.41 Obtain blood for systemic soluble markers according to 
instructions in Appendix 2. 
 
8.3.1.42 Obtain blood for flow cytometry according to instructions in 
Appendix 2. 
 
 
Before Initiation of SCD Treatment 
 
8.3.1.43  The PI must review all safety data of the Subject and determine 
their suitability to move to the SCD treatment. Further, the WBC 
count must be >4000/mm3, neutrophil count >500 and platelet 
count >50,000/mm3 in prior treatments.  
  
 
Ionized calcium during SCD Treatment 
 
8.3.1.44  The PI may draw more frequent iCa using i-STAT device if 
deemed necessary for safety concerns.  
 
 
8.4 
Detailed Study Measures 
 
 
 
 
 
8.4.1 Echocardiographic Methods 
Complete transthoracic echocardiograms including structural imaging, 
color Doppler for evaluation of valvular regurgitation, spectral Doppler for 
hemodynamic quantitation and longitudinal strain in 3 views for 
calculation of global longitudinal strain (GLS) will be performed at each 
time point as per the specified protocol.  
 
All echocardiograms will be performed on an identical echocardiographic 
platform (Epiq, Philips Ultrasound, Andover MA) using identical platform 
upgrades and software. Standard measures of left ventricular dimensions 
and volume from which ejection fraction will be calculated will be 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
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31 
performed off-line using the digitized images. The calculation of GLS will 
be performed using the integrated software of the platform.  
 
Specific echocardiographic parameters to be quantified at each time point 
are as noted on the echocardiographic case report form. 
 
Because the majority of echocardiographic parameters which reflect left 
ventricular contractility are both pre-and afterload dependent a substantial 
range of findings across patients is unavoidable and it is not feasible 
within the scope of a study this size to identify “normative” values nor is it 
possible to accurately identify thresholds of change in parameters such as 
ventricular size or ejection fraction in patients in whom intravascular 
volume and systemic systolic pressures vary. Each patient will therefore 
serve as his or her own control comparing pre-and post-dialysis 
echocardiograms following standard dialysis compared to pre-and post-
echocardiograms following investigational dialysis using the SCD 
device36,37. 
 
Assessment: Echocardiographic parameters which are less (but not 
entirely) preload and afterload dependent include quantitation of regional 
wall motion abnormalities as well as calculation of GLS. Normative 
values for regional wall motion abnormalities are defined as normal 
thickening and endocardial excursion in all regions and any deviation from 
normal thickening or excursion is considered abnormal. Regional wall 
motion will be scored using a standard wall motion scoring scheme. (1= 
normal; 2=hypokinetic; 3= akinetic; 4=dyskinetic). Scores will be 
tabulated for each of 16 predefined segments and a global wall motion 
score calculated as the sum of individual scores divided by the number 
visualized segments. For this scheme a score of 1 represents normal 
ventricular function with progressively higher numbers representing 
progressively worse systolic function. Scores from pre HD, post HD and 
24 hour post HD Echos from all 10 patients will be collated and analyzed 
for statistical significance between Treatment 1 and Treatment 2 groups. 
 
Global longitudinal strain will be obtained using tissue tracking 
methodology38. There is a significant range within the left ventricle of 
normal values for regional strain depending on wall location. Values for 
normal GLS in normal controls have ranged from -16.0 to -22.0.  Patients 
with systemic diseases including hypertension, diabetes and renal disease 
have all been described to have reduced GLS in the absence of overt 
systolic dysfunction. As “normal” values for GLS cannot be predicted in 
the patient population under consideration each patient will serve as his or 
her own control for tracking improvement or deterioration in global 
longitudinal strain.  
 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
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32 
Assessment: The largest body of data regarding using global longitudinal 
strain for tracking myocardial performance is in the patients receiving 
cardiotoxic chemotherapeutic agents where a threshold of 10-15% change 
has been considered as significant variation from baseline39. This will be 
used as a dichotomous threshold for defining either improvement or 
deterioration in GLS.   
 
Echocardiographic images will be interpreted at the Echo Laboratory, 
Frankel Cardiovascular Center, Floor 3. Area B, University of Michigan, 
Ann Arbor, MI 
 
8.4.2 Soluble Markers Assay Methods 
 
Assays for soluble markers (Table 3) are either sandwich or competitive 
ELISAs’ and will be performed according to manufacturer’s suggested 
protocols. High sensitivity Quantikine kits from R&D Systems will be run 
with Quantikine® Immunoassay Control Group 10 Catalog Number: 
QC41 which provides high, medium and low reference for high sensitivity 
kits, including IL-1, IL-6, IL-8, IL-10 and TNFα.  MCP-1 Quantikine kit 
will be run with Immunoassay Control Group 1 Catalog Number: QC01-1, 
which provides high, medium and low reference for a wide range of 
soluble markers including MCP-1. Inter assay controls are provided within 
the kits for CD62L, elastase, hsCRP, and neopterin. The 96 well format 
plates will be read using a Molecular Devices Spectramax M5 plate 
reader, and acquired data analyzed using SoftMax Pro 6.5.1 Software.  
Inter and Intra Assay precision will be calculated and criteria for 
acceptance established using expected values provided by the kit 
manufacturers. Non-compliant analysis will be repeated until criteria are 
met. 
 
The slated soluble markers are expected to deviate from reported normal 
values with in patient populations with myocardial stunning. Baseline 
values will be compared to reported normal and diseased values as 
reported in the literature and where reported by kit manufacturers. Each 
patient’s pre-treatment value will be used as its own baseline and this 
value compared to those obtained with the normal hemodialysis session 
and with SCD therapy. Statistical significance of assay values will be 
determined using Anova for repeated measures and paired student t test 
where appropriate.  
 
Table 3. Assays for Soluble Markers  
Soluble Marker 
Assay Kit 
Assay Type 
Inter Assay Controls 
Elastase 
ThermoFisher BMS269 
Sandwich ELISA 
High/Low Included in Kit 
Hs CRP 
ALPCO 30-9710s 
Sandwich ELISA 
High/Low Included in Kit 
IL-1 
R&D Systems HSLB00D Sandwich ELISA 
R&D Systems QC41 
IL-6 
R&D Systems HS600B 
Sandwich ELISA 
R&D Systems QC41 
IL-8 
R&D Systems HS800 
Sandwich ELISA 
R&D Systems QC41 

 
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33 
IL-10 
R&D Systems HS100C 
Sandwich ELISA 
R&D Systems QC41 
TNF 
R&D Systems HSTA00E Sandwich ELISA 
R&D Systems QC41 
CD62L (L-Selectin) Abcam  
Sandwich ELISA 
Single Control 
MCP-1 
R&D systems DCP00 
Sandwich ELISA 
R&D Systems QC01-1 
Neopterin 
TECAN IBL RE59321 
Competitive ELISA 
High/Low Included in Kit 
 
 
 
8.4.3 Flow Cytometry Methods 
 
Blood will be drawn into EDTA tubes and processed immediately on wet 
ice. Erythrocytes will be lysed with ammonium chloride buffer, and 
remaining leukocytes washed by centrifugation and suspended in protein 
free buffer for live dead labelling to allow for the elimination of false 
positives. Leukocytes will be transferred at 106 cells/100 L/test into 
tubes containing the following antibody cocktails and incubated for 30 
minutes. Tubes will be simultaneously fixed and undergo secondary lysis 
with BD FACS lyse buffer which has the added benefit of allowing 
leukocyte cell populations to be identified using scatter profiles.  
 
In Panel 1, antibodies targeting human CD91, CD14, CD16, HLADR, 
CD192 and CD197 will be used to determine changes in the circulating 
monocyte population. Neutrophils and monocytes mobilize intracellular 
stores of CD11b to the cell surface as they become activated, allowing a 
real-time measurement of systemic acute neutrophil and monocyte 
activation. Blood treated with a saturating amount of anti-human CD11b 
allowing for the quantitative analysis of expression to be reported as 
relative fluorescence intensity. 
 
Systemic Blood Panel 1: CD11b acute activation and MO subtypes  
Target 
Channel 
Vendor 
Catalog# 
Clone 
CD11b 
BL1-FITC 
BioRAD 
MCA551F 
ICRF44 
CD91 
BL2-PE 
ThermoFisher 
12-0919-42 
A2MR-a2 
CD14 
BL3-PerCP Cy5.5 
BioRAD 
MCA1568 
Tük4 
CD192 
RL1-Alexa Fluor 647 
BD Biosciences  
558406 
48607 
CD16 
RL3-APC H7 
BD Biosciences  
560195 
3G8 
CD197  
VL1-BV421 
BioLegend 
353208 
Go43H7 
Live Dead 
VL2-Fixable Aqua 
ThermoFisher 
L34966 
NA 
HLA-DR 
 V3-BV605, 
BD Biosciences  
562845 
TU36 
 
 
Using panel 2, platelet activation will be measured by the percentage of 
platelets associated with monocyte using the pan monocyte marker CD91 
and the platelet membrane glycoprotein recognized by anti-human CD42a. 
Neutrophil life cycle will be evaluated using anti-human CD10, CD184 
(CXCR4) and CD177. Immature neutrophils do not express CD10, while 

 
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34 
CD177 and CD184 are expressed on aging neutrophils. A saturating 
amount of CD62L (L-selectin) will be used to allow for comparison of this 
activation marker across neutrophil subsets. 
 
Systemic Blood Panel 2: CD62 on NE, monocyte platelet aggregates 
Target 
Channel 
Vendor 
Catalog# 
Clone 
CD62L  
BL1-FITC 
BD Biosciences  
555543 
DREG-56  
CD91 
BL2-PE 
ThermoFisher  
12-0919-42 
A2MR-a2 
CD10 
BL3-PERCP Cy5.5 
BD Biosciences  
563508 
  HI10a 
CD42a 
RL1-Alexa Fluor 647 
BioRAD 
MCA1227A647 GRP-P 
CD177 
VL1-BV421 
BD Biosciences  
564240 
MEM-166 
Live Dead VL2-Fixable Aqua 
ThermoFisher 
L34966 
NA 
 
Events will be collected using the ThermoFisher Attune flow cytometer 
and data analyzed using FlowJo software. Gates will be confirmed using 
fluorescence minus one controls, and a blue laser control bead will be used 
to ensure inter assay consistency with CD11b and CD62L that will be 
expressed as relative fluorescence in the blue laser line. Specificity of the 
antibodies will be confirmed using matched isotype controls. Statistical 
significance of differences in population percentages and relative 
fluorescence intensity values will be determined using Anova for repeated 
measures and paired student t test where appropriate. 
 
8.5 
Study Exit Procedures 
 
A Study Termination form will be completed for all patients who have completed the 
Study Procedures according to the protocol as well as for those who are terminating early 
for any cause 
 
 
9. 
Statistical Considerations 
 
Sample size determination for primary outcome regional wall abnormalities: Our 
consultant, C. McIntyre has previously demonstrated a difference in this variable in 8 
to10 patients using a similar protocol to this proposal when comparing standard and 
biofeedback dialysis and dialysis cooling 33,34. Sample size of 10 would appear to be 
sufficient to detect a difference of 20% and is based upon a standard deviation of 14%, 
significance level of 0.05 and 80% power. In the McIntyre studies, differences of greater 
than 20% were observed. We plan to recruit 10 patients in this study, to better ensure an 
adequate sample size to obtain statistically relevant primary and secondary endpoint 
comparisons. The patients will serve as their own controls, comparing BL-SHH 
parameters to SCD therapy parameters. Independent t-test will be used to compare the 
peak frequency of MS between SHH and SCD sessions. Global LVEF and wall motion in 
16 segments in 8 regions at each time point in the dialysis session will be compared using 
repeated measures and Bonferroni’s test for multiple comparisons. IDWG will be 
compared using paired and unpaired non-parametric testing or t-test if the variable is 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
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35 
normally distributed. These approaches have shown significance in prior studies for MS 
in HD. Statistical correlations are planned for regional wall abnormalities, inflammatory 
indices, monocyte subsets and pre-dialysis blood pressures 33,34  
 
10. 
Adverse Events 
 
           10.1 
Definitions 
 
An Adverse Event is any change from the Subject’s baseline and usual (pre-treatment) 
condition, whether or not it is believed related to the experimental treatment.  An adverse 
event, therefore, is any unfavorable and/or unintended sign, symptom, or disease that is 
temporally associated with the use of the experimental treatment and occurs for the first 
time after treatment initiation or, if present at the time of enrollment and treatment 
initiation, intensifies or indicates a worsened clinical condition.. 
 
Any Adverse Event, whether considered study-treatment related or not, which fits 
any of the criteria below, is considered a Serious Adverse Event (SAE): 
 
❖ Results in death. 
❖ Is life-threatening (meaning that the Subject was at risk of death at the time of the 
event; this does not refer to an event which might have caused death if it had 
occurred in a more severe form). 
❖ Requires inpatient hospitalization or prolongs the existing hospitalization. 
❖ Is a persistent disability/incapacity. 
❖ Is a congenital anomaly or birth defect. 
❖ Is considered an important medical event by the Investigator (e.g., surgery, return 
to ICU, emergency procedures, etc.)  
 
Medical judgment should be exercised in deciding whether other medical events 
may be considered serious.  Important medical events which may not be immediately life 
threatening or result in death or hospitalization but which may jeopardize the Subject or 
require intervention to prevent one of the serious outcomes listed above should be 
considered serious.  
 
Any Adverse Event, which is not consistent in specificity or severity with the current 
Investigator’s Brochure including all amendments, is considered “unexpected”.   
 
Causality is defined as the probability that the adverse event may have been caused by 
the study treatment.  The following definitions for causality assessment will be used in 
this study: 
 
❖ DEFINITELY RELATED:  A clinical event, including a significant change in a 
laboratory test, that occurs in a plausible time relationship to the study 
hemofiltration treatment, and which cannot be explained by concurrent disease or 
other drugs, chemicals, or procedures.  
 

 
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36 
❖ PROBABLY RELATED:  A clinical event, including a significant change in a 
laboratory test, occurring within a reasonable time sequence in relationship to the 
study hemofiltration treatment that is unlikely to be attributed to concurrent 
disease, other drugs, chemicals, or procedures, and that follows a clinically 
reasonable response upon withdrawal of the study hemofiltration treatment. 
 
❖ POSSIBLY RELATED:  A clinical event, including a significant change in a 
laboratory test, occurring within a reasonable time sequence in relationship to the 
study hemofiltration treatment that could also be explained by concurrent disease, 
drugs, chemicals, or procedures.  The clinical course after withdrawal of the study 
hemofiltration treatment may be unclear with respect to the contribution of the 
study hemofiltration treatment to the adverse event. 
 
❖ DEFINITELY NOT:  An adverse event, including a significant change in a 
laboratory test, with a temporal relationship to the SCD treatment that makes an 
association with the study hemofiltration treatment improbable, and in which 
other drugs, procedures or underlying disease(s) provide likely explanation. 
 
The intensity of all adverse events should be evaluated using the following 
definitions: 
 
❖ SEVERE: An event requiring immediate intervention; causes significant 
discomfort 
 
❖ MODERATE: An event that requires non-routine intervention; i.e., a new 
clinical treatment or diagnostic procedure, administered within an hour of the 
event; causes annoying discomfort 
 
❖ MILD: An event that requires minimal clinical treatment, or an adverse event 
requiring monitoring but no intervention or treatment; causes slight discomfort 
 
10.2 
Reporting Requirements 
 
All adverse events occurring from Time 0 through Day 14 must be recorded on the 
Adverse Event page of the Case Report Form (CRF).  
 
Serious Adverse Events 
 
 
In addition to recording data on the CRF, any SERIOUS adverse event (regardless 
of relationship to the study hemofiltration treatment) that occurs during the first 
study hemofiltration treatment will be reported to the IRB. The clinical site will 
be required to complete a written Serious Adverse Event report, which must be 
signed by the Sponsor-Investigator. 
 

 
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37 
For any serious adverse event that is ongoing at the time of the initial report, 
periodic follow-up information will be required until the adverse event is resolved 
or is considered to be chronic and stable.  
 
Sponsor Investigator Responsibilities  
 
The Sponsor-Investigator will promptly review documented adverse effects and 
abnormal test findings to determine 1) if the abnormal test finding should be 
classified as an adverse effect; 2) if there is a reasonable possibility that the 
adverse effect was caused by the investigational device or, if applicable, other 
study treatment or diagnostic product(s); and 3) if the adverse effect meets the 
criteria for a serious adverse effect. 
 
In accordance with 21 CFR Part 812.150(a)(1) and (b)(1), the sponsor shall 
promptly report the results of an evaluation of any serious and unanticipated 
adverse device effect to FDA, the University of Michigan IRBMED and 
participating investigators (if any) as soon as possible, but not later than 10 
working days after the sponsor first receives notice of the effect.  Thereafter, the 
sponsor shall submit such additional reports concerning the effect as the FDA 
requests.  Complications and non-serious or anticipated adverse events should be 
documented and tabulated but need not be submitted by the sponsor to the FDA as 
individual reports. 
 
 
Independent Data Review and Data and Safety Monitoring Committee  
To protect the interests of research subjects and ensure that they are not exposed 
to undue risk, this trial will be monitored by an independent Data and Safety 
Monitoring Committee (DSMC). The DSMC will been appointed by the Sponsor-
Investigator, and shall have no formal involvement with the subjects or the 
investigation and function independently of Sponsor-Investigator. The DSMC 
will be members independent from the sponsor-investigator and co-investigators. 
The DSMC will provide an independent, and unbiased assessments of adverse 
events and any need for study termination. The Committee will consist of one 
nephrologist and one cardiologist with expertise in heart failure and who are 
independent of the study team.   
 
The DSMC will monitor the progress of the trial with a scheduled meeting or 
conference call. In addition to reviewing Serious Adverse Events (SAEs), the first 
DSMC meeting will focus on over all safety of the trial and study device and will 
make a determination as to whether or not the study should proceed. 
 
The DSMC will also serve as the Clinical Events Committee (CEC), and will 
adjudicate all adverse events for clinical accuracy and relatedness to the 
treatment, and will also ensure a unified evaluation by applying standardized even 
criteria. The CEC will perform final adjudication of adverse events. 
 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
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38 
 
10.3 
Clinical Research Monitoring  
 
 
 
To assure adequate protection of the rights of human subjects, per 21 CFR §812.40, 
812.43 and 812.46, this study will be monitored by the University of Michigan Institute 
of Clinical and Health Research (MICHR).  Routine monitoring will be scheduled at 
appropriate intervals, with more frequent visits occurring at the beginning of the study.  A 
site activation visit will take place, followed by routine monitoring visits.  Additional 
visits can be scheduled at the request of the Sponsor-Investigator. 
 
The established monitoring plan will ensure the quality and integrity of the data 
throughout the study conduct to verify adherence to the protocol, completeness and 
accuracy of study data and samples collected, dispensing and inventory of the device, and 
compliance with regulations. 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
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39 
11. 
Investigator Responsibilities and Statement 
 
By my signature, I confirm that my staff and I have carefully read and understand this protocol 
and agree to comply with the conduct and terms of the study specified therein.  In particular, we 
have agreed to: 
 
 
❖ Conduct the study according to the protocol, its amendments, and study guides. 
 
❖ Obtain Institutional Review Board approval of the study, any amendments to the study, 
and periodic re-approval, as required. 
 
❖ Obtain witnessed, written informed consent from each study participant or their legal 
representative. Affirm each Subject meets the inclusion and exclusion criteria with study 
monitor. 
 
❖ Report all serious adverse events as required by the protocol and IRB regulations to the 
IRB. 
 
❖ Maintain confidentiality and assure security of confidential documents such as the 
protocol, consent form, case report form, final study reports, manuscript, and/or 
unpublished data and correspondence. 
 
 
 
 
_______________________________________________________________ 
Principal Investigator                                                           Date 
 

 
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Appendix 1. Schedule of Events 
 
Event 
4-week 
Screening 
Period 
Hemodialysis  
(Procedures to be repeated on days study 
hemodialysis treatment(s) are given) 
24 hour after 
( ± 4 hours) 
Pre-Rx 
Baseline 
(time 0) 
Rx start 
>0–<1h 
1h 
2h 
3h 
4h 
5h 
Informed consent 
X 
 
 
 
 
 
 
 
 
Review of entry criteria 
X 
 
 
 
 
 
 
 
 
Echocardiogram1 
 
X 
 
 
 
 
 
X 
X 
albumin 
 
X 
 
 
 
 
 
 
 
Basic Metabolic Panel6 
 
X 
 
 
 
 
 
X 
 
CBC/diff/plt6 
 
X 
 
 
 
 
 
X 
X 
Pregnancy test4 
X 
 
 
 
 
 
 
 
 
Systemic soluble markers 2 
 
X 
 
 
 
 
 
X 
X 
Leukocyte flow cytometry  
 
X 
 
 
 
 
 
X 
X 
Physical examination 
 
X 
 
 
 
 
 
 
 
Review/update medical 
history 
 
X 
 
 
 
 
 
 
 
BP, HR, RR5 
 
X 
X 
X 
X 
X 
X 
X 
X 
Weight/temp 
 
X 
 
 
 
 
 
X 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
x 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
x 
 iCa3,6 
 
 
 
X7 
X 
X 
X 
X 
 
Visual inspection for 
hemolysis and clotting in 
blood circuit 
 
 
 
X 
 
 
Notes: 
1. Hemodialysis procedures should begin within 2 hours of completion of echocardiogram and 
completion of baseline procedures (physical examination, review/update medical history, vital 
signs (BP, HR, RR Weight/temp) and recording and review of concomitant medications. 
2. Elastase, Hs CRP, IL-6, IL-10,IL-17, IL-23, G-CSF, TNF-α, , MCP-1, IL-17, IL-23, IL-8, G-
CSF, IL-1β, Neopterin. 
3. For SCD Treatment Protocol only, iCa will be drawn. Levels of iCa will be determined from 
extracorporeal circuit before citrate infusion site. Additional iCa may be obtained if clinically 
indicated and post SCD treatment session, upon PI’s determination.  
4. Pregnancy test: Quantitative bHCG test will be obtained in the screening period.  
5.   Vital signs (BP, HR, RR) would be recorded within 20 minutes of indicated times.  
6. iCa, CBC/diff.plt, basic metabolic panel would be collected within 15 minutes of indicated 
times.  
7.   For SCD Treatment Protocol only, iCa will be drawn during this hour just prior to initiation of 
therapy, and within 10 minutes of starting therapy.  
 
 

 
SCD Myocardial Stunning Protocol V3.2 10/24/2022  
CONFIDENTIAL 
44 
Appendix 2. Laboratory Analyses 
 
Test 
Specimens 
Volume (mL) 
Total volume (mL) 
Albumin 
No additive 
1 ml 
1 ml 
Basic metabolic 
panel 
No additive 
2 ml  
8 ml 
iCa* 
No additive 
0.5 ml 
3 ml 
CBC and plt 
EDTA 
3 ml 
18 ml 
Systemic soluble 
markers  
EDTA 
 
11 ml 
 
66 ml 
Leukocyte flow 
cytometry 
EDTA 
1 ml 
 
6 ml 
 
Quantitative 
bHCG  
Red top or SST 
tube 
0.5 ml 
0.5 ml 
 
*Ionized calcium will only be sampled during SCD treatment.  Ionized calcium will be 
drawn with i-STAT Device