Prevention of Dialysis-Induced Hypotension by Inhibiting Plasma Kallikrein
Phase: PHASE2
Conditions: Hemodialysis Complication, Hypotension of Hemodialysis
Sponsor: Vanderbilt University Medical Center

12/16/24 
  
 
 
 
 
 
Hemodialysis.-Induced Hypotension Therapy for 
End Stage Kidney Disease (Hinder) 
 
 
 
 
 
NCT05297786 
 
 
 

12/16/24 
 
 
 
 
 
 
 
 
 
 
 
 
Prevention of Dialysis-Induced Hypotension by 
Inhibiting Plasma Kallikrein 
 
 
T. Alp Ikizler 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

12/16/24 
 
Table of Contents: 
 
Study Schema 
1.0 
Background 
2.0 
Rationale and Specific Aims 
3.0 
Animal Studies and Previous Human Studies 
4.0 
Inclusion/Exclusion Criteria 
5.0 
Enrollment/Randomization 
6.0 
Study Procedures 
7.0 
Risks of Investigational Agents/Devices (side effects) 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk 
to Participants or Others 
9.0 
Study Withdrawal/Discontinuation 
10.0 Statistical Considerations 
11.0 Privacy/Confidentiality Issues 
12.0 Follow-up and Record Retention 
 
Appendices 
Appendix A Summary of study procedures 
 

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1.0 
Background 
 
A. Definition of DIH. Various definitions have been used for intradialytic hypotension. 
The National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) 
has defined DIH as a reduction in systolic blood pressure or mean arterial pressure 
during hemodialysis, which it is associated with symptoms such as muscle cramps, 
anxiety, yawning, dizziness, fainting, or abdominal discomfort.1 The reduction in blood 
pressure should be equal to 
or greater than 20 mmHg for 
systolic blood pressure and 
equal to or greater than 10 
mmHg for mean arterial 
blood pressure. Most of the 
reduction of blood pressure 
during hemodialysis occurs 
during the first quarter of 
treatment with a gradual 
decrease during the 
remaining treatment time 
(Figure 1).2 Some 
investigators use a nadir-
based DIH definition—when 
the systolic blood pressure 
falls below 90 or 100 mmHg.,3 or the need for nursing intervention in addition to 
experiencing a fall in blood pressure and clinical symptoms.4 The reduction in blood 
pressure can also be asymptomatic. Thus, it is important to recognize the occurrence of 
repeated episodes of hypotension that will damage organs including the brain, heart, 
gut, and liver as well as skeletal muscle. Furthermore, it is important to identify patients 
who are susceptible to intradialytic hypotension to prevent the undesirable 
consequences of DIH. 
B. Morbidity and mortality of DIH. Approximately 75% of patients suffer at least one 
episode of hypotension during hemodialysis,5 and DIH occurs in approximately 20 to 
30% of all regular hemodialysis treatments.5, 6 DIH is a common clinical complication of 
hemodialysis, and it is associated with increased morbidity and mortality.7 It has been 
shown that DIH may induce myocardial dysfunction due to reduced myocardial blood 
flow.8 Recurrent episodes of hypotension are also associated with frontal lobe atrophy in 
the brain,9 and with mesenteric ischemia.10 Previous studies have identified an 
association between DIH and cardiovascular morbidity-mortality,11 and all-cause 
mortality.12 Two more recent studies, using large databases, also showed the 
association between DIH and mortality.3, 13  
Nursing interventions during hemodialysis are usually initiated by patient-reported 
symptoms. Among them, nausea, dizziness, cramps, and fatigue are common during 
hemodialysis.14, 15 DIH is associated with some of these symptoms, particularly dizziness 
and cramps.16 Furthermore, DIH and a higher ultrafiltration rate have been associated 
with longer hemodialysis recovery time,17 a measure of the quality of life (QOL) that has 
been validated in patients on hemodialysis that correlates well with longer and more 
complex QOL questionnaires.18  
C. Multiple factors contribute to the pathophysiology of DIH. The pathogenesis of 
DIH and intradialytic hypotension have been attributed to the rapid removal of plasma 
volume during hemodialysis, a high rate of ultrafiltration and the inadequate mechanisms 
Time on hemodialysis (min)
Systolic Blood Pressure
(mmHg)
Heart reate
(beats/minute)
0
50
100
150
200
250
80
90
100
110
120
75
80
85
Nursing intervention
SBP
Heart rate
Figure 1. Blood pressure reduction during hemodialysis

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to respond to hypovolemia in patients with ESRD.19 Thus, the occurrence of DIH would 
depend on the rate of fluid removal and the compensatory mechanism for refilling the 
plasma volume (Figure 2). The rate of fluid removal can be controlled by limiting the 
ultrafiltration rate or increasing the hemodialysis time. Conversely, the compensatory 
mechanisms to hypovolemia are more difficult to control, and they depend on the 
patient’s comorbidities—such as impaired cardiac contractility, reduced cardiac reserve, 
autonomic dysfunction, and reduced venous compliance.19 Cardiac compensations 
include increasing the heart rate and the contractility.20 Venous tone is also an important 
compensatory mechanism since more than three liters of plasma volume is located 
within the veins.21 The increase of arteriolar vasoconstriction is another normal response 
to hypovolemia and hypotension.19 Thus, it has been proposed that patients with DIH 
have impaired compensatory mechanisms.20 
The autonomic nervous system controls many of the compensatory mechanisms to 
hypovolemia, such as heart rate, venous compliance, and arteriolar tone. Thus, it has 
been proposed that autonomic dysfunction plays a major role in DIH.22 In fact, although 
patients on hemodialysis frequently present with dysfunction of the autonomic nervous 
system,23, 24 the real prevalence in this population is unknown. Due to fluid removal, 
hemodialysis activates the sympathetic nervous system; thus, inappropriate activation of 
this system contributes to DIH. 
The lack of vasoconstriction in response to hypovolemia has been implicated as one of 
the impaired responses during DIH. This may be due to the removal of vasoconstrictors 
or the increased production of vasodilators. Vasopressin, a vasoactive peptide that 
increases during hypovolemia, seems to have a blunted response during hemodialysis in 
patients with DIH.25 Nitric oxide, another potent vasodilator, has been found elevated in 
patients with DIH.26-28 Adenosine has also been implicated in the occurrence of DIH 
through the inhibitory effect on 
norepinephrine release.29 
Besides, hypo-perfused tissues 
may release adenosine that may 
have a local effect on 
vasodilation, which may worsen 
blood pressure reduction.20  
Accordingly, a recent study 
showed that blocking adenosine 
A1 receptor may improve DIH.30 
Bradykinin is another vasoactive 
substance that is released during 
hypoperfusion and may have a 
role in the pathogenesis of DIH. It 
is noteworthy to mention that 
bradykinin may also act locally by 
stimulating cardiac vagal afferent 
chemoreceptors leading to 
sympathetic inhibition.31  
D. Activation of the kallikrein-kinin system during hemodialysis increases 
bradykinin and may contribute hypotension. Bradykinin, a potent vasoactive peptide, 
results from the cleavage of high molecular kininogen (HMWK) by tissue and plasma 
kallikreins.32 Bradykinin induces vasodilation by stimulation of the bradykinin B2 
receptor.33 Hemodialysis induces the activation of the kallikrein-kinin system and the 

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production of bradykinin.34 During hemodialysis, contact of blood with the dialyzer also 
activates the contact system,35 which in turn also increases bradykinin levels.36  
Bradykinin levels are also increased during cardiopulmonary bypass,37 and one of the 
complications of cardiopulmonary bypass is protamine-induced hypotension. Our group 
has previously shown that the hypotensive events coincide with increased levels of 
bradykinin.38 Furthermore, blocking the bradykinin B2 receptor with icatibant attenuates 
the hypotensive response to protamine. Thus, bradykinin may also induce hypotension 
during hemodialysis by inducing vasodilation. We have previously reported that 
bradykinin B2 receptor blockade does not affect blood pressure reduction during 
hemodialysis,39 but we did not assess the contribution of bradykinin to DIH. 
A novel therapeutic alternative to inhibit the activation of the kallikrein-kinin system is 
lanadelumab, a human monoclonal antibody against plasma kallikrein, that prevents the 
cleavage of H<WK and the subsequent increase in bradykinin. Lanadelumab is an FDA 
approved drug against hereditary angioedema; however, the role of lanadelumab on 
dialysis induced hypotension has not been explored. 
 
2.0 
Rationale and Specific Aims 
 
A. Specific Aims 
In Specific Aim 1 we will test the hypothesis that in patients with DIH, inhibition of 
plasma kallikrein system with lanadelumab prevents the reduction of blood 
pressure and maintains hemodynamic stability. For this purpose, we will monitor 
heart rate and blood pressure during hemodialysis. Importantly, we will conduct the 
study in an outpatient clinic, using the patients’ 
usual hemodialysis dose and settings as for a 
regular hemodialysis session. This approach will 
minimize the risk that our findings were biased by 
conducting the study in a clinical research setting. 
In Specific Aim 2 we will test the hypothesis that 
in patients with DIH, inhibition of plasma 
kallikrein system with lanadelumab prevents 
symptoms associated with DIH such as 
cramps, dizziness, and nausea and improve 
recovery time after hemodialysis. Hemodialysis 
is associated with many complications, including 
DIH, that negatively affect the QOL of patients and 
their families. Any intervention that prevents the 
occurrence of DIH will result in a faster recovery 
from hemodialysis. The present study will evaluate 
the impact of lanadelumab on preventing 
symptoms associated with DIH and reducing 
recovery time after hemodialysis. 
 
3.0 
PRELIMINARY RESULTS 
Bradykinin increases during hemodialysis  
Hemodialysis activates the kallikrein-kinin system and increases the levels of bradykinin. 
Accordingly, we have previously shown that bradykinin levels increase during the first 30 
minutes of hemodialysis in 15 subjects that received 5 mg of ramipril for seven days 
(Figure 3).40 
0
20
40
60
0
25
50
75
100
125
150
175
200
225
250
275
Ramipril
Placebo
Time (min)
Bradykinin
fmol/ml
Figure 3. Effect of one- week treatment with
ramipril or placebo on bradykinin concentrations
in response to hemodialysis

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Bradykinin B2 receptor blockade prevents an excessive decrease in blood 
pressure  
Another method for evaluating the effects of bradykinin during hemodialysis is by 
blocking its receptor. Thus, we evaluated the effect of icatibant on blood pressure during 
hemodialysis. For this purpose, we performed a secondary analysis in a randomized, 
double-blind, placebo-controlled study designed to examine the effect of icatibant on 
mitochondrial function during hemodialysis (NCT03177798). Icatibant or placebo was 
continuously IV-infused 30 minutes before the initiation of hemodialysis and throughout 
the whole hemodialysis session. Icatibant was infused at a dose of 100 ug/kg/h before 
hemodialysis, which was then changed to 50 ug/kg/h for the duration of hemodialysis. As 
we previously reported, we found that icatibant has no overall effect on blood pressure 
or heart rate during hemodialysis. We then stratified the analysis based on a reduction of 
systolic blood pressure (SBP) equal to or greater than 20 mmHg during hemodialysis. 
We found that in those patients with a reduction in blood pressure, icatibant prevented 
the decrease in SBP compared to placebo (Figure 4A-B). We also found that icatibant 
blunted the rise in heart rate during hemodialysis in patients whose blood pressure 
reduction was equal to or greater than 20 mmHg (Figure 4C). Icatibant did not affect 
either blood pressure or heart rate in patients who did not have a significant blood 
pressure reduction during hemodialysis. 
4.0 
Inclusion/Exclusion Criteria 
 
Study population 
Participants will be recruited from Vanderbilt Dialysis Outpatient Clinics. We will enroll 
patients who are on maintenance hemodialysis for at least six months, with pre-dialysis 
blood pressure between 110 and 170 mmHg, who are being adequately dialyzed (Kt/V 
>1.2), and who are between 18 and 85 years old, who have experienced dialysis-
induced hypotension (DIH) episodes at least four times in a period of 12 weeks prior to 
enrollment. We define DIH as the drop of systolic blood pressure (SBP) of more than 30 
mmHg with associated symptoms such as nausea, dizziness, cramps, yawning, and 
abdominal discomfort. We will also look for nursing intervention during the hypotensive 
episode, but it will not be used as an inclusion criterion. Nursing intervention is defined 
as a temporary interruption of ultrafiltration, Trendelenburg positioning, or administration 
of intravenous fluids. We will exclude patients who suffered severe DIH episodes that 
required the use of vasopressors and the termination of hemodialysis treatment. Patients 
who have been hospitalized during the last three months or with clinical evidence of 
inflammatory or infectious disease or with severe anemia (hemoglobin less than 8 g/dl) 
will be excluded. Institutional review board approval and written informed consent will be 
Time (min)
∆ Systolic Blood Pressure
(mmHg)
-100
-50
0
50
100
150
200
-10
0
10
20
Placebo
Icatibant
Drug p<0.001
Time x Drug p=0.1
Time (min)
Heart reate
(beats/minute)
-100
-50
0
50
100
150
200
75
80
85
90
Placebo
Icatibant
Drug p=0.005
Time p=0.002
Figure 4. Effect of icatibant on blood pressure and heart rate during hemodialysis in patients with
a reduction of blood pressure ≥ 20 mmHg (n=7).
Time (min)
Systolic Blood Pressure
(mmHg)
-100
-50
0
50
100
150
200
110
120
130
140
Placebo
Icatibant
Drug p=0.3
Time x Drug p=0.024
A.
B.
C.

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obtained from all study subjects.  We expect that 60% of our subjects will be African 
American and 40% will be women. 
 
Inclusion criteria 
• 
Subjects age 18 to 85 years 
• 
On thrice-weekly hemodialysis for at least six months 
• 
Clinically stable, adequately dialyzed (single-pool Kt/V > 1.2), with polysulphone 
membrane for at least three consecutive months before the study 
• 
Subjects with pre-dialytic systolic blood pressure between 110 and 170 mmHg. 
• 
Subjects with a reduction of systolic blood pressure during hemodialysis equal to 
or greater than 30 mmHg, with associated symptoms such as nausea, vomiting, 
muscle cramps, dizziness, or anxiety. 
• 
Hypotensive episodes should occur four times or more in four weeks (12 
hemodialysis sessions). 
 
Exclusion criteria 
• 
Subjects with intradialytic hypotension that require the use of pharmacological 
intervention such as midodrine or vasopressin 
• 
Subjects with pre-dialytic systolic blood pressure greater than 170 mmHg or 
diastolic blood pressure greater than 110 mmHg 
• 
History of myocardial infarction or cerebrovascular event within 3 months 
• 
History of serious hemorrhage (including cerebral hemorrhage) in the past 12 
months  
• 
INR outside of the therapeutic range in the last 6 months before enrollment 
• 
Advanced liver disease 
• 
Ejection fraction less than 30% 
• 
Anticipated live donor kidney transplant 
• 
History of poor adherence to hemodialysis or medical regimen 
• 
Severe anemia (hemoglobin less than 8 g/dl) requiring blood transfusions 
• 
Use of immunosuppressive drugs within one month before study enrollment 
• 
Active connective tissue disease 
• 
History of acute infections disease within one month before study enrollment 
• 
Inability to provide consent 
• 
Pregnancy 
 
5.0 
Enrollment/Randomization 
 
This is a parallel study where participants will be assigned to either taking the study drug 
(lanadelumab) or taking the placebo (saline pre-filled syringes.) Patients will be randomly 
assigned to the treatment order using a permuted-block randomization algorithm. The 
study drug, lanadelumab, will be shipped from Takeda as pre-filled syringes along with 
matching placebo, also in prefilled syringes.The Vanderbilt Investigational Drug Services 
(IDS) will be responsible for the storage, preparation, dispensing, and labeling of the 
investigational agents. The Vanderbilt IDS will also maintain accurate drug storage and 
dispensing logs. Subjects will be randomized to receive a placebo or 300 mg of 
lanadelumab (Takeda Pharmaceutical, Cambridge, MA). Subjects randomized who do 

12/16/24 
not complete the whole protocol for any reason will be replaced, and their data will be 
analyzed separately. The half-life of lanadelumab is 14 days, and the time to reach 
maximum concentration is five days. For this reason, we will monitor blood pressure and 
the occurrence of DIH for three weeks after the administration of the second dose of the 
study drug.  
 
6.0 
Study Procedures 
 
Study protocol 
After obtaining consent, study subjects will undergo the following procedures. 
COVID-19 precautions prior to and during visits. Pre-visit phone call – we will contact 
the patient before all of their study visits to ask a series of COVID-19-related screening 
questions. Depending on their answers, we will continue with the study visit or postpone 
for another time. The patient will be asked to wear a face covering during all portions of 
their study visits in which they are in the presence of hospital staff. We will also 
encourage frequent hand washing and/or provide alcohol-based hand sanitizer. 
Subjects will participate in a randomized, parallel-group, double-blind, placebo-controlled 
study in which they will receive two doses of placebo or 300 mg of lanadelumab 
subcutaneously. Participants will continue their usual medications throughout the study. 
One week (Day -7) before the administration of the first dose of the study drug, we will 
conduct a study visit at the hemodialysis unit. During this visit, we will give the 
participants a physical activity monitor to be worn for at least 5 consecutive days and will 
obtain baseline blood samples. During a second study visit at the dialysis unit (Day -1), 
we would obtain a second baseline blood sample one to three days before the 
administration of the first dose of the study drug. In this visit, we will also measure 

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muscle oxygenation using near-infrared spectroscopy (NIRS). Patients will be then 
asked to come to the Vanderbilt Clinical Research Center (CRC) on a non-dialysis day. 
During this visit (Day 0), we will obtain a detailed history, perform a physical 
examination, administer a quality of life (QOL) questionnaire, obtain the dialysis recovery 
time, and evaluate body composition and physical performance. We will then administer 
the first dose of the study drug and monitor the appearance of any Type I (immediate) 
hypersensitivity reaction for two hours before discharging patients from the CRC. We will 
repeat the same protocol, as outlined for Day 0 and administer the second dose of the 
study drug two weeks later at the CRC (Day 14).  
The next two consecutive dialysis treatments after each drug administration (days 1 and 
3, and days 15 and 17), we will conduct follow-up visits at the dialysis unit to collect 
information regarding symptoms after discharge from the CRC. During these visits, at 
the end of every hemodialysis session, we will also inquire, through a standardized 
questionnaire, about the presence of any symptoms associated with hypotension. This 
questionnaire will include symptoms such as cramps, dizziness, nausea, and will be 
scored according to the severity from 0 to 4 (none to severe). We will also collect blood 
samples at the dialysis unit for pharmacokinetics and special laboratory analysis. During 
the six-week length of the study, we will monitor the occurrence of DIH episodes and 
changes in blood pressure in every dialysis session. For this purpose, we will use the 
dialysis clinic blood pressure monitor logs. We will also conduct two additional visits at 
the dialysis units (Day 29 and 43) to draw blood, administer the symptomatology 
questionnaire, and measure blood flow with NIRS. In the final hemodialysis visit (day 43) 
we will also give the patients an activity monitor that will be collected after five 
consecutive days of continuous use. During this last visit, we will also administer the 
QOL questionnaire, obtain the dialysis recovery time, and perform body composition and 
physical performance tests (except for the six-minute walk test). Details of the study 
protocol can be found in Figure 5, Tables 1 and 2, and Appendix 1 
Hemodialysis 
All subjects will be dialyzed with their usual 
prescription. The duration of the dialysis 
treatment will vary between subjects, but it 
will be the same as the usual standard of 
care. Dialysis will be performed with 
biocompatible polysulfone membranes 
(Fresenius F80-A, Walnut Creek, CA). We 
will use new dialyzers on each study day. 
Dialyzers will be stored for further analysis of 
the proteins adsorbed to the membrane. 
Crit-Lines®, which monitors hematocrit, percent change in blood volume, and oxygen 
saturation during hemodialysis, will be applied every hemodialysis session during the 
study if the device is available and the nursing staff is trained appropriately. 
Collection of blood samples 
Blood samples will be collected for clinical laboratory analysis in the pre-dialysis blood 
sample. Blood samples at the dialysis unit will also be obtained at the arterial and 
venous sites before dialysis, 15 minutes and one hour after dialysis initiation, and at the 
end of hemodialysis for research labs (e.g., markers of the kallikrein-kinin system) and 
pharmacokinetics analysis. 
 
 
Table 1. HD study visit 
• 
Activity monitor (Day -7 and 43) 
• 
NIRS (Days -1, 15, 29, and 43) 
• 
Symptomatology questionnaire 
• 
Blood draw at the venous and 
arterial sites: t=0, t=15min, 
t=1h, t=end of HD for markers of 
kallikrein-kinin system and PK 

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Hemodynamic measurements 
During the baseline visit, we will obtain three 
supine blood pressure measurements. During 
hemodialysis study days, blood pressure will 
be taken in the arm contralateral to the 
access for dialysis using an automated 
oscillometric recording device. We will obtain 
three measurements during a period of 15 
minutes before starting dialysis. The average 
of these measurements will be considered the 
baseline blood pressure. During hemodialysis, we will obtain blood pressure every 15 
minutes. At the end of hemodialysis, we will obtain two more blood pressure 
measurements that will be average to obtain the post-dialysis blood pressure 
Physical performance tests 
Physical performance tests will include the six-minute walk test (6MWT), physical battery 
(gait speed and chair stand tests), and the handgrip strength, and they will be performed 
as previously described.41-43 Briefly, the 6MWT consists of instructing the patients to 
walk back and forth on a 30-meter corridor. The distance will be recorded in meters. 
Handgrip strength will be assessed in both hands using a dynamometer. The mean from 
three consecutive efforts will be used for the analysis. 
Repeated chair stands: The participants will be asked to move from a sitting position to a 
standing position on a 42-cm high chair as quickly as possible five times. Time to 
complete the five repetitions will be recorded. 
Gait speed: it will be performed on a 20-meter straight path, with 5 m for acceleration, 10 
m for steady state walking, and 5 m for deceleration. Time will be measured by a 
stopwatch as the patient reaches the markers and the end of the path.  The physical 
battery will be evaluated using standardized tests, and the results will be scored 
accordingly to complete the assessment of physical performance. 
Quality of life (QOL) questionnaire 
In addition, we will evaluate the overall QOL (physical function and health status) using 
the Kidney Disease Quality of Life-Short form (KDQOL-SF) version 1.3.44 The KDQOL-
SF is a self-report questionnaire of 24 items designed for individuals with CKD on MHD. 
Each answer was scored on a 0 to 100 range; a higher score correlates with a better 
health state and physical function. 
Body composition 
We will measure body composition using the bioelectrical impedance analysis (BIA) and 
skinfold thickness, as previously described.45 BIA will be measured using a standard 
single frequency (50 KHz) bioelectrical impedance analyzer. For this purpose, four 
electrodes will be placed on the foot after cleaning the skin with alcohol pads. A small 
current (~800 uA) will be passed through the electrodes and the body. Total body water 
and the percent of body fat will be calculated by the analyzer according to the 
predetermined regression equations. Mid-upper arm muscle circumference (MUAMC) 
measured. This estimates the circumference of the bone and muscle portions of the 
upper arm; which in turn helps estimate body fat. Skinfold calipers (Lange) will be used 
to measure the tricipital skin folds. The circumference of the upper arm will also be 
measured. 
 
Table2. CRC study visit 
• 
 Physical exam and history  
• 
Body composition - physical 
performance tests 
• 
QOL questionnaire/recovery 
time 
• 
Study drug administration 

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Near-infrared spectroscopy 
Skeletal muscle tissue oxygenation will be measured, when possible, using near-infrared 
spectroscopy (NIRS), as previously described.46 For this purpose, a rigid emitter-
detector device will be placed over the belly of the quadriceps muscle. The device 
transmits near-infrared light at two wavelengths (735 and 810 nm) and will detect the 
reflected light to measure oxygenated hemoglobin and deoxygenated hemoglobin. The 
regional oxygen saturation, which is a measurement of tissue oxygenation, will be 
calculated as the ratio of oxygenated hemoglobin to the total hemoglobin. Skeletal 
muscle oxygenation will be measure before and during the hemodialysis session. 
Dialysis Recovery Time  
We will ask the patients “How long does it take to recover from a hemodialysis session”, 
as described in a previous study.18 This information will be collected during the follow-up 
phone call or the visit at the next regular hemodialysis session. The answer will be 
recorded in minutes. We will convert the following answers to numbers:1. One day = 
1440 minutes; 2. More than one day = 2160 minutes, or 3. Half-day or next day = 720 
minutes 
Symptoms questionnaire 
We will conduct a post-dialysis symptoms questionnaire at the next regular dialysis 
session at the Vanderbilt Dialysis Clinic, as previously described.16 The symptoms will 
include, but not limited, to complaints associated with a reduction in blood pressure such 
as cramps, dizziness, nausea, vomiting, yawning. We will score the severity of the 
symptoms using a scale from 0 to 4 (0=none, 1=minor, 2=mild, 3= moderate, 4=severe). 
 
7.0 
Risks 
a. Risks to human subjects 
1. Redness, swelling, burning, rash, or discomfort may occur at the site of the 
lanadelumab injection. Should this occur we will put ice on the site. 
2. Lanadelumab may increase the risk of upper respiratory infections. Cold 
symptoms such as runny nose, sore throat, and sneezing are commonly 
observed. We will closely monitor the occurrence of those symptoms, and if 
necessary, we will stop the study. 
3. Other side effects of lanadelumab include headache, muscle pain, and diarrhea. 
These side effects are uncommon but will be monitored during the study. If any 
of them persist, the patient will be withdrawn from the study. 
4. Lanadelumab may induce elevation of transaminases, which is rare and 
transient. We will closely monitor the transaminase levels, particularly after the 
administration of the study drugs. 
5. Lanadelumab may pose unforeseeable risks to the subject, an embryo or fetus, 
or a pregnant woman. Pregnant women are excluded. 
6. Should new information become available during the study that may influence a 
subject’s willingness to participate, we will make that information available and 
amend the consent form appropriately. 
7. The collection and storage of DNA for genotyping creates the risk of release of 
information that could link subjects to stored samples and genotyping results. 

12/16/24 
 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk 
to Participants or Others 
 
Protection against risk 
• 
Investigators will obtain a detailed medical history to look for the exclusion and 
inclusion criteria. Patients will also undergo a complete physical examination prior 
to being included in the study. The assessment will include a thoughtful evaluation 
of the cardiovascular system, including blood pressure.  
• 
Patients will be monitored for the presence of Type I hypersensitivity reaction after 
the administration of the first study drug. For this purpose, the patient will remain in 
the CRC for two hours after the administration of the study. If the patient presents 
this type of reaction, proper treatment will be administered in the CRC. Also, the 
patient will not receive the second dose of the study drug and will be withdrawn 
from the study. 
• 
Baseline laboratory analysis and metabolic panels will be obtained to screen for 
any hematological or biochemistry abnormality. 
• 
A resting electrocardiogram (ECG) will be obtained during the CRC visits to look 
for the presence of abnormal ST segments, T-wave inversion, or cardiac 
arrhythmias. 
• 
Diagnosis of myocardial infarction will require the presence of at least two of the 
following criteria: typical chest pain with or without radiation, electrocardiogram 
compatible with myocardial infarction, and elevation of cardiac enzymes (creatine 
kinase MB or troponin). Stroke will be defined as new and sudden onset of 
neurological deficits that lasts longer than 24 hours. 
• 
We will review blood pressures obtained at the dialysis center. If at any time the 
pre-dialysis systolic blood pressure exceeds 189 mmHg or diastolic blood 
pressure exceeds 114 mmHg, blood pressure will be closely monitored. In the 
case of uncontrolled high blood pressure, subjects will be discontinued from the 
study. 
• 
A serum pregnancy test will be obtained the day of the study drug 
administration  in all women with childbearing potential to exclude pregnancy. 
• 
Serum electrolytes will be measured before study visits in blood draws for clinical 
labs (See Appendix A). Also, we will monitor potassium levels using the monthly 
labs obtained in the hemodialysis unit. For serum potassium from 5.5-5.9 mmol/L, 
the dietary restriction will be emphasized, and the potassium content of the 
dialysate will be adjusted to decrease serum potassium. Predialysis serum 
potassium of 6.0-6.4 mmol/L, if confirmed and not corrected with adjustment of 
dialysate potassium concentration, will result in discontinuation of the study.  
Confirmed predialysis serum potassium of 6.5 mmol/L or greater will result in 
immediate discontinuation.  All potassium measurements will be obtained before 
dialysis. 
• 
Transaminases levels will be monitor after the administration of the first study drug. 
If the levels increase four times the upper limit of normal the patient will be 
excluded from the study and will not receive the second dose of the study drug. 

12/16/24 
Also, if the levels of the transaminases do not return to normal within one week 
after the elevation, the patient will not receive the second dose and will be 
excluded from the study. 
• 
There are many safeguards in place to prevent the release of information from this 
study.  All research samples are coded with the subject’s unique identifier. Data 
sets used for the analysis also only contain this identifier. The key to the code is 
protected.  Only the investigator, co-investigators, and research nurse have access 
to information that identifies subjects as participating in the study.  The results of 
tests run on research samples will not be recorded in any subject’s medical record, 
and neither the subject nor his or her doctor will be told of the results, except in the 
case of unsuspected significant arrhythmia or myocardial infarction. Access to the 
Vanderbilt computer network is protected at the level of firewalls, TCP wrappers, 
and University assigned user IDs.  Data are secured with encryption algorithms, 
and the network is maintained by the Medical Center’s Network Computer Service.   
Data and Safety Monitoring Plan 
 
The principal investigator will be responsible for ensuring the data 
integrity and safety of all the study participants. All the adverse events will be recorded 
and reported to the Vanderbilt University Medical Center Institutional Review Board 
(IRB). The study progress report will be prepared every 6 months to describe: the 
screening and recruitment process, demographic of the participants, status and 
occurrence of adverse events (AEs), drug toxicities, treatment adherence, and any 
incident of non-compliance with the protocol. These reports will be prepared by the 
principal investigator. The reports will be presented to the Data and Safety Monitor 
(DSM) committee. The DSM may choose to perform an interim analysis; however, it is 
expected that this would not occur without reasonable concern related to either patient 
safety or data validity. The DSM may choose to become unblinded; however, it is 
expected that such unblinding would not occur without reasonable concern related to 
either patient safety or data validity. 
 
Protocol changes will be reported to the IRB and will not be implemented until approval 
is obtained.  
The DSM will objectively review the treatment results as they relate to human 
safety and data quality. Drs. Italo Biaggioni, Kerri Cavanaugh, Jonathan Mosley, and 
Thomas Stewart have agreed to be members of the DSM committee. Dr. Italo Biaggioni, 
Professor of Medicine and Pharmacology and Director of the Vanderbilt Autonomic 
Dysfunction Center, with extensive experience in human research and clinical trials, has 
agreed to take the role of DSM committee chair. Dr. Cavanaugh is Associate Professor 
in the Division of Nephrology who focuses on patient education and awareness 
regarding chronic kidney disease. Dr. Mosley is Assistant Professor in the Division of 
Clinical Pharmacology with background in epidemiology and bioinformatics. Dr. Stewart 
is a biostatistician with extensive experience as a consultant with the Department of 
Medicine. None of the members of the DSM committee have any conflict of interest, 
whether financial or intellectual with the investigator or the sponsor of the study. 
All protocols have been or will be reviewed and approved by the Vanderbilt 
University Medical Center IRB before any subject is enrolled.  
 
The principal investigator and co-investigators will closely oversee the protocol in 

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conjunction with the dedicated research nurse.  Any AEs or toxicities will be reported to 
the IRB as per IRB guidelines.  Any untoward medical event will be classified as an AE, 
regardless of its causal relationship with the study. An adverse event will be classified as 
serious if it a) results in death, b) is life-threatening, c) requires inpatient hospitalization or 
prolongation of existing hospitalization, d) results in persistent or significant disability or 
incapacity, or e) is a congenital anomaly or birth defect.  Serious adverse events will be 
reported to the DSM, the IRB, the National Institutes of Health (NIH), and the FDA within 7 
days of the PI's notification of the event. Non-serious, unexpected adverse events and 
instances of non-compliance with the protocol will be reported to the DSM and IRB at the 
time of continuing review. 
 
 
9.0 
Study Withdrawal/Discontinuation 
 
Subjects who develop an adverse event that is not transient (such as persistent nausea, 
diarrhea, headache, etc.) will have any study drug discontinued and will be withdrawn 
from the study. Subjects who do not tolerate the first dose of lanadelumab will be 
withdrawn from the study. Subjects who are withdrawn will be treated and/or followed as 
appropriate until any symptoms are resolved. If in the opinion of the investigator a 
subject is non-compliant, the subject will be withdrawn from the study. Subjects may 
withdraw from the study at any time. 
 
10.0 Statistical Considerations 
 
a. Sample size 
The primary outcome will be the change in blood pressure during hemodialysis. For this, 
we will average blood pressure during hemodialysis of three hemodialysis sessions 
within the second week of treatment. Secondary endpoints will also be recorded during 
the second week of treatment and will include the number of hypotensive events, 
frequency of nursing interventions, average of dialysis recovery times, and average 
symptoms severity score. Based on our preliminary studies with icatibant and assuming 
a standard deviation of differences of 13.6 mmHg (pooled SD of the delta), a sample 
size of 16 in each arm will have 80% power to detect a difference in means of -13.7 
mmHg, using a paired t-test with a 0.05 two-sided significance level.  
b. Data analysis plan 
Standard graphing and screening techniques will be used to detect outliers and to 
ensure data accuracy. Distributions of the continuous outcomes will be assessed for 
normality. If normality is violated, proper data transformation will be applied, or non-
parametric analysis methods will be considered. The primary endpoints are SBP and 
DBP. The secondary endpoints include heart rate, and the R-R interval (autonomic 
function), the time to recover after HD, symptoms associated with DIH, and the distance 
walked during the six-minute walk test.  
Mixed effect models will be used to analyze the primary endpoint (blood pressure) with a 
random subject effect and with the treatment (lanadelumab vs placebo) and the time 
trend (measurements every 15 minutes) as fixed effects. The focus of this study will be 
the treatment effect and the time trend of the endpoints; however, mixed effect models 
also provide the flexibility of controlling for and evaluating covariates. However, we will 
be careful not to over-fitting the model due to the limited sample size.  

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Besides the above evaluation of the treatment effect and the time trend through the 
regression models, the direct treatment effect will also be estimated as within-subject 
mean difference along with their 95% confidence intervals. For the secondary endpoints, 
a paired t-test will be performed (lanadelumab vs placebo). If the normality of the data is 
violated, we will use non-parametric tests.  
For binary endpoints (e.g., occurrence of hypotensive events), we will use the McNemar 
test to compare lanadelumab and placebo.  
Missing Data. Based on our previous studies, we anticipate a drop-out rate of 10% or 
less. Subjects who drop out will be replaced. Specific inferences on effects of interest 
will be made by reporting a point estimate along with a 95% confidence interval and the 
p-value. Hypotheses will be tested at the level of α=0.05. We will use SPSS (version 
25.0, SPSS, Chicago, IL) and the open-source statistical package R (R Core Team, 
2017) for analyses.47  
11.0 Privacy/Confidentiality Issues 
 
We will use the web-based Vanderbilt Research Electronic Data Capture (REDCap) 
system to design electronic data-collection forms in all Aims. These forms will be pilot 
tested before use. Data will be input into a protected, web-based case report form 
(which can be readily downloaded into SAS, STATA, R, or SPSS). The form allows for 
direct data entry by investigators and is designed to minimize errors and erroneous 
values. Expected ranges are pre-specified to prevent errors such as the shifting of 
decimal points. The program includes a computerized audit trail so that the identity of 
individuals entering or changing data and, in the case of changes, both original and 
revised data are saved. Data are backed up daily. 
 
A unique identification case number will be used to protect the confidentiality of the 
study participants. Only case numbers will be included in spreadsheets used for the 
statistical analysis.   
 
12.0 Follow-up and Record Retention 
All research records will be accessible for inspection and copying by authorized 
representatives of the IRB, federal regulatory agency representatives, and the 
department or agency supporting the research. All study documents will be retained for 
at least six years after the closure of the study with the IRB.  

12/16/24 
 
Appendix A Summary of study procedures 
 
  
+/-3 days 
 
+/-4days 
  
Day-7 
Day -1 
Day 0 
Day 1 
Day 3 
Day 13 
Day 14 
Day 15 
Day 17 
Day 29 
Day 43 
CRC visit 
x 
 
x 
HD visit 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Blood draw PK 
x 
x 
x 
 
x 
x 
x 
x 
Blood draw clinical labs 
x 
 
 
 
x 
x 
 
 
x 
x 
 
Blood draw research labs 
 
x 
 
x 
 
 
 
x 
 
 
x 
Serum pregnancy test 
 
 
x 
 
 
 
x 
 
 
 
 
Drug administration 
x 
 
x 
Medical history /PE 
x 
 
QOL questionaire/ recovery 
time 
x 
 
x 
x 
Symptoms questionnaire/ 
BP monitoring log 
x 
x 
 
x 
x 
x 
x 
NIRS 
x 
 
x 
x 
x 
Physical performance tests 
- Body composition*** 
x 
 
x 
x*** 
Collect dialyzer 
x 
x 
x 
 
x 
x 
x 
x 
activity monitor* 
x* 
 
x* 
* monitor ends after at least 5 days of consecutive use 
 
**It includes: physical performance tests (six-minute walk test, physical battery, and handgrip strength), bioelectrical impedance 
analysis, and MUAMC 
***Physical performance will only include handgrip strength 
 

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