Study of Tacrolimus vs Mycophenolate Mofetil in Pediatric Patients With Frequently Relapsing or Steroid Dependent Nephrotic Syndrome: a Randomized, Multicenter, Open-label, Parallel-arm Study
Phase: PHASE4
Conditions: Nephrotic Syndrome in Children
Sponsor: The Children's Hospital of Zhejiang University School of Medicine

Protocol No.: NSTAMF02
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Version No.: V2.1, Version Date: June 10, 2019
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Study of Tacrolimus vs Mycophenolate Mofetil in Pediatric patients
with Frequently Relapsing or Steroid-dependent Nephrotic
Syndrome: a Prospective, Randomized, Multicenter, Open-label, and
Parallel-arm Study on Efficacy and Safety (the STAMP study)
Main research unit:
The Children's Hospital, Zhejiang
University School of Medicine
Principal investigator:
Mao Jianhua
Sponsor:
Hangzhou Zhongmeihuadong
Pharmaceutical Co., Ltd.
Protocol No.:
NSTAMF02
Version No.:
V 2.1
Version date:
June 10, 2019
NCT No.:
NCT04048161
This clinical trial protocol is confidential and owned by the Sponsor. Without the
permission from the Sponsor, it is not allowed to provide the contents, in part or in
full, to any third party (group or individual).

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Contents
Contents.............................................................................................................................................. 2
Compliance Statement........................................................................................................................5
For investigator's signature.................................................................................................................6
For Sponsor's signature.......................................................................................................................7
Abbreviations......................................................................................................................................8
Protocol Abstract...............................................................................................................................10
1.1 Abstract............................................................................................................................... 10
1.2 Research Plan......................................................................................................................12
1.3 Clinical trial flow chart.......................................................................................................13
1. Background...................................................................................................................................17
2. Purpose..........................................................................................................................................20
2.1 To observe the efficacy of test drugs on the frequently relapsing or steroid-dependent
nephrotic syndrome in pediatric patients..................................................................................20
2.2 To observe the safety outcomes of test drugs.....................................................................20
3. Design basis, type, principle and case allocation.........................................................................20
3.1 Design basis........................................................................................................................20
3.2 Design type......................................................................................................................... 20
3.3 Design principle and case allocation..................................................................................20
4. Selection of cases..........................................................................................................................21
4.1 Inclusion criteria.................................................................................................................21
4.2 Exclusion criteria................................................................................................................21
4.3 Elimination criteria.............................................................................................................22
4.4 Withdrawal criteria............................................................................................................. 22
4.5 Drop-out and treatment.......................................................................................................23
4.6 Relevant definitions in inclusion and exclusion criteria.................................................... 23
5. Test drugs and their allocation......................................................................................................24
5.1 Drug name and specifications............................................................................................ 24
5.2 Administration method, dose, route and course of treatment............................................ 24

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5.3 concomitant medication......................................................................................................26
5.4 Management of test drugs...................................................................................................27
5.5 Medication adherence.........................................................................................................28
6. Test process and steps...................................................................................................................28
7. Evaluation of efficacy and safety................................................................................................. 28
7.1 Primary efficacy outcomes................................................................................................. 28
7.2 Efficacy evaluation............................................................................................................. 29
7.3 Safety evaluation................................................................................................................ 29
8. Reporting adverse events..............................................................................................................29
8.1 Definition of adverse events...............................................................................................29
8.2 Definition of serious adverse event....................................................................................34
8.3 Records of adverse events.................................................................................................. 34
8.4 Report of serious adverse events........................................................................................36
9. Quality control and assurance of the trial.....................................................................................37
9.1 Quality control measures in laboratory.............................................................................. 37
9.2 Quality control and assurance in the trial process..............................................................37
9.3 Measures to improve subject compliance.......................................................................... 39
9.4 Quality control and quality assurance systems.................................................................. 39
10. Data management....................................................................................................................... 40
10.1 Data management system.................................................................................................40
10.2 Data record........................................................................................................................40
10.3 Data supervision............................................................................................................... 40
11. Statistical analysis.......................................................................................................................40
11.1 Analysis data set................................................................................................................40
11.2 Statistical method..............................................................................................................41
11.3 Content of statistical analysis........................................................................................... 41
11.3.1 Basic value equilibrium analysis...................................................................................41
11.3.2 Effectiveness analysis....................................................................................................42
11.3.3 Primary efficacy analysis...............................................................................................42
11.3.4 Secondary efficacy analysis...........................................................................................42

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11.3.5 Other efficacy analysis...................................................................................................42
11.3.6 Safety analysis............................................................................................................... 43
12. Ethical principles........................................................................................................................ 43
12.1 Ethical review................................................................................................................... 43
12.2 Benefits and risks..............................................................................................................43
12.3 Informed consent process.................................................................................................43
12.4 Medical treatment and protection of subjects.................................................................. 44
12.5 Protection of subject privacy............................................................................................44
13. Ethical requirements................................................................................................................... 44
14. Data preservation........................................................................................................................44
15. Expected progress.......................................................................................................................45
16. Follow-up and medical measures after the trial......................................................................... 45
17. References...................................................................................................................................45
Appendix 1 Estimation of glomerular filtration rate........................................................................48
Appendix 2 Blood pressure reference values for children...............................................................49
Appendix 3 Comparison and acceptance criteria of laboratory observation indexes......................51
Appendix 4 Parameters and results sample size calculation............................................................52

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Compliance Statement
This clinical research will comply with the Good Clinical Practice (GCP) and
relevant regulations of the China Food and Drug Administration (CFDA).
The investigators and clinical research staff responsible for the implementation,
management and supervision of this project need to complete GCP training.
This Protocol, Informed Consent Form, recruitment materials and other subject
materials have been
Submitted to the Ethics Committee for review and approval. Subject recruitment
would begin after the Protocol and Informed Consent Form are approved by the
Ethics Committee. Any revision of the Protocol during this research must be reviewed
and approved by the Ethics Committee before its implementation. In addition, all
revisions to the Informed Consent Form shall be approved by the Ethics Committee.
Subjects who have signed the old Informed Consent Form and are still in the groups
shall re-sign the new version of Informed Consent Form.

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For investigator's signature
I hereby agree:

To be responsible for the normal operation of this research in our center.

To carry out this research in accordance with the research protocol and its
amendment as well as the relevant research implementation specifications
provided by Hangzhou Zhongmeihuadong Pharmaceutical Co., Ltd.

Not to change or violate this research protocol without the review and written
approval from the Sponsor and the Medical Ethics Committee, unless it is for the
purpose to eliminate the harm to the subjects as soon as possible or for needs of
trial management (requiring permission from the corresponding regulatory
authority).

I am fully familiar with the rational application of the research medicine
described in the Protocol and the relevant materials provided by the Sponsor,
including
but
not
limited
to
the
Clinical
Investigator
Manual
or
the
corresponding
documents
provided
by
Hangzhou
Zhongmeihuadong
Pharmaceutical Co., Ltd., as well as the supplementary contents of the
Investigator Manual (if necessary) and the product description.

I understand and will abide by the GCP and all relevant regulations and rules.

To ensure that all personnel assisting me in this research are fully familiar with
the research medicine from Hangzhou Zhongmeihuadong Pharmaceutical Co.,
Ltd. as well as the responsibilities and functions related to this research as
described in this Protocol.

I have been informed that some regulatory authorities require the Sponsor to
provide the ownership interests of the investigators in the research medicine and
the financial relationship with the Sponsor. Hangzhou Zhongmeihuadong
Pharmaceutical Co., Ltd. will use or provide such information for the purpose of
complying with the requirements of the regulatory authorities.
Research center:
Investigator (signature):
Date:

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For Sponsor's signature
(Sponsor) Statement: Our company will be responsible for initiating, applying for,
organizing, supervising and inspecting this clinical trial and providing trial funds in
accordance with the provisions of GCP. In particular, we will provide treatment
compensation to the subjects who would suffer from the trial-related damage or death
during the trial, and provide legal and economic guarantees to the investigators.
Sponsor representative name (signature)____________
Sponsor name (seal)_____________
Date:__________(YYYY/MM/DD)

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Abbreviations
Abbreviations
Description
ALT
Alanine aminotransferase
ALB
Albumin
AUC
Area under curve
ACEi
Angiotensin converting enzyme inhibitor
ARB
Angiotensin II receptor blocker
AE
Adverse event
ANCOVA
Analysis of covariance
BID
Bis in die
CMV
Cytomegalovirus
CsA
Cyclosporin A
CR
Complete remission
CSR
Clinical Study Report
CRF
Case Report Form
CMH
Cochran’s and Mantel-Haenszel
DAE
Drug adverse event
EB
Epstein-Barr
EBV-DNA
Epstein-Barr virus deoxyribonucleic acid
eGFR
Glomerular filtration rate
eCRF
Electronic Case Report Form
FAS
Full analysis set
FR
Frequent relapse
FDA
Food and Drug Administration
FK506
Tacrolimus
FK-BP-12
Tacrolimus binding protein-12
FK-BP-52
Tacrolimus binding protein-52
FK506-FKBP
Tacrolimus - tacrolimus binding protein
FRNS
Frequently relapsing nephrotic syndrome
GCP
Good Clinical Practice
g
Gram
GTP
Guanine nucleotide
HBV
Hepatitis B virus
HbsAg
Hepatitis B surface antigen
HbeAg
Hepatitis B E antigen

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HbcAb
Hepatitis B core antigen
HCV
Hepatitis C virus
hr
Hour
ITT
Intentionality
LSMEAN
Least squares mean
LC-MS
Liquid chromatography-mass spectrometry
MMF
Mycophenolate mofetil
MPA
Mycophenolic acid
MPA-d3
Mycophenolic acid-d3
MPA-AUC
Mycophenolic acid - Area under curve
MI
Myocardial infarction
mg
Milligram
NR
No remission
PP
Per-protocol
PR
Partial remission
PML
Progressive multifocal leukoencephalopathy
PRCA
Pure red cell aplasia
PPS
Per-protocol set
SAS 9.4
STATISTICAL ANALYSIS SYSTEM Version 9.4
SD
Steroid-dependent
SDNS
Steroid-dependent nephrotic syndrome
SRNS
Steroid-resistant nephrotic syndrome
SCV
Site close-out visit
SAE
Serious adverse event
SOP
Standard Operation Procedures
SS
Safety set
Scr
Serum creatinine
TBiL
Total bilirubin
TIMP-1
Tissue inhibitor of metalloproteinase-1
TIA
Transient ischemic attack
WHO
World Health Organization
WBDC
Web-based data collection
α
Inspection level
β
Power of test
δ
Cut-off value

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Protocol Abstract
1.1
Abstract
Title: Study of Tacrolimus vs Mycophenolate Mofetil in Pediatric Patients with Frequently
Relapsing or Steroid-dependent Nephrotic Syndrome: a Prospective, Randomized, Multicenter,
Open-label, and Parallel-arm Study on Efficacy and Safety
Objective: To evaluate the efficacy and safety of tacrolimus and mycophenolate mofetil in the
treatment of frequently relapsing and steroid-dependent nephrotic syndrome in children, in order
to provide a more effective and safer choice for the treatment of nephrotic syndrome in pediatric
patients.
Design: Prospective, randomized, multicenter, open-label, and parallel-arm trial
Primary center: The Children's Hospital, Zhejiang University School of Medicine
Test drug name: Saikeping® Mycophenolate Mofetil Dispersible Tablets; Saifukai® Tacrolimus
Capsules
Subjects: Pediatric patients with confirmed steroid-sensitive but frequently relapsing or
steroid-dependent primary nephrotic syndrome
Treatment course: 1 year
Medication:
(1) Tacrolimus group: FK506 dose: 0.05-0.10 mg/kg/day, BID; in the induction period (the first
six months after administration), the trough plasma concentration of tacrolimus is maintained at
5-10 ng/mL; in the maintenance period (the last six months after administration), the trough
concentration is less than 5 ng/mL.
(2) Mycophenolate mofetil group: MMF dose: 20-30 mg/kg/day, BID; in the induction period
(the first six months after administration), the plasma concentration MPA-AUC is maintained at
30-50 μg.h/mL; in the maintenance period (the last six months after administration), the
MPA-AUC is ≤40 μg.h/mL.
(3) Prednisone dose: The initial dose is 1.0-1.5 mg/kg every other day or 0.5-0.75 mg/kg every
day. The dose shall be reduced after 4 weeks by 0.25 mg/kg (every other day) or 0.125 mg/kg
(every day) every 2-4 weeks. If the condition is stable, continue to reduce and maintain at 5mg
(body surface area > 1 m2) and 2.5mg (body surface area < 1 m2) every other day.
Efficacy outcomes:
Primary observation outcomes: 1-year relapse-free survival
Secondary observation outcomes: Renal function; cumulative steroid dosage; blood pressure;
height; body weight; blood lipids; hemoglobin; serum albumin; urinary protein/creatinine
(morning urine); 24hr urinary protein quantification (applicable to subjects > 3 years old);

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frequency of relapses; the time of the first relapse after enrollment; relapse-free rate in the first six
months after enrollment; adverse reactions;
Safety outcomes: Changes of vital signs (respiration and heart rate), blood and urine routine, liver
function, blood glucose, ECG, chest X-ray, and observation of clinically reported adverse events
and adverse reactions.
Sample size: 270 cases. Including 135 cases in MMF Group, and 135 cases in FK506 Group.
Statistical analysis: SAS 9.4 software for data statistical analysis.

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1.2
Research Plan
Research Plan
Obtain the Informed Consent Form
Screen the eligible subjects according
to the inclusion and exclusion criteria
Excluded

Fail to meet the inclusion
criteria

Refuse to be included

Other reasons
2-week running-in period

Guidance on collection of 24h urine and morning urine, and
application of urine protein test paper. Education and
training on compliance, etc.

In case of combined use with other immunosuppressants, its
application will be halved when entering the running-in
period and stopped within 2 weeks
Randomized
FK506 Group
Take FK506 and steroid
MMF Group
Take MMF and steroid
Assigned
to groups
Included
Follow-up
Statistical analysis
Loss of follow-up /
treatment completion /
interruption
Loss of follow-up /
treatment completion /
interruption

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1.3
Clinical trial flow chart
Clinical trial flow chart
Items
Screening and
enrollment period
Treatment and follow-up period
Screen
(V0)
Visit 1
(V1)
Visit 2
(V2)
Visit 3
(V3)
Visit 4
(V4)
Visit 5
(V5)
Visit 6
(V6)
Visit 7
(V7)
Visit 8
(V8)
Visit 9
(V9)
Follow-up week
Day -30 - 0
Included
Day 7
Day 28
Day 56
Day 112
Day 168
Day 224
Day 280
Day 364
Sign the Informed Consent Form
√
Inclusion/Exclusion Criteria
√
Stop the original
immunosuppressants after 2 weeks
＄
＄
Randomized
√
General data
√
Medical history (course of disease,
frequency of relapses in 1 year and 6
months before enrollment, steroid
dosage)
√
Vital signs
√
√
√
√
√
√
√
√
√
√

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Items
Screening and
enrollment period
Treatment and follow-up period
Screen
(V0)
Visit 1
(V1)
Visit 2
(V2)
Visit 3
(V3)
Visit 4
(V4)
Visit 5
(V5)
Visit 6
(V6)
Visit 7
(V7)
Visit 8
(V8)
Visit 9
(V9)
Height and weight
√
√
√
√
√
√
√
√
√
√
Physical examination
√
◎
√
√
√
√
√
√
√
√
Blood routine examination
√
◎
√
√
√
√
√
√
√
√
Urine routine examination
√
◎
√
√
√
√
√
√
√
√
Fasting blood glucose
√
√
√
√
√
√
√
√
√
Serum liver function
√
◎
√
√
√
√
√
√
√
√
Blood lipid
√
◎
√
√
√
√
√
√
√
√
Serum renal function
√
◎
√
√
√
√
√
√
√
√
Blood EBV-DNA, and CMV
antibody
√
√
24h urinary protein (>3 years old)
√
◎
√
√
√
√
√
√
√
√
Urinary protein / creatinine
√
◎
√
√
√
√
√
√
√
√
eGFR
√
◎
√
√
√
√
√
√
√
√

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Items
Screening and
enrollment period
Treatment and follow-up period
Screen
(V0)
Visit 1
(V1)
Visit 2
(V2)
Visit 3
(V3)
Visit 4
(V4)
Visit 5
(V5)
Visit 6
(V6)
Visit 7
(V7)
Visit 8
(V8)
Visit 9
(V9)
Tacrolimus concentration in plasma
√
√
√
√
√
√
√
Mycophenolic acid concentration in
plasma
√
√
Chest X-ray
√
√
ECG
√
√
Markers of hepatitis B and hepatitis
C virus
√
Examination of Mycobacterium
tuberculosis and fungi
√
Biological samples of blood and
urine
√
√
√
Drug distribution and measurement
√
√
√
√
√
√
√
√
√
Guidance on the administration of
test drug
√
√
√
√
√
√
√
√
√

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Items
Screening and
enrollment period
Treatment and follow-up period
Screen
(V0)
Visit 1
(V1)
Visit 2
(V2)
Visit 3
(V3)
Visit 4
(V4)
Visit 5
(V5)
Visit 6
(V6)
Visit 7
(V7)
Visit 8
(V8)
Visit 9
(V9)
Clinical efficacy (relapse or no)
√
√
√
√
√
√
√
√
Concomitant medication
√
√
√
√
√
√
√
√
√
√
Adverse event
√
√
√
√
√
√
√
√
Record case report form
√
√
√
√
√
√
√
√
√
√
Remarks:
1.
Liver function: ALT, TBiL, ALB; Renal function: creatinine, urea nitrogen, uric acid, Cystatin C;
2.
Blood lipids: Triglycerides, cholesterol; Urinary protein / creatinine: morning urine; Markers of hepatitis B and hepatitis C virus: HBsAg, HBeAg, HBcAb, HCV;
3.
Mycobacterium tuberculosis examination: T-sport; Fungal examination: fungal G test or other; Estimated glomerular filtration rate: eGFR = K × height (cm) / serum creatinine (mg /
dL) (see Appendix);
4.
Visit time window: ±3 days for visit 2, and ±7 days for other visits;
5.
$ items are applicable to the pediatric patients with combined use of other immunosuppressants before enrollment; ◎items are optional, depending on the judgment and decision of
the investigators;
6.
This research accepts the examination data from our hospital within 2 weeks before the screening period, and no repeated test is needed.

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1. Background
Primary nephrotic syndrome, the most common glomerular disease in children, accounts for about
90% of the total nephrotic syndrome cases in pediatric patients[1]. It is reported that the annual
incidence rate of pediatric nephrotic syndrome is about 2-4/100000, and the prevalence rate is
about 16/100000[2, 3]. The statistics of hospitalized children in some provincial and municipal
hospitals in China show that primary nephrotic syndrome accounts for about 20% of hospitalized
children with urinary system diseases[4]. Renal biopsy shows minimal lesions in more than 80% of
patients. This disease can occur at any age, but it mostly occurs at the age of 2-6. It is more
common in boys, with a male/female ratio of about 3:2. Since the 1950s, glucocorticoids have
been recognized as the first-line treatment. About 80%-90% of pediatric patients with primary
nephrotic syndrome can achieve complete remission after initial steroid treatment, but 76%-93%
of the pediatric patients have relapses, of which 45%-50% show frequent relapses (FR) or steroid
dependence (SD)[5]. The relapses of proteinuria, especially frequently relapsing/steroid-dependent
nephrotic syndrome, have always been a very difficult and urgent problem for clinicians. Some
pediatric patients may have steroid resistance after repeated relapses and eventually develop into
chronic dysfunction. The long-term or repeated use of steroids at high doses will lead to side
effects such as obesity, growth inhibition, hypertension, diabetes, glaucoma, cataract, osteoporosis
and
serious
infection.
Its
combined
use
with
traditional
immunosuppressants
such
as
cyclophosphamide and cyclosporine A (CSA) will bring some serious irreversible side effects.
Therefore, it is particularly important to explore new immunosuppressants and their application
schemes.
Tacrolimus is a 23-membered macrolide antibiotic extracted from the fermentation of
Streptomyces. It was used clinically in 1989 for the first time, and officially used in the United
States after being approved by the U.S. Food and Drug Administration (FDA) in 1995. It was
registered as an imported drug in China in 1998 and gradually used in clinical application.
Tacrolimus, a new type of calcineurin inhibitor, can be combined with FK506 binding protein-12
(FK-BP-12) and FK506 binding protein-52 (FK-BP-52) receptors in the cytoplasm of T
lymphocytes in vivo to form FK506-FKBP complex, with an function of inhibiting the
phosphorylase activity of calmodulin phosphatase, thus inhibiting the proliferation of T
lymphocytes. This indirectly affects the production of B lymphocytes and antibodies, and finally
causes immunosuppression
[6]to achieve the purpose of treating glomerular diseases. Its
immunosuppressive effect is 10 - 100 times that of cyclosporine A[7]. In addition to its strong
immunosuppressive effect, tacrolimus also has its non-immunosuppressive effects: (1) It can
produce hormone-like effect or reduce the dosage of hormone; (2) It can significantly
down-regulate the expression of tissue inhibitor of metalloproteinase-1 (TIMP-1), while CsA can

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up-regulate the expression of TIMP-1. Therefore, tacrolimus shows weaker effect on tissue
fibrosis than CsA; (3) It can inhibit platelet aggregation, reduce thrombosis and reduce
inflammatory reaction[8]; (4) It has podocyte protection effect. The studies by Li Xiayu et al.[ [9]
have shown that as compared with cyclophosphamide, tacrolimus can induce the remission of
nephrotic syndrome more quickly in adult patients with steroid dependence and minimal lesion in
pathology. About 72.7% of patients using tacrolimus can successfully stop the application of
steroid. In the treatment of steroid-dependent or steroid-resistant focal segmental sclerosis, the
studies by Hong Ren et al. [10]have shown that tacrolimus and cyclophosphamide have similar
effects, both of which can reduce urinary protein, improve renal function and blood albumin level.
The previous clinical studies of the Department of Nephrology of the Children's Hospital,
Zhejiang University have also found that tacrolimus can effectively reduce the frequent relapses or
the relapse frequency of steroid-dependent nephrotic syndrome, and down-regulate the total
amount of hormone use.
Mycophenolate mofetil (MMF) is a precursor of mycophenolic acid (MPA). Mycophenolic acid is
a reversible and non-competitive inhibitor of hypoxanthine monophosphate dehydrogenase, a rate
limiting enzyme in purine synthesis. It can significantly inhibit the classical synthesis pathway of
guanine nucleotide (GTP), without any impact on other synthesis pathways and remedial synthesis
pathways.[11] MMF will not significantly damage liver, kidney or bone marrow cells, and can
avoid cytotoxic damages caused by other immunosuppressants[12]. MMF can quickly inhibit the
synthesis of antibodies, and effectively inhibit the secretion of surface adhesion molecules, to play
the pharmacological role in anti-inflammatory response. In addition, MMF can also significantly
inhibit the proliferation rate of vascular smooth muscle cells and endothelial cells, inhibit the
production of cell adhesion molecules and aggregation of a large number of leukocytes near the
inflammatory tissues, enhance its pharmacological effect of immunosuppression by inducing
lymphocyte apoptosis, and finally significantly reduce the degree of renal parenchyma damage
and avoid the occurrence of glomerulosclerosis[13]. Animal researches have also confirmed that
MMF can play a great role in the process of activation under the activation of inflammatory cells,
transdifferentiation of myofibroblasts and massive aggregation of extracellular matrix, so as to
prevent the pathological process of renal interstitial fibrosis[14]. In 1998, Briggs et al. first used
MMF in the treatment of adult steroid-resistant or steroid-sensitive but recurrent nephrotic
syndrome, showing a good curative effect[15]. Then, many studies at home and abroad have shown
that mycophenolate mofetil can reduce the relapse frequency of frequently relapsing nephrotic
syndrome and reduce the dosage of steroid. Recent studies by Gellermann et al. [16]have shown
that cyclosporine A is better than mycophenolate mofetil in reducing the relapse frequency of
frequently relapsing nephrotic syndrome, but mycophenolate mofetil is significantly better than
cyclosporine A in protecting the renal function. In short, it is believed that MMF can effectively

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reduce the relapse rate of nephropathy, reduce and even stop the steroid use, with less adverse
reactions and no nephrotoxicity. It is an effective and safe immunosuppressant for the treatment of
FRNS in pediatric patients.
In addition, domestic and foreign expert guidelines, such as KDIGO Clinical Practice Guideline
for Glucorulonephritis (2012), Evidence-based Guideline for the Diagnosis and Treatment of
Steroid-resistant Nephrotic Syndrome (2016) and Evidence-based Guideline for the Diagnosis and
Treatment of Steroid-sensitive and Recurrent/Dependent Nephrotic Syndrome in Pediatric Patients
(2016),
all
recommend
tacrolimus
and
mycophenolate
mofetil
for
frequently
relapsing/steroid-dependent nephrotic syndrome[17-19]. Among these two types of drugs, tacrolimus
with the dual effects of immunosuppression and podocyte protection, is more widely used in
Department of Nephrology, and mycophenolate mofetil has also gradually obtained the attention
from nephrologists in recent years because of its non-nephrotoxicity, less adverse reactions and
high safety. However, currently there are no multicenter studies comparing the efficacy of
tacrolimus
and
mycophenolate
mofetil
in
pediatric
patients
with
frequently
relapsing/steroid-dependent nephrotic syndrome at home and abroad. Therefore, the purpose of
this research is to observe the efficacy and safety of tacrolimus and mycophenolate mofetil in the
treatment of frequently relapsing/steroid-dependent nephrotic syndrome in pediatric patients with
a prospective, randomized, multicenter, open-label and parallel-arm approach, and evaluate their
safety, hoping to provide a more effective and safe treatment scheme for frequently
relapsing/steroid-dependent nephrotic syndrome in pediatric patients.

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2. Purpose
2.1 To observe the efficacy of test drugs on the frequently relapsing
or steroid-dependent nephrotic syndrome in pediatric patients
Efficacy outcomes:
Primary observation outcomes: 1-year relapse-free survival
Secondary observation outcomes: Renal function; cumulative steroid dosage; blood pressure;
height; body weight; blood lipids; hemoglobin; serum albumin; urinary protein/creatinine
(morning urine); 24hr urinary protein quantification (applicable to subjects > 3 years old);
frequency of relapses; the time of the first relapse after enrollment; relapse-free survival in the
first six months after enrollment; adverse reactions;
2.2 To observe the safety outcomes of test drugs
Changes of vital signs (respiration and heart rate), routine blood and urine tests, liver function,
renal function, blood glucose, ECG, chest X-ray, and observation of clinically reported adverse
events and adverse reactions.
3. Design basis, type, principle and case allocation
3.1Design basis

Pharmaceutical Administration Law of the People's Republic of China, 2001

Drug Registration Regulation, 2007

Good Clinical Practice (GCP), 2003

Declaration of Helsinki, 2008

Results of pharmacodynamic and toxicological studies of tacrolimus and mycophenolate
mofetil ingredients, and current clinical trial experience
3.2Design type
This trial adopts a prospective, randomized, multicenter, open-label and parallel-arm clinical
research method. The whole observation period is 1 year for this trial. See P12 “Clinical trial flow
chart” for details.
3.3Design principle and case allocation
3.3.1
Difference analysis
In this research, Logrank method is used to compare the difference of 1-year relapse-free survival
between the two groups.

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Eligible patients will be randomly divided into FK506 Group or MMF Group at the ratio of 1:1.
The random codes are generated by the computer and the random envelopes are made according
to these random codes. Grouping information is attached in each envelope. Each code is provided
with a corresponding random envelope, and the random numbers are given to the subjects from
small to large according to the time sequence when the subjects meet the inclusion criteria. The
corresponding random envelopes can only be opened when grouping. Any random number falling
off midway after use cannot be used again.
3.3.2
Determination of the number of cases
It is estimated that 1-year relapse-free survival is 0.56 in MMF Group, and 0.70 in FK506 Group.
The enrollment time of this research is expected to be 2 years, and the total time of this research is
3 years, with a test level α= 0.05, and a power of test 1- β= 80%. It is estimated to have 114
patients in MMF group and 115 patients in FK506 group, with a total of 229 patients (see
Appendix 4 for details). With the consideration of 15% loss of follow-up, a total of 270 patients
are needed, including 135 patients in each group.
4. Selection of cases
4.1 Inclusion criteria
Only those who meet all the conditions listed in this column can be considered for inclusion in this
research:
(1)
Steroid-sensitive nephrotic syndrome with frequent relapse (FRNS) or steroid dependence
(SDNS);
(2)
Age: 2-18 years old;
(3)
Normal renal function: eGFR≥90mL/min/1.73m2;
(4)
At the time of enrollment, urinary protein <1+ or urinary protein/creatinine <0.2g/g (< 20
mg/mmol) in the morning for 3 consecutive days or more;
(5)
No
use
of
tacrolimus,
mycophenolate
mofetil,
cyclosporine
A,
rituximab
or
cyclophosphamide within 2 years before enrollment;
4.2 Exclusion criteria
Anyone with one of the following conditions cannot be included in this research:
(1)
Steroid-resistant nephrotic syndrome (SRNS);
(2)
Family history of nephrotic syndrome, chronic glomerulonephritis or uremia;
(3)
Leukopenia (leukocyte ≤3.0*109/L);
(4)
Moderate and severe anemia (hemoglobin < 9.0 g/dL);
(5)
Thrombocytopenia (platelet count < 100*1012/L);

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(6)
Those with positive HBV serological indexes (HBsAg or/and HBeAg or/and HBcAb),
positive HCV or abnormal liver function (ALT or total bilirubin exceeding 2 times or more
of the upper limit, with a continuous increase for 2 weeks);
(7)
There are chronic active
infections such as Epstein-Barrvirus, cytomegalovirus or
Mycobacterium tuberculosis, and the usage of steroids and immunosuppressive agents may
aggravate the state of an illness;
(8)
Secondary nephrotic syndrome (such as purpura nephritis ,lupus nephritis,etc);
(9)
Those who with hematological or endocrine system diseases as well as serious organs illness
such as heart, liver or kidney;
(10) Other autoimmune diseases or primary immunodeficiency or tumors;
(11) Those who was known be sensitized to tacrolimus, mycophenolate mofetil, glucocorticoids
or any ingredient of the above drugs;
(12) Those who have participated in other clinical trials within three months before enrollment;
(13) Those who was not suitable for participating this study judged by investigator;
4.3 Elimination criteria

Those who fail to take the test drugs as required, with a compliance <80% or >120%;

Those who cannot cooperate well or complete the follow-up as planned, and those who
change the drug dose at will;
4.4 Withdrawal criteria
Patients are free to withdraw from the trial at any time without any reason.
Patients must withdraw from this research in the following conditions:

Withdrawal of the Informed Consent Form;

Violation of the inclusion criteria or compliance with the exclusion criteria;

No administration of the test drug according to the Protocol for 14 consecutive days due to
various reasons;

For two consecutive times, the measured value of SCr with an interval of at least 4 weeks has
increased more than twice the baseline, and eGFR < 60mL/min.1.73m2;

The target concentration of tacrolimus or mycophenolate mofetil can not be reached after
dose adjustment for one month;

ALT or total bilirubin levels reach more than 2 times of the upper limit after medication, with
a continuous increase for 2 weeks; if ALT or total bilirubin levels still rise to more than 2
times of the upper limit after 2 weeks of liver protection drug treatment, stop the test drug.
In case of no recovery after 2 weeks of drug withdrawal, the patient shall withdraw from
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
Occurrence of unknown adverse events of unacceptable nature, severity and/or duration, or
occurrence of known unacceptable adverse events or the occurrence frequency exceeding
expectations;

The clinical events or safety-affecting events result in withdrawal from the clinical trial, and
the investigators believe that such subjects shall withdraw from the trial;

If pregnancy occurs during treatment, withdraw from the trial;

Unauthorized use of drugs prohibited by this research (see "5.3 Concomitant medication");
4.5 Drop-out and treatment
4.5.1
Definition of drop-out: All patients who have completed the Informed Consent Form
and screened to be enrolled in the trial have the right to withdraw at any time. Whenever
and for whatever reason, subjects who fail to complete the observation period specified in
the Protocol are considered as drop-out cases, including the following situations:

The subject has serious adverse events and the clinician believes that he/she should withdraw
from the clinical trial;

The subject shows aggravated condition or has other symptoms affecting the trial observation
during the trial, and the clinician believes that he/she should withdraw from the clinical
trial;

Important deviations occur in the implementation of clinical trial protocol, such as poor
compliance, which would cause difficulty in evaluating the drug effect;

The subject is unwilling to continue the clinical trial and asks to withdraw from the clinical
trial, or loss of follow-up has occurred although no request to withdraw from the trial is
proposed.
4.5.2
Treatment of drop-off cases: The investigators shall contact the drop-off subjects by
means of visiting, making an appointment for follow-up, calling, letter and so on, to ask
the reasons, record the last medication time and complete the evaluation items that can be
completed. For the cases withdrawing from the trial due to allergy or other adverse
reactions and ineffective treatment, the investigators shall take corresponding treatment
measures according to the actual situation of the subjects. The investigators shall properly
keep the relevant test data of the drop-off cases, not only for filing, but also for full
analysis and statistics.
4.6 Relevant definitions in inclusion and exclusion criteria
4.6.1
Steroid-sensitive nephrotic syndrome (SSNS): Complete remission after 4 weeks of
prednisone or prednisolone at standard dose [2mg/kg.d or 60mg/m2. d].

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4.6.2
Steroid-resistant nephrotic syndrome (SRNS): Lack of complete remission at 4 weeks
of therapy with daily prednisone or prednisolone at standard dose [2mg/kg.d or 60mg/m2.
d].
4.6.3
Steroid-dependent nephrotic syndrome (SDNS): Two consecutive relapses during
therapy with prednisone or prednisolone (either at full dose or during tapering) or within
15 days of prednisone or prednisolone discontinuation.
4.6.4
Frequently relapsing nephrotic syndrome (FRNS): ≥2 relapses per 6 months within
6months of disease onset or 24 relapses per 12 months in any subsequent 12-month
period.
4.6.5
Secondary nephrotic syndrome: It refers to the nephrotic syndrome with clear causes.
Secondary nephrotic syndrome can be caused by autoimmune diseases (such as systemic
lupus erythematosus), diabetes, infections (such as bacteria and hepatitis B virus),
circulatory system diseases, drug poisoning, etc.
5. Test drugs and their allocation
5.1 Drug name and specifications
(1)
Tacrolimus capsules (trade name: Saifukai®，capsules, 1.0 mg/capsule, 0.5 mg/capsule);
Storage conditions: Keep away from sunlight, and store in a dry place below 25°C after
sealing.
(2)
Mycophenolate mofetil dispersible tablets (trade name: Saikeping®, tablets, 250 mg/tablet);
Storage conditions: Store under 30°C and keep away from sunlight.
(3)
Storage conditions of prednisone tablets (tablets, 5 mg/tablet): Keep away from sunlight, and
store at room temperature after sealing.
[Prednisone tablets can be replaced by other glucocorticoids during the test, but the dose shall
have the same therapeutic effect, for example prednisone 5mg = prednisolone 5mg, prednisone
5mg = methylprednisolone 4mg, etc.]
5.2 Administration method, dose, route and course of treatment
5.2.1
Initial administration protocol
FK506 dose: 0.05-0.10 mg/kg/day, BID
Maintained concentration: In the induction period (the first six months after treatment) (visit 2, 3,
4, 5 and 6), the trough plasma concentration of tacrolimus is 5 - 10 ng/mL;
In the maintenance period, drug dose is gradually reduced when the patient's condition is
stable:

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In the last six months after administration (visit 7, 8, and 9), the trough concentration is <5
ng/mL
MMF dose: 20-30 mg/kg/day, BID
Plasma concentration (AUC) [Formula: MPA-AUC =7.75+(6.49*C0)+(0.76*C0.5)+(2.43*C2)]
Maintained concentration: In the induction period (the first six months after treatment) (visit 2, 3,
4, 5 and 6)
MPA-AUC=30 - 50 μg.h/mL
In the maintenance period, drug dose is gradually reduced when the patient's condition is
stable:
In the last six months after administration (visit 7, 8, and 9), MPA-AUC≤40 μg.h/mL
Prednisone dose: The initial dose is 1.0-1.5 mg/kg every other day or 0.5-0.75 mg/kg every day.
The dose shall be reduced after 4 weeks by 0.25 mg/kg (qd alt) or 0.125 mg/kg (every day) every
2-4 weeks. If the condition is stable, continue to reduce to 5mg (body surface area > 1 m2) and
2.5mg (body surface area < 1 m2) qd alt. Maintain at such doses until this research is completed.
5.2.2
Treatment of relapses
If the disease is complicated with infection in the relapse for the pediatric patients, anti-infection
treatment can be given first. After infection control, if the disease still shows relapse, the
prednisone dose shall be restored to 1.0-1.5 mg/kg per day, with a maximum dose ≤60mg; If there
is no infection at the time of relapse in the pediatric patients, the prednisone dose should be
restored to 1.0-1.5 mg/kg per day directly, with a maximum dose ≤60mg. 5-7 days after the urine
protein turns into negative results, the prednisone dose is reduced by 1.0-1.5 mg/kg every other
day or 0.5-0.75mg/kg per day × 4 weeks. Then the dose is reduced as per the above steroid
reduction method, while the dose of MMF or FK506 remains unchanged.
5.2.3
Dose adjustment of tacrolimus (FK506)
5.2.3.1 Adjust the dose according to the trough plasma concentration of tacrolimus. If the trough
plasma concentration cannot meet the target concentration, it can be increased by adding
Wuzhi capsules, ketoconazole, Hexin Shuang or cimetidine. If the trough plasma
concentration of tacrolimus is >10 ng/mL, the dose of tacrolimus shall be reduced, and
the trough concentration shall be rechecked after one week to adjust the target
concentration. After treatment, the increase of SCr ≥30% of the basic value and eGFR <
60mL/min.1.73m2 (excluding non-drug factors) shall prompt tacrolimus dose reduction
by 50%. If the concentration still fails to reach the target after tacrolimus dose adjustment
for one month, the subject shall withdraw from the trial.
5.2.3.2 If the trough plasma concentration of tacrolimus in visit 7 is ≥5 ng/mL, the dose of
tacrolimus needs to be reduced by 20%-30%, and the trough concentration shall be
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it is necessary to continue to reduce the dose of tacrolimus by 20%-30%, and recheck this
concentration in visit 9.
5.2.4
Dose adjustment of mycophenolate mofetil (MMF)
5.2.4.1 Adjust the dose according to the plasma concentration of mycophenolic acid. If
MPA-AUC fails to meet the target, increase the oral dose of mycophenolate mofetil, but
the maximum dose shall not exceed 1.0g each time, BID. Recheck MPA-AUC after 1
week and adjust the drug administration to meet the target concentration. If the patient
has blood neutrophils less than 1300 per μL or total leukocytes less than 3000 per μL,
diarrhea or severe infection, the dose of mycophenolate mofetil needs to be reduced by
25%. If the side effect persists, it shall be adjusted to half of the original dose. If the case
of mycophenolate mofetil dose adjustment, the plasma concentration shall be measured
according to the judgment of the investigators. If the concentration still fails to reach the
target after mycophenolate mofetil dose adjustment for one month, the subject shall
withdraw from the trial.
5.2.4.2 If MPA-AUC is ≥40 ng/mL in visit 6, the dose of mycophenolate mofetil needs to be
reduced by 20%-30%. After that, retest is no longer required.
5.3 concomitant medication

Statins are allowed for use during this research, which can be increased or decreased
according to the blood lipid status.

Various anticoagulant drugs are allowed for use during this research.

Immunosuppressants other than the test drug are prohibited for use.

Plasma exchange and biological agents are prohibited for treatment.

IVIG can be used during this research, but the reason needs to be recorded.

When hypertension occurs during treatment, angiotensin converting enzyme inhibitor (ACEi)
or angiotensin II receptor blocker (ARB) cannot be used, but dihydropyridine calcium
antagonists, β- receptor blocker, diuretic and/or α-receptor blocker can be used for control,
with a target blood pressure of: <120/80 mmHg.

Liver protection drugs are allowed for use during this research.

If blood glucose rises during treatment, the blood glucose shall be actively controlled with
hypoglycemic drugs.

Various Chinese herbal medicines are prohibited for the treatment of kidney diseases during
this research.

The investigators shall ask the subjects to bring all the drugs they are taking at the time of
follow-up, so as to check the concomitant medication for the subjects. For the other drugs
or treatments that must be continued for the complicated diseases, the drug name (or

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other treatment name), dosage, times of use and time must be recorded on the Clinical
Study Report for analysis and reporting during summary.
5.4 Management of test drugs
5.4.1
Distribution and storage of test drugs
The distribution and management of test drugs shall be carried out according to the steps
described in the Protocol. According to the requirements of registration regulations, only the
subjects enrolled in the trial can get the test drugs; and only authorized personnel (drug
administrators) in each research center can provide and keep the test drugs. All test drugs shall be
stored in a safe place, and only a few personnel related to the test are allowed to get in and out for
the drugs. The authorized test personnel shall ensure that the amount of the test drugs is consistent
with that on the test drug requisition.
All the test drugs shall be locked and stored in a safe, dark and dry place before distribution. The
storage temperature shall be below 25°C and 30°C respectively for tacrolimus and mycophenolate
mofetil. Each research center shall have a registration form for drug reception and drug
distribution, which shall always be kept by a person (drug administrator) designated by the
research center. The drug administrator shall ensure that the drugs are intact when they are
distributed to the subjects, and the remaining period of validity shall be at least 3 months.
5.4.2
Count of test drugs
The drug administrator has the responsibility to ensure that the quantity of drugs is consistent with
the registered quantity, and has the responsibility to keep the drug registration records. According
to the requirements of registration laws and regulations, the drug administrator shall keep the drug
inventory and verification records throughout the research process, including the records of the
quantity of test drugs received from Hangzhou Zhongmeihuadong Pharmaceutical Co., Ltd., the
quantity of test drugs stored and/or distributed, and the quantity of drugs returned by the subjects
to the research center.
When the test drugs arrive at each research center, the drug administrator shall sign on the drug
reception form to confirm the receipt of test drugs for trial use. The form includes but is not
limited to: drug name, batch number, quantity, receiving date and drug inspection report.
The drug administrator shall record all the distributions on the distribution checklist. At the end of
this research, the quantity of the test drugs on the checklist shall be consistent with the quantity
sent by the Sponsor, the quantity of drugs kept in the center, the quantity sent to the subjects and
the quantity returned. At the same time, a reasonable explanation shall be given for any
discrepancy. During this research, the drugs shall be recycled in stages, and after this research, all
empty boxes for used drugs and unopened drugs shall be returned to the Sponsor, with signatures
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Sponsor. The destruction of drugs is carried out by authorized special personnel who shall have a
certain sense of prevention against the possible dangers in drug destruction. At the same time, they
shall not begin such operation without written authorization from the Sponsor. The whole process
of destroying drugs will be completely recorded and archived.
5.4.3
Packages and labels of test drugs
The test drugs are packaged by Hangzhou Zhongmeihuadong Pharmaceutical Co., Ltd. according
to the relevant laws and regulations, and the labels of the test drugs comply with the requirements
of relevant laws and regulations.
5.5 Medication adherence
Distribute the tacrolimus capsules or mycophenolate mofetil dispersible tablets according to the
Dosage and Administration specified in the Protocol. The quantity of drugs distributed before
administration, the quantity of drugs used and the quantity returned by each subject shall be
recorded in detail. Including the following content:
A: Name, date and quantity of drugs distributed to subjects
B: Name, date and quantity of drugs returned by subjects
The clinical research associate shall check the inventory drugs, returned drugs and drug
distribution records of the research center on a regular basis. At the end of this research, the
remaining drugs, returned drugs and their packages shall be counted and recovered.
The medication adherence is calculated as follows, and shall be ranging from 80% to 120%:
adherence =
actual administration
×100%
planned administration
At each follow-up, the investigators shall emphasize the importance of medication adherence to
the subjects.
6. Test process and steps
The selected patients are randomly divided into two groups. Patients in FK506 Group receive
tacrolimus capsules and steroids for one year; and patients in MMF Group receive mycophenolate
mofetil dispersible tablets and steroids for one year. Both groups follow the "clinical trial flow
chart" in operation.
7. Evaluation of efficacy and safety
7.1 Primary efficacy outcomes
1-year relapse-free survival

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7.2 Efficacy evaluation
7.2.1
Primary observation outcomes: 1-year relapse-free survival
7.2.2
Secondary observation outcomes:
(1)
Frequency of relapses; the time of the first relapse after enrollment; relapse-free survival in
the first six months after enrollment;
(2)
Renal function: Serum creatinine and glomerular filtration rate (eGFR, see Appendix 1 for
the calculation method)
(3)
Cumulative steroid dosage: The total amount of steroids taken during this research and the
total amount of steroids in the first half of the year
(4)
Others: Blood pressure (see Appendix 2 for details), height, weight, blood lipid, hemoglobin,
blood albumin, urinary protein/creatinine (morning urine), etc.
(5)
Adverse reaction
(6)
24hr urinary protein quantification (applicable to subjects > 3 years old)
7.2.3
Efficacy criteria

Complete remission (CR): Completely normal in blood biochemistry test and urine
examination;

Partial remission (PR): Urinary protein positive < (+++);

No remission (NR): Urinary protein positive ≥(+++).
7.2.4
Relapse criteria
For 3 consecutive days, morning urinary protein changes from negative to (+++) or (++++), or
24hr urinary protein quantification ≥50 mg/kg, or urinary protein/creatinine (mg/mg) ≥2.0.
7.3 Safety evaluation
Changes of vital signs: Respiration and heart rate.
Various indexes in laboratory examination: Blood and urine routine examination, liver function,
renal function, ECG, chest X-ray examination.
Clinically reported adverse events and adverse reactions.
8. Reporting adverse events
8.1 Definition of adverse events
Adverse event (AE) refers to the adverse medical conditions or deterioration of the original
medical condition after or during drug treatment, regardless of whether there is a causal
relationship with the drug. Adverse medical conditions can be symptoms (such as nausea, and
chest pain), signs (such as tachycardia, and hepatomegaly), or abnormal examination results (such

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as laboratory examination, and ECG). In clinical researches, AE can occur at any time, including
the adverse medical conditions in the screening period, even if no study treatment is received.
The term AE includes severe ones and non-severe ones.
8.1.1
Concerned averse reactions of test drug FK506:
Adverse reactions associated with immunosuppressive drugs are often difficult to be determined
due to the underlying diseases of patients and combined use of multiple drugs at the same time.
The following adverse reactions are reversible, or can be reduced or eliminated after dose
reduction. Compared with intravenous administration, oral administration has a lower incidence of
adverse reactions.
Cardiac abnormalities
Common: Ischemic coronary artery disease, and tachycardia; Unusual: Ventricular arrhythmia and
cardiac arrest, heart failure, cardiomyopathy, ventricular hypertrophy, supraventricular arrhythmia,
palpitation, abnormal ECG, abnormal heart rate and pulse; Rare: Pericardial effusion; Very rare:
Abnormal echocardiography.
Blood and lymphatic system abnormalities
Common: Anemia, leucopenia, thrombocytopenia, leucocytosis and abnormal erythrocyte analysis;
Unusual: Abnormal coagulation function, pancytopenia, and neutropenia; Rare: Thrombotic
thrombocytopenic purpura, and low prothrombin; Unknown: Pure red cell aplasia, agranulocytosis,
and hemolytic anemia.
Neurologic abnormalities
Very common: Tremor, and headache; Common: Epilepsy, disturbance of consciousness,
paresthesia and dullness, peripheral neuropathy, vertigo, dysgraphia and nervous system disorders;
Unusual: Coma, central nervous system hemorrhage and cerebrovascular accident, paralysis and
local anesthesia, encephalopathy, abnormal language function and cognitive impairment; Rare:
Hypertonia; Very rare: Myasthenia.
Eye and ear abnormalities
Common: Blurred vision, photophobia, and eye discomfort; Unusual: Cataract; Rare: blindness,
abnormal ear and labyrinth; Common: Tinnitus; Unusual: Hearing retardation; Rare: Neurogenic
deafness; Very rare: Hearing loss.
Respiratory, chest and mediastinum abnormalities
Common: Dyspnea, abnormal lung parenchyma, pleural effusion, pharyngitis, cough, nasal
congestion and inflammation; Unusual: Respiratory failure, respiratory diseases, and asthma; Rare:
Acute respiratory distress syndrome; Unknown: Interstitial lung disease, and pulmonary
embolism.
Gastrointestinal abnormalities

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Very common: Diarrhea, and nausea; Common: Gastrointestinal inflammation, gastrointestinal
ulcer and perforation, gastrointestinal bleeding, stomatitis and ulcer, ascites, vomiting, abdominal
pain, dyspepsia, constipation, abdominal distention, loose stools and other gastrointestinal
symptoms and signs; Unusual: Paralytic intestinal obstruction, peritonitis, acute and chronic
pancreatitis, elevated blood amylase, gastroesophageal reflux and abnormal gastric emptying;
Rare: Intestinal obstruction, and pancreatic pseudocyst.
Renal and urinary abnormalities
Very common: Kidney injury; Common: Renal failure, oliguria, tubular necrosis, toxic
nephropathy, and bladder and urethral symptoms; Unusual: Anuria, and hemolytic uremic
syndrome; Very rare: Kidney disease, and hemorrhagic cystitis; Unknown: Membranous
glomerulonephritis, hydronephrosis, nephromegaly, and nephrotic syndrome.
Skin and subcutaneous tissue abnormalities
Very common: Pruritus, rash, hair loss, acne, and hyperhidrosis; Unusual: Dermatitis, and
photosensitivity; Rare: Toxic epidermal necrolysis (Lyell's syndrome); Very rare: Stevens-Johnson
syndrome; Unknown: Melanoderma.
Skeletal muscle and connective tissue abnormalities
Common: Joint pain, muscle spasm, limb pain, and back pain; Unusual: Joint disorder; Unknown:
Bone defect, kyphosis, patellar pain syndrome, and rhabdomyolysis.
Endocrine abnormalities
Rare: Hirsutism; Unknown: Diabetes ketoacidosis.
Metabolic and nutritional abnormalities, and other electrolyte abnormalities
Very common: Hyperglycemia, diabetes, and hyperkalemia; Common: Hypomagnesemia,
hypophosphatemia, hypokalemia, hypocalcemia, hyponatremia, fluid retention, hyperuricemia,
decreased appetite, anorexia, metabolic acidosis, hyperlipidemia, hypercholesterolemia, and
hypertriglyceridemia. Other electrolyte abnormalities: Unusual: Dehydration, hypoproteinemia,
hyperphosphatemia and hypoglycemia.
Infection and invasion
Like other potent immunosuppressants, tacrolimus administration shows an increased risk of
infection (viruses, bacteria, fungi and protozoa). Existing infections may be aggravated, and the
systemic and local infections may occur. Patients treated with immunosuppressants, including
tacrolimus, have been reported to have BK virus-related nephropathy and JC virus-related
progressive multifocal leukoencephalopathy (PML).
Injury, intoxication and operation complications
Benign, malignant and unclear tumors (including cysts and polyps). Patients treated with
immunosuppressants have an increased risk of malignant tumors. Benign and malignant tumors,

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including EBV-related lymphoid hyperplasia and skin malignancies, have been reported to have
possible association with the tacrolimus treatment.
Vascular abnormalities
Very common: Hypertension; Common: Bleeding, thrombus and local ischemia, peripheral
vascular abnormalities, and hypotension; Unusual: infarction, limb deep vein thrombosis, and
shock.
General abnormalities and administration site symptoms
Common: Weakness, fever, edema, pain and discomfort, elevated blood alkaline phosphatase,
weight gain, and body temperature sensation disorder; Unusual: Multiple-organ failure, influenza
like symptoms, temperature intolerance, chest compression, tension, paresthesia, elevated blood
lactate dehydrogenase and weight loss; Rare: Thirst, fall, reduced activity, and ulcer; Very rare:
Increased adipose tissue; Unknown: Death or sudden cardiac death, and abnormal gait.
Immune system abnormalities and hepatobiliary abnormalities
Allergic and anaphylactic reactions are observed in patients treated with tacrolimus.
Common: Abnormal liver function, cholestasis and jaundice, hepatocyte injury, hepatitis and
cholangitis; Rare: Hepatic artery thrombosis, and venous occlusive liver disease; Very rare: Liver
failure, and biliary stricture;
Reproductive system and breast abnormalities
Unususal: Dysmenorrhea and uterine bleeding; Unknown: Benign prostatic hyperplasia, and
mental disorders; Very common: Insomnia; Common: Anxiety, confusion and disorientation,
despondency, depression, emotional instability and disorder, nightmares, hallucinations and
mental disorders; Unusual: Mental abnormality; Unknown: Aggressive behavior, and agitation.
8.1.2
Concecrned adverse reactions of test drug MMF:
Infection
It refers to the local tissue inflammatory reaction and systemic inflammatory reaction caused by
bacteria, viruses, fungi, parasites and other pathogens invading the human body. Serious
life-threatening infections, such as meningitis and infective endocarditis, are occasionally reported,
and some evidences show that certain types of infections, such as conjugated and atypical waste
bacilli infections, lay have a high incidence
Gastrointestinal adverse reactions
Gastrointestinal
adverse
reactions include nausea, vomiting,
dyspepsia,
abdominal
pain,
constipation,
upper
and
lower
gastrointestinal
discomfort,
gastrointestinal
inflammation,
gastroduodenal ulcer, gastrointestinal bleeding and perforation, etc. Colitis (sometimes caused by
cytomegalovirus), pancreatitis, and individual cases of intestinal villus atrophy.
Blood system and immune system

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In patients treated with this product in combination with other immunosuppressants, pure red cell
aplasia (PRCA) and hypogammaglobulinemia have been reported.
Congenital diseases
Congenital malformations, including ear, face, heart and nervous system abnormalities, have been
reported in the children of mothers treated with this product and other immunosuppressants during
pregnancy. There are also reports of spontaneous abortion in early pregnancy.
Pregnancy, puerperium and perinatal periods
Spontaneous abortion has been reported in patients (mainly in early pregnancy) exposed to
mycophenolate mofetil.
Malignant tumors
Patients taking this product as part of immunosuppression for immunosuppressive regimen,
including the patients with combined use of drugs, have an increased risk of lymphoma and
malignant tumors, especially skin tumors. In a controlled clinical trial for patients with a
follow-up of at least 1 year after kidney, heart and liver transplantation, lymphoproliferative
disease or lymphoma develop in 0.4% to 1% of the patients treated with this product (2g or 3g
daily) in combination with other immunosuppressants. Non-melanoma skin cancer develops in
1.6% to 3.2% of the patients; 0.7% to 2.1% of patients have other types of malignant tumors. In
the 3-year safety data of kidney and heart transplantation patients, the incidence rate of malignant
tumors shows no unexpected difference with that in the 1-year data. All the patients with liver
transplantation are followed up for more than 1 year and less than 3 years. In the controlled trial of
refractory renal transplantation, the incidence of lymphoma is 3.9% with an average follow-up of
42 months.
Children (aged 3 months to 18 years)
In a clinical study of 100 pediatric patients aged 3 months to 18 years, the type and frequency of
adverse reactions after oral administration of 600 mg/m2 mycophenolate mofetil (BID) are
generally similar to those observed in adult patients with daily administration of 1g
mycophenolate mofetil (BID). However, as compared with the adult patients, the following
treatment-related adverse events with a frequency of 10% are more common in the pediatric
population, especially in children under the age of 6 years, including diarrhea, leukopenia, sepsis,
infection and anemia.
Elderly patients (≥65 years old)
As compared with young people, the elderly, especially the elderly patients receiving this product
as part of the combined immunosuppressive regimen, have an increased risk of some infections
(including cytomegalovirus tissue invasion disease), possible gastrointestinal bleeding and
pulmonary edema.
Toxicity criteria

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Based on the revised standard of the World Health Organization (WHO) on the grading of acute
and subacute toxicity of drugs.
8.2 Definition of serious adverse event
Serious adverse event (SAE) refers to the AE occurring at any stage of this research (i.e. screening
period, follow-up period) and complying with one or more of the following criteria:

Causing death

Immediate life-threatening

Requiring hospitalization or extension of the original length of stay

Causing sustained or significant deformity/disability, or seriously impairing the ability to
complete normal life functions

Congenital malformation or defect at birth

An important medical event that may cause harm to the patient or may require medical
intervention to prevent one of the above outcomes
8.3 Records of adverse events
The information of AEs to be collected in this research includes the following aspects:

Endpoint event

Adverse events related to the test drugs (according to the judgment of the investigators)

Serious adverse event
Cycle of adverse event collection
The collection of AEs and adverse drug reactions (DAEs) of concern will be carried out
throughout this research, from randomization to site close-out visit (SCV, included).
SAE records will be carried out throughout this research, from the time of signing the Informed
Consent Form to SCV (included).
Follow-up of unresolved adverse events
If any AE, DAE and SAE of concern remain unresolved at the patient's last study visit, the
investigators shall follow up these events in accordance with the medical instructions as required
for medical needs in this research, but it is not necessary to record further in the electronic case
report form (eCRF). If deemed necessary, the Sponsor reserves the right to obtain the additional
information on unresolved AE/SAE of concern.
Variables
For each non-serious AE and DAE of concern, the following variables will be collected:

AE (verbatim record);

AE start and end dates;

Maximum intensity;

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
Whether the AE is serious;

The investigators’ assessment of the causal relationship with the test drug (yes or no);

Measures and outcomes taken for the test drug
In addition, the following variables will be collected for SAE:

Date when AE meets SAE criteria;

Date when the investigators find SAE;

Reasons for classifying AE as SAE;

Date of admission:

Date of discharge:

Possible causes of death

Date of death:

Autopsy performed (if any);

Autopsy results

AE description

Assessment of causality with this research procedure;

Assessment of causality with the other drugs
It is important to distinguish serious AE from severe AE. Severity is the index of intensity
evaluation, while seriousness is defined according to the criteria in Section 8.2. AE with severe
intensity is not necessarily serious. For example, nausea for several hours may be considered as
severe nausea, but not SAE. On the other hand, a stroke that results in only a limited degree of
disability may be considered as a mild stroke, but should be considered as SAE.
The definition of intensity classification is as follows:
1.
Mild (signs or symptoms are felt but easily tolerated)
2.
Moderate (the degree of discomfort is enough to interfere with normal activities)
3.
Severe (resulting in disability and inability to perform normal activities)
Collection of causalities
The investigators will assess the causalities between the test drugs and each case of AE, and
answer the following questions with "Absolutely related, Probably related, Possibly related,
Possibly unrelated, and Unrelated".
"Do you think there is a reasonable possibility that the event is caused by the test drug?"
For SAE, the causalities between the event and other drugs and research procedures also need to
be evaluated. Note: for SAE related to any research procedure, causality should be "possibly
related".
Adverse events based on signs and symptoms
All concerned AEs (see sections 8.1.1 and 8.1.2), including those spontaneously reported by the
patients, those reported in response to the open-ended question by the investigators, "Have you

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had any health problems since the last visit/inquiry?", or those found through observation will be
all collected and recorded in eCRF. In the collection of AE information, the list of signs and
symptoms shall be preferred as the record of diagnosis (if possible). However, if the diagnosis is
known and there are other signs or symptoms not usually present in the diagnosis, the diagnosis
and each other sign or symptom shall be recorded separately.
Adverse events based on examination and inspection
During this research, the laboratory safety assessment will not be carried out routinely (except at
baseline), but can be carried out at the discretion of the investigators. When an AE, DAE, SAE or
potential endpoint of concern is involved, different assessments may be required, including local
laboratory assessment, and appropriate collection is needed before entry into eCRF.
The examination results of vital signs mandated by the Protocol shall be summarized in the
clinical study report (CSR). Therefore, when the laboratory test values and protocol-mandated
vital signs evaluation by the investigators show that the results are worse than the baseline level
and meet the AE criteria or when they act as are the reasons for discontinuing the test drug
treatment, such situations will be reported as AE.
If the deterioration of laboratory test values/vital signs is related to clinical signs and symptoms,
the signs and symptoms will be reported as AE and relevant laboratory results/vital signs will be
used as supplementary information. Investigators shall use clinical terms rather than laboratory
terms (e.g. renal failure rather than elevated creatinine) as much as possible in the report. If no
clinical signs or symptoms are present, the clinically relevant deterioration of non-mandatory
parameters shall be reported as AE and SAE.
8.4 Report of serious adverse events
All SAEs must be reported, regardless of whether they are considered to have causalities with the
test drugs or study procedure. All SAEs will be recorded in eCRF.
In case of any SAE during this research, the investigators or other staff of the center shall notify
the relevant Sponsor representative immediately or no later than 24 hours after learning of the
event.
The designated Sponsor representative shall work with the investigators to ensure that all
necessary information is provided to the Sponsor's patient safety data entry center within 1
working day after the first receipt of fatal and life-threatening events and 5 working days after the
first receipt of all other SAEs.
For fatal and life-threatening AEs, if important or relevant information is missing, immediate
active follow-up is required. The investigators or other staff of the center shall notify the Sponsor
representative of any follow-up information about the previously reported SAE immediately or no
later than 24 hours after receiving the information.

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If the Web-based data collection (WBDC) system is not available, the investigators or other staff
of the center shall report SAE to the appropriate Sponsor representative by telephone, noting that
the same reporting window (24 hours) is still applicable.
If initial or subsequent reporting is made through the means other than WBDC system, the
investigators must finalize any SAE information into the eCRF through WBDC system as soon as
this system is enabled again.
9. Quality control and assurance of the trial
9.1 Quality control measures in laboratory
9.1.1
Quality control before analysis

Each center appoints a technician from the Clinical Laboratory Department to be responsible
for the laboratory inspection related matters for this project. The appointed technician shall
test the samples in time according to the requirements, and strictly abide by the rules of
keeping and taking the samples on time.

Project training shall be completed before trial initiation.
9.1.2
Quality assurance during analysis

In the middle of the project (progress of about 50%), a comparison test of the laboratory
observation indicators is conducted (5 samples for each project, and see Appendix 3 for the
comparison criteria).
9.1.3
Quality assurance after analysis

Each center can keep the test results for a long time;

According to the requirements of this project, the remaining blood and urine samples (serum
for blood samples, and the residual samples of 24h urine protein quantitation for the urine
samples) shall be stored in the refrigerator of -80℃, and the preserved samples shall be
transported regularly (within 3 months) to the Children's Hospital, Zhejiang University
School of Medicine for centralized testing.

Before the end of the project (progress of about 90%), another comparison test of the
laboratory observation indicators is conducted (5 samples for each project, and see
Appendix 3 for the comparison criteria).
9.2 Quality control and assurance in the trial process
(1)
All hospitals participating in the clinical trial shall adopt standard operating procedures to
ensure the implementation of quality control and quality assurance systems for the clinical
trial.

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(2)
In order to ensure the quality of the multicenter trial, the principals of the participating
hospitals shall discuss and prepare the clinical study plan together before the formal trial
starts. The relevant medical personnel participating in the trial are trained in GCP at the
same time.
(3)
The hospitals participating in the trial shall, in accordance with the uniform clinical research
protocol, start and end the trial at the same time as possible.
(4)
All hospitals participating in the trial are required to manage the test drugs with the same
procedures, including drug receiving, storage, distribution and recycling.
(5)
All observed results and abnormal findings in the clinical trial shall be carefully verified and
recorded in time to ensure the reliability of the data. All instruments, equipment, reagents
and reference materials used in various test items in the clinical trial shall have strict quality
standards and ensure that they work under normal conditions. The recording and transfer of
clinical data must be in the charge of experienced physicians and supervised or checked by
special personnel to ensure the scientificity and accuracy of the data. Various conclusions of
the clinical trial must be derived from the original data. All the original data and CRF shall
be kept for 5 years.
(6)
The physicians in charge of the trial shall fill in the case report form (CRF) in a complete,
detail and accurate manner. After each subject completes the trial, all data related to the trial
shall be centrally managed and analyzed before submission to the superior physician for
signature, and then submitted or kept according to the specified procedures.
(7)
Procedures shall be established for data keeping, data transmission and data query. The data
to be kept include: medical records, imaging data, CRF, drug use registration form, subject
code form, serious adverse event report form, GCP form to be filled by each hospital,
follow-up report form and various original medical documents of the subjects. The data to
be transmitted include: total randomization form of subjects, CRF, serious adverse event
report form, as well as data and materials to be used for summarization. The drug regulatory
authorities, the Sponsor and its entrusted supervisors, and the relevant leaders of the
hospitals have the right to consult the relevant test data and original records of each hospital
with the consent of the professor in charge of the trial. Finally in the sorting of all the test
reports, the team leader’s unit and the person in overall charge can consult or access the
data and original records of all subjects with consent.
(8)
In the summarization and analysis of the clinical trial results, standardized statistical analysis
methods must be adopted, and personnel familiar with biostatistics should be invited for
participation.
(9)
In order to ensure the reliability and integrity of the test data, the person in overall charge of
the team leader’s unit, the Sponsor and its CRO supervisor shall regularly conduct

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systematic supervision on the clinical hospitals, to determine whether the implementation of
the trial is consistent with the Protocol and whether the reported data is consistent with the
records of the clinically participating units. A visit report shall be written for each
supervision and visit.
(10) In order to better supervise and inspect the trial, the research and development unit and the
leading unit of this clinical trial shall carry out irregular inspection on each clinical trial
hospital. It aims to determine whether the implementation of the trial, data recording and
analysis are consistent with the requirements specified in the Protocol, drug clinical trial
management specifications and regulations. An report shall be written after the audit.
(11) The test drug keeper must carefully keep the test drugs according to the drug storage
conditions proposed by the Sponsor.
(12) The responsible unit shall organize experts to train the investigators on the Protocol before
the clinical trial, and conduct the consistency test of all quantitative standards.
(13) During the clinical trial, the supervisor of CRO company signed with the Sponsor will
regularly visit the research centers to ensure that all content of the Protocol is strictly
observed, and check the original data to ensure that the information filled in CRF is true,
complete and correct.
9.3 Measures to improve subject compliance
To ensure that the enrolled patients can positively complete the trial, importance must be attached
to the measures of subject compliance.
(1)
For each enrolled patient, it is necessary to clarify the possible benefits and risks of the test
drugs to them.
(2)
The Informed Consent Form must be signed by each enrolled patient or his/her legal
representative and guardian.
(3)
Each enrolled patient must be required to use the test drug or control drug in a sufficient
amount and an effective way each time.
(4)
If it is found that any subject refuses to use drugs (including the control drug) in study, the
ideological work shall be actively done for the subject and the guardian. In addition, it must
be immediately reported to the competent physician for treatment.
9.4 Quality control and quality assurance systems
The investigator shall perform their respective responsibilities, strictly follow the clinical trial
protocol and adopt standard operating procedures to ensure the implementation of quality control
and quality assurance systems for the clinical trial.

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The investigators shall follow the principles of GCP in the whole process of this research, and
shall record all the content in CRF in a truthful, detailed and careful manner. All the observations
and findings in the clinical trial shall be verified to ensure the reliability of the data. All laboratory
tests shall strictly follow the standard operation procedures (SOP) to ensure that all provisions in
the Protocol are strictly followed and the research data are filled in correctly.
10.Data management
10.1 Data management system
The electronic data management system - clinical research integration platform is adopted in this
research to collect data and deal with relevant questions. The investigators shall ensure that the
data are recorded in the electronic case report form (eCRF) in a timely manner in accordance with
the provisions of the Protocol and the instructions provided. The research staff will receive
training and be responsible for inputting the data specified in the Protocol into the electronic data
management system according to the eCRF instructions.
10.2 Data record
In accordance with the guidelines for completing the case report form, the investigators shall
ensure the accuracy, completeness and timeliness of the recorded data, and ensure the response to
data queries. The investigators shall verify the data that are significantly higher than or beyond the
range of clinical acceptance, and make necessary explanations.
In modifying the data during filling in, the investigators shall indicate the reason for modification
in the popped-up eCRF dialog box. Any modification by investigators will leave traces to ensure
the authenticity of the data. For the questions in the CRF, the data administrator will generate a
data query form and send a query to the investigators through the electronic data management
system. The investigators shall give and return the answer as soon as possible.
10.3 Data supervision
The clinical supervisor shall regularly review the CRF and timely feed back the problems found to
the person in charge of this research, until signature for confirmation upon compliance with the
requirements.
11.Statistical analysis
11.1
Analysis data set

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Full analysis set (FAS): It refers to the set of eligible cases and drop-off cases. The cases are
required to have evaluation data after at least one treatment, but excluding the eliminated cases.
Per-protocol set (PPS): It refers to the set of cases that meet the inclusion criteria, do not meet the
exclusion criteria and complete the treatment plan, that is, the analysis of cases that meet the trial
protocol, have good compliance and complete the specified content in CRF (PP analysis).
Safety set (SS): It refers to the actual data with safety index records after receipt of at least one
treatment. The missed safety values shall not be carried forward. It includes some eliminated cases
that can be evaluated, such as those whose age exceeds the inclusion criteria, but excludes those
whose safety judgment cannot be made due to the use of banned drugs. For the incidence of
adverse reactions, the number of cases in the safety set is used as the denominator.
11.2
Statistical method
11.2.1 General statistical methods
Two-sided test is adopted for all statistical tests. If the P value is less than 0.05, the tested
difference will be considered “statistically significant” (unless otherwise specified).
Descriptive analysis: Sort out and summarize a large number of data obtained from the survey to
find out the internal law of these data - centralized trend and decentralized trend. Single factor
analysis is mainly carried out with the help of statistics represented by various data, such as mean
and percentage.
11.2.2 Statistical inference method

The description of quantitative indicators includes the calculation of the mean, standard
deviation, median, minimum value, maximum value, lower quartile (Q1), upper quartile (Q3),
as well as the number and percentage of various types of classification indicators.

In the comparison of the general conditions between the two groups, appropriate methods
shall be adopted for analysis according to the type of indicators. The group t-test or Wilcoxon
rank sum test is used for the comparison of quantitative data between two groups; Chi-square
test or exact probability method is used for classification data; Wilcoxon rank sum test or
CMH test is used for hierarchical data.

The report is mainly expressed in tables: The tables are self-evident, that is, they have table
titles, table notes and number of cases.
11.2.3 Statistical software
SAS 9.4 software is adopted for statistical analysis.
11.3
Content of statistical analysis
11.3.1 Basic value equilibrium analysis

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The demographic characteristics, general conditions and baseline conditions (basic value
indicators) of the two groups are analyzed to measure the comparability of the two groups. Group
t-test or Wilcoxon rank sum test is used for measurement data; Wilcoxon rank sum test is used for
classification or grade data; χ2 test or Fisher test is used for classification data.
11.3.2 Effectiveness analysis
All effectiveness analysis/global indicators will be based on ITT principles, and FAS is adopted,
for only the adjudicated endpoint events. The investigators are required to report all the potential
endpoint events in eCRF.
11.3.3 Primary efficacy analysis
Logrank test is used for the analysis of relapse-free survival rate which is then used as a covariate
for stratification by centers. HR and its 95% confidence interval (CI) are calculated with Cox
proportional hazard model to estimate the efficacy, the confidence interval is applied to verify the
superiority of the experimental group and the control group, with a cut-off value of 1 (risk ratio).
The model incorporates the same covariate as the Logrank test for fitting, and the definition
method of covariates is also the same as that in the Logrank test. The Kaplan-Meier curve of
relapse-free survival is drawn by treatment groups. The 1-year relapse-free survival rate and its
confidence interval are then calculated.
11.3.4 Secondary efficacy analysis
Secondary outcomes (renal function; cumulative steroid dosage; blood pressure; height; body
weight; blood lipids; hemoglobin; serum albumin; urinary protein/creatinine (morning urine); 24hr
urinary protein quantification (applicable to subjects > 3 years old); frequency of relapses; the
time of the first relapse after enrollment; relapse-free rate in the first six months after enrollment)
are described and compared with use of the above general statistical methods, and the adverse
reactions are analyzed by descriptive analysis.
11.3.5 Other efficacy analysis
(1)
Case distribution: Different data sets in each group, case distribution in each center,
comparison of total drop-off rate, detailed list of termination reasons, and descriptive
analysis.
(2)
Compliance analysis: Compare whether the two groups of patients take the test drugs on time
and in quantity, whether they take the drugs and foods prohibited in the Protocol, and
conduct the same descriptive analysis as well as χ2 test or Fisher test for analysis.

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(3)
The incidence of drug withdrawal or drug change due to adverse reactions in the clinical trial
shall be analyzed with χ2 test or Fisher test. The efficacy in the long-term follow-up after
the trial is evaluated by descriptive analysis and χ2 test or Fisher test.
11.3.6 Safety analysis
Safety analysis mainly adopts safety set. All adverse events are coded by MedDRA 20.0 to
describe the total number and incidence of adverse events (including serious adverse events), and
the frequency table is used to describe the frequency, severity of each adverse event and its
relationship with the treatment. Adverse events relevant (related, probably related, and possibly
relayed) to this research treatment are described and listed separately. Other safety indicators will
also be described and summarized. The laboratory changes with clinical significance will be
counted as AE.
12.Ethical principles
12.1 Ethical review
The clinical trial protocol shall be submitted to the Ethics Committee for approval before
implementation. If this Protocol is to be revised during the clinical trial implementation, it shall be
submitted to the Ethics Committee for approval again before implementation. If important but
new information concerning the test drugs is found, the Informed Consent Form must be revised
in writing and submitted to the Ethics Committee for approval before signing by the subjects
again.
12.2 Benefits and risks
This test drug in this research is already on the market, and no serious adverse reactions have been
reported in clinical application. In case of possible side effects, the investigators shall take the
corresponding medical countermeasures according to the specific conditions of the patients and
shall have the right to suspend the clinical trial based on their own judgment.
The research could expand the application scope of the marketed drug which may be used for the
other patients with similar conditions. Subjects will receive good medical care during this
research.
12.3 Informed consent process
The investigators must explain to the subjects about the details of the clinical trial, including its
purpose, procedure, possible benefits and risks, the rights and obligations of the subjects, etc., so
that the subjects can fully understand it and have plenty of time for consideration. The clinical trial

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can be started after the subjects get satisfactory answers to the questions raised, and sign the
Informed Consent Form upon agreement. Whenever a patient signs the Informed Consent Form,
the physician shall leave his/her contact number to the patient so that the patient can find him/her
at any time if any condition change occurs. Informed Consent Form shall be submitted to the
Ethics Committee for review.
12.4 Medical treatment and protection of subjects
The investigators are responsible for the medical treatment of the subjects, making medical
decisions related to the clinical trial, and ensuring that the subjects could receive appropriate
treatment in case of adverse events during the trial.
12.5 Protection of subject privacy
Only the investigators and supervisors involved in the clinical trial may have access to the
personal medical records of the subjects. During data processing, the method of "data anonymity"
is adopted, and the information that can identify the individual identity of the subjects will be
omitted.
13.Ethical requirements
The clinical trial must be conducted in accordance with the Declaration of Helsinki and the
relevant clinical trial research norms and regulations in China. The clinical trial can be
implemented after the Protocol is approved by the Ethics Committee of the unit in charge of the
clinical research.
Before each patient is enrolled in this research, the research physician has the responsibility to
completely and comprehensively introduce the purpose, procedure and possible risks of this
research to the patient or his/her designated representative in a written form, and let the patients
know that they have the right to withdraw from this research at any time. Before enrollment, each
patient or his family members must be given a written Informed Consent Form. The research
physician has the responsibility to obtain the Informed Consent before each patient is included in
this research. The Informed Consent Form shall be kept as a clinical trial document for future
reference.
14.Data preservation
The trial protocol and its amendment (signed), Informed Consent Form (format), approval from
the Ethics Committee, membership list of the Ethics Committee, original outpatient or inpatient

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medical record, case report form (filled in, signed and dated), original of adverse event report and
electronic data management system database.
15.Expected progress
15.1 Trial start time: This Protocol will be officially implemented after being approved by the
Ethics Committee. It is planned to start the clinical trial after the test drugs, research materials, and
research funds are in place and the project kick-off meeting.
15.2 Planned enrollment time: Complete the enrollment of subjects within 24 months after the
start of the trial.
15.3 The time of clinical trial data collection, statistics and summary is shown in the table below:
Working contents
Plan completion time
Kick-off meeting
2019.6
Enrollment of the first subject
2019.7
Enrollment of half the subjects
2020.7
Enrollment of the last subject
2021.7
Phased analysis and summary
2020.7
End of the observation
2022.7
Data collection
2019.7 - 2022.7
Statistical analysis
2022.9
Summary, article
2022.12
16.Follow-up and medical measures after the trial
If the subjects have adverse events/reactions during the clinical trial, they must be followed up
within 1 month after the treatment to ensure their safety. If the subjects still need therapy for their
uncured conditions after the end of the trial, the current standard therapeutic drugs can be used for
treatment.
17.References
1.
Filler G, Young E, Geier P, Carpenter B, Drukker A, Feber J (2003) Is there really an increase
in non-minimal change nephrotic syndrome in children? Am J Kidney Dis 42:1107-1113.
2.
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Wong W (2007) Idiopathic nephrotic syndrome in New Zealand children, demographic,
clinical features, initial management and outcome after twelve-month follow-up: results of a
three-year national surveillance study. J Paediatr Child Health 43:337-341.

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全国儿童常见肾脏病诊治现状调研工作组(2014) 我国儿童激素敏感、复发/依赖肾病综
合征诊疗现状的多中心研究. 中华儿科杂志52:194-200.
5.
Tarshish P, Tobin JN, Bernstein J, Edelmann CM, Jr. (1997) Prognostic significance of the
early course of minimal change nephrotic syndrome: report of the International Study of
Kidney Disease in Children. J Am Soc Nephrol 8:769-776.
6.
Shaw KT, Ho AM, Raghavan A, Kim J, Jain J, Park J, Sharma S, Rao A, Hogan PG (1995)
Immunosuppressive drugs prevent a rapid dephosphorylation of transcription factor NFAT1 in
stimulated immune cells. Proc Natl Acad Sci U S A 92:11205-11209.
7.
Koefoed-Nielsen PB, Karamperis N, Hojskov C, Poulsen JH, Jorgensen KA (2006) The
calcineurin activity profiles of cyclosporin and tacrolimus are different in stable renal
transplant patients. Transpl Int 19:821-827.
8.
吴晓明, 夏正坤(2014) 他克莫司在儿童肾脏疾病中的临床应用及作用机制. 国际儿科
学杂志41:386-389.
9.
Li X, Li H, Chen J, He Q, Lv R, Lin W, Li Q, He X, Qu L, Suya W (2008) Tacrolimus as a
steroid-sparing agent for adults with steroid-dependent minimal change nephrotic syndrome.
Nephrol Dial Transplant 23:1919-1925.
10.
Ren H, Shen P, Li X, Pan X, Zhang W, Chen N (2013) Tacrolimus versus cyclophosphamide
in steroid-dependent or steroid-resistant focal segmental glomerulosclerosis: a randomized
controlled trial. Am J Nephrol 37:84-90.
11.
汤京华, 汤婷, 方莉, 冯曦(2011) 吗替麦考酚酯治疗难治性原发性肾病综合征疗效观察.
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12.
李艳伟, 夏天(2009) 难治性肾病综合征的治疗及其进展. 医学综述15:2497-2499.
13.
Sepe V, Libetta C, Giuliano MG, Adamo G, Dal Canton A (2008) Mycophenolate mofetil in
primary glomerulopathies. Kidney Int 73:154-162.
14.
郝海英, 郑朝霞, 徐岚(2011) 吗替麦考酚酯联合泼尼松治疗老年难治性肾病综合征的
临床分析. 中国医师进修杂志34:29-31.
15.
Briggs WA, Choi MJ, Scheel PJ, Jr. (1998) Successful mycophenolate mofetil treatment of
glomerular disease. Am J Kidney Dis 31:213-217.
16.
Gellermann J, Weber L, Pape L, Tonshoff B, Hoyer P, Querfeld U, Gesellschaft fur
Padiatrische N (2013) Mycophenolate mofetil versus cyclosporin A in children with
frequently relapsing nephrotic syndrome. J Am Soc Nephrol 24:1689-1697.
17.
KDIGO Board Members (2012) KDIGO Clinical Practice Guideline for Glomerulonephritis.
Kidney International 2:139-251.
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中华医学会儿科学分会肾脏学组(2017) 激素耐药型肾病综合征诊治循证指南（2016).
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19.
中华医学会儿科学分会肾脏学组(2017) 儿童激素敏感及复发/依赖肾病综合征诊治询
证指南（2016）中华儿科杂志55:729-734.
20.
Schwartz GJ, Brion LP, Spitzer A (1987) The use of plasma creatinine concentration for
estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin North
Am 34:571-590.

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Appendix 1 Estimation of glomerular filtration rate
Estimation of glomerular filtration rate
1. The glomerular filtration rate (eGFR) is calculated and estimated with Schwartz formula[20]:
eGFR (mL/min/1.73m2)＝K×height (cm)/Scr (mg/dL), where K is the proportional constant:
K=0.55 (girls over 2 years old, boys 2-12 years old)
K=0.70 (boys over 12 years old)
2. At the same time: Unit conversion for serum creatinine (SCR) value: 1 mg/dL = 88.4 μmol/L

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Appendix 2 Blood pressure reference values for children
Boy
Diastolic blood pressure, mmHg
Age
Systolic blood pressure, mmHg
Height percentile
Height percentile
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
98
99
101
103
104
106
106
54
54
55
56
57
58
58
2
101
102
104
106
108
109
110
59
59
60
61
62
63
63
3
104
105
107
109
110
112
113
63
63
64
65
66
67
67
4
106
107
109
110
112
114
115
66
67
68
69
70
71
71
5
108
109
110
112
114
115
116
69
70
71
72
73
74
74
6
109
110
112
114
115
117
117
72
72
73
74
75
76
76
7
110
111
113
115
117
118
119
74
74
75
76
77
78
78
8
111
112
114
116
118
119
120
75
76
77
78
79
79
80
9
113
114
116
118
119
121
121
76
77
78
79
80
81
81
10
115
116
117
119
121
122
123
77
78
79
80
81
81
82
11
117
118
119
121
123
124
125
78
78
79
80
81
82
82
12
119
120
122
123
125
127
127
78
79
80
81
82
82
83
13
121
122
124
126
128
129
130
79
79
80
81
82
83
83
14
124
125
127
128
130
132
133
80
80
81
82
83
84
84
15
126
127
129
131
133
134
135
81
81
82
83
84
85
85
16
129
130
132
134
135
137
137
82
83
83
84
85
86
87
17
131
132
134
136
138
139
140
84
85
86
87
87
88
89

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Girl
Systolic blood pressure, mmHg
Diastolic blood pressure, mmHg
Age
Height percentile
Height percentile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
1
100
101
102
104
105
106
107
56
57
57
58
59
59
60
2
102
103
104
105
107
108
109
61
62
62
63
64
65
65
3
104
104
105
107
108
109
110
65
66
66
67
68
68
69
4
105
106
107
108
110
111
112
68
68
69
70
71
71
72
5
107
107
108
110
111
112
113
70
71
71
72
73
73
74
6
108
109
110
111
113
114
115
72
72
73
74
74
75
76
7
110
111
112
113
115
116
116
73
74
74
75
76
76
77
8
112
112
114
115
116
118
118
75
75
75
76
77
78
78
9
114
114
115
117
120
121
122
77
77
77
78
79
80
80
10
116
116
117
119
120
121
122
77
77
77
78
79
80
80
11
118
118
119
121
122
123
124
78
78
78
79
80
81
81
12
119
120
121
123
124
125
126
79
79
79
80
81
82
82
13
121
122
123
124
126
127
128
80
80
80
81
82
83
83
14
123
123
125
126
127
129
129
81
81
81
82
83
84
84
15
124
125
126
127
129
130
131
82
82
82
83
84
85
85
16
125
126
127
129
130
131
132
82
82
83
84
85
85
86
17
125
126
127
129
130
131
132
82
83
83
84
85
85
86
The blood pressure at 95th percentile standard14

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Appendix
3
Comparison
and
acceptance
criteria
of
laboratory observation indexes
(Compared with the results from the Children's Hospital, Zhejiang
University School of Medicine)
Serum index
Acceptance criteria
Urine index
Acceptance criteria
Serum
creatinine
±8.8 μmol/L
Or ±10%, whichever is
larger
Total urinary protein
≤0.2g/L
Or ±15%, whichever is
larger
Uric acid
±15%
Urinary creatinine
±15%
Urea
±15%
Albumin
±10%
Total
bilirubin
±20%
ALT
±20%
According to the above standards, if the results of 80% of the samples are within the range, such
samples shall be deemed “accepted”; if 4 samples in the middle and late period are deemed
“accepted”, this comparison test shall be deemed “accepted”.

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Appendix 4 Parameters and results sample size calculation
Parameters and results in sample size calculation:
N1: MMF Group
N2: FK506 Group