Deferoxamine for the Prevention of Cardiac Surgery-Associated Acute Kidney Injury
Phase: PHASE2
Conditions: Acute Kidney Injury
Sponsor: Brigham and Women's Hospital

 
 
 
 
 
 
 
 
 
 
Detailed Protocol 
November 4, 2025 
 
 
 
Principal Investigator: 
 
David E. Leaf, MD, MMSc 
Associate Professor of Medicine, Harvard Medical School 
Director of Clinical and Translational Research, Division of Renal Medicine, Brigham and Women’s 
Hospital 
 
Co-Investigators: 
 
Aranya Bagchi, MBBS (site PI at Massachusetts General Hospital) 
Assistant Professor of Anaesthesia, Harvard Medical School 
Assistant Anesthetist, Massachusetts General Hospital 
 
Shahzad Shaefi, MD, MPH (site PI at Beth Israel Deaconess Medical Center) 
Associate Professor of Anaesthesia, Harvard Medical School 
Program Director, Critical Care Fellowship Program, Department of Anesthesia, Critical Care and Pain 
Medicine, Beth Israel Deaconess Medical Center 
 
 
 
 
 
 

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TABLE OF CONTENTS 
 
ABBREVIATIONS ................................................................................................................................. 3 
SYNOPSIS ............................................................................................................................................ 4 
1. BACKGROUND AND SIGNIFICANCE .............................................................................................. 6 
1.1   Overview .................................................................................................................................... 6 
1.2   Preclinical and clinical studies supporting the proposed research .............................................. 7 
1.3   Rationale for investigation of DFO for AKI prevention in humans ............................................. 10 
1.4   Rationale for DFO dosing regimen ........................................................................................... 11 
2. SPECIFIC AIMS .............................................................................................................................. 12 
3. SUBJECT SELECTION ................................................................................................................... 13 
3.1   Inclusion criteria ....................................................................................................................... 13 
3.2   Exclusion criteria ...................................................................................................................... 13 
3.3   Source of subjects .................................................................................................................... 13 
3.4   Recruitment methods ............................................................................................................... 14 
4. SUBJECT ENROLLMENT .............................................................................................................. 15 
4.1   Methods of enrollment and procedures for obtaining informed consent .................................... 15 
4.2.  Procedures for obtaining informed consent .............................................................................. 15 
4.3   Treatment assignment and randomization ................................................................................ 17 
5. STUDY PROCEDURES .................................................................................................................. 18 
5.1   Drugs to be used ...................................................................................................................... 18 
5.2   Data to be collected .................................................................................................................. 18 
5.3   Methods for data collection ....................................................................................................... 18 
5.4   Biological sample collections .................................................................................................... 18 
5.5   Sending biosamples and data outside MGB ............................................................................. 20 
6. BIOSTATISTICAL ANALYSIS ........................................................................................................ 21 
6.1   Primary endpoint definition ....................................................................................................... 21 
6.2   Statistical analysis for the primary endpoint .............................................................................. 21 
6.3   Sample size and power ............................................................................................................ 21 
6.4   Secondary endpoints ................................................................................................................ 21 
6.5   Statistical analysis for secondary endpoints ............................................................................. 22 
6.6   Modified intention-to-treat analysis ........................................................................................... 22 
7. RISKS AND DISCOMFORTS .......................................................................................................... 23 
7.1   Hypersensitivity reactions ......................................................................................................... 23 
7.2   Hypotension ............................................................................................................................. 23 
7.3   ARDS ....................................................................................................................................... 23 
7.4   Infection.................................................................................................................................... 24 
7.5   Vision changes ......................................................................................................................... 24 
7.6   Hearing loss ............................................................................................................................. 24 
7.7   Summary of all potential adverse effects of DFO, and their frequency ...................................... 24 
7.8   Risks of blood draw .................................................................................................................. 25 
7.9   Loss of confidential patient information ..................................................................................... 25 
8. POTENTIAL BENEFITS .................................................................................................................. 26 
8.1   Potential benefits to participating individuals ............................................................................ 26 
8.2   Potential benefits to society ...................................................................................................... 26 
9. MONITORING AND QUALITY ASSURANCE ................................................................................. 27 
9.1   Independent monitoring of source data .................................................................................... 27 
9.2   Study team composition, oversight, and governance ................................................................ 27 
9.3   Safety monitoring and reporting ................................................................................................ 27 
9.4   DSMB ....................................................................................................................................... 29 
9.5   Single IRB ................................................................................................................................ 30 
10. REFERENCES .............................................................................................................................. 31 
 

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ABBREVIATIONS 
AEs = Adverse Events 
AESI = Adverse Events of Special Interest 
AKI = Acute Kidney Injury 
ARDS = Acute Respiratory Distress Syndrome 
ATN = Acute renal failure Trial Network 
BIDMC = Beth Israel Deaconess Medical Center 
BWH = Brigham and Women’s Hospital 
CABG = Coronary Artery Bypass Graft 
CKD  = Chronic Kidney Disease 
CPB = Cardiopulmonary Bypass 
CTCAE = Common Terminology Criteria for Adverse Events 
DEFEAT-AKI = Deferoxamine for the Prevention of Cardiac Surgery-Associated Acute Kidney Injury 
DFO = Deferoxamine 
DFP = Deferiprone 
DFX = Deferasirox 
DSMB = Data and Safety Monitoring Board 
ECMO = Extracorporeal Membrane Oxygenation 
eGFR = Estimated Globular Filtration Rate 
eIC = Electronic Informed Consent 
FDA = Food and Drug Administration 
FiO2 = Fraction of inspired oxygen 
GI = Gastrointestinal 
Hi-DEF = High-Dose Deferoxamine in Intracerebral Hemorrhage 
HFpEF = Heart failure with preserved ejection fraction 
HFrEF = Heart failure with reduced ejection fraction 
ICH = Intracerebral Hemorrhage 
ICU = Intensive Care Unit 
i-DEF = Intracerebral Hemorrhage Deferoxamine 
IRB = Internal Review Board 
IRI = Ischemia-Reperfusion Injury 
IV = Intravenous 
KDIGO = Kidney Disease: Improving Global Outcomes 
KIM-1 = Kidney Injury Molecule-1 
MGH = Massachusetts General Hospital 
NGAL = Neutrophil Gelatinase-Associated Lipocalin 
NIDDK = National Institute of Diabetes and Digestive Kidney Diseases 
NIH = National Institutes of Health 
PaO2 = Partial pressure of arterial oxygen 
PEEP = Positive end-expiratory pressure 
PI = Principal Investigator 
PMBCs = Peripheral Blood Mononuclear Cells 
POD = Post-Operative Day 
RBCs = Red Blood Cells 
RCT = Randomized Clinical Trial 
RRT = Renal Replacement Therapy 
SOFA = Sequential Organ Failure Assessment 
STEMI = ST-Elevation Myocardial Infarction 
VAD = Ventricular Assist Device 
 
 

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SYNOPSIS 
 
Title 
Deferoxamine for the Prevention of Cardiac Surgery-Associated Acute Kidney 
Injury 
Short Title 
DEFEAT-AKI 
Phase 
2 
Study Design 
Randomized, double-blind, placebo-controlled, parallel assignment 
IND Status#  
Exempt 
ClinicalTrials.gov # 
NCT04633889 
Funding 
National Institutes of Health (NIH) / National Institute of Diabetes and Digestive 
Kidney Diseases (NIDDK) grant R01DK125786 (PI: Leaf) 
Rationale 
Multiple lines of evidence support a central role of iron in causing acute kidney 
injury (AKI), including the finding that prophylactic administration of iron 
chelators attenuates AKI in numerous animal models. Patients undergoing 
cardiac surgery may be particularly susceptible to iron-mediated kidney injury 
due to the profound hemolysis that often occurs from cardiopulmonary bypass 
(CPB), along with intraoperative transfusion of red blood cells.  
Target Population 
Adults undergoing cardiac surgery who are at high risk of postoperative AKI 
Inclusion Criteria 
1. Age ≥18 years 
2. Undergoing coronary artery bypass graft (CABG) and/or valve surgery with 
CPB. 
3. AKI risk score ≥6 at the time of screening (Table 4) 
4. Written informed consent from the patient or surrogate 
Exclusion Criteria 
1. AKI, defined as any of the following: 
▪ Increase in serum creatinine ≥0.3 mg/dl in 48h 
▪ Increase in serum creatinine ≥50% in 7d (if no value available in last 7d, 
use most recent value in last 3 months) 
▪ Urine output ≤0.5 ml/kg/h x 6 consecutive hours (only assessed in patients 
with hourly monitoring via Foley catheter) 
▪ Receipt of renal replacement therapy (RRT) within 7d 
2. Advanced chronic kidney disease (eGFR <15 ml/min/1.73m2 or end-stage 
kidney disease receiving RRT) 
3. Hemoglobin <8 g/dL (closest value in the prior 3 months) 
4. Fever (temperature ≥38⁰C) in the last 48h 
5. Suspected or confirmed bacteremia, endocarditis, or pyelonephritis 
6. Pneumonia, aspiration, or bilateral pulmonary infiltrates from an infectious 
etiology reported on chest x-ray or CT scan in the last 7d 
7. Positive COVID-19 test in the last 10d 
8. Previous iron chelation therapy (including prior participation in DEFEAT-AKI) 
9. Known hypersensitivity to DFO 
10. Taking prochlorperazine 
11. Known severe hearing loss 
12. Pregnant or breastfeeding 
13. Prisoner 
14. Concurrent participation in another interventional research study in which the 
intervention has potential interaction with DFO 
15. Surgery to be performed under conditions of circulatory arrest 
16. Receiving extracorporeal membrane oxygenation 
17. Durable ventricular assist device (VAD) prior to surgery (does not include 
Impella device or intra-aortic balloon pump) 
18. Any condition which, in the judgement of the investigator, might increase the 
risk to the patient 
19. Conflict with other research studies 
Number of Subjects 
330 
Length of Participation 
Until hospital discharge 

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Interventions 
Deferoxamine 30 mg/kg (max total dose, 6g) or an equal volume of normal 
saline placebo administered as a continuous intravenous infusion over 12h, 
beginning immediately prior to cardiac surgery 
Primary Objectives and 
Primary Endpoint 
Primary objective: 
To evaluate the potential efficacy of deferoxamine in reducing the risk of 
postoperative AKI in patients undergoing cardiac surgery. 
 
Primary endpoint: 
Incidence of postoperative AKI, defined as follows: urine output <0.5 ml/kg/h for 
6 consecutive hours (assessed within the first 48h or until the Foley catheter is 
removed, whichever occurs first); an increase in serum creatinine ≥0.3 mg/dl 
within the first 48h; an increase in serum creatinine ≥50% in the first 7 days; or 
receipt of renal replacement therapy in the first 7 days. 
Secondary Objectives 
and Corresponding 
Endpoints 
Secondary objectives: 
▪ To evaluate the potential efficacy of deferoxamine in reducing renal tubular 
injury in patients undergoing cardiac surgery. 
▪ To evaluate the potential efficacy of deferoxamine in reducing the risk of 
postoperative myocardial injury, atrial fibrillation, prolonged mechanical 
ventilation, and sepsis in patients undergoing cardiac surgery. 
 
Secondary endpoints: 
▪ Urinary markers of tubular injury, NGAL and KIM-1, assessed preoperatively, 
at the end of CPB, on arrival to the ICU, and daily for 2 days postoperatively. 
▪ Postoperative myocardial injury, atrial fibrillation, prolonged mechanical 
ventilation, and sepsis within 7 days following cardiac surgery. 
Exploratory Objectives 
and Corresponding 
Endpoints 
Exploratory objectives: 
To test the effects of deferoxamine on circulating markers of iron, oxidative 
stress, and inflammation 
 
Exploratory endpoints: 
Circulating markers of iron status (catalytic iron, total iron, total iron binding 
capacity, ferritin, and hepcidin), oxidative stress (F[2]-isoprostane and 
myeloperoxidase), and inflammation (monocyte phenotype), each assessed pre- 
and postoperatively. 
Sites 
Brigham and Women’s Hospital (BWH) 
Massachusetts General Hospital (MGH) 
Beth Israel Deaconess Medical Center (BIDMC) 
Study Duration 
Estimated total study duration is 4 years 
Data and Safety 
Monitoring Committee 
(DSMB) 
A DSMB will convene prior to study launch and after enrollment of 10, 25, 50, 
and 75% of the total enrollment has taken place to review safety data and any 
unanticipated problems. The DSMB will make recommendations as needed. The 
DSMB will not perform a futility analysis or consider early study completion for 
efficacy. 
 
 
 

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1. BACKGROUND AND SIGNIFICANCE 
 
1.1   Overview  
 
1.1.1   Burden of acute kidney injury 
Acute kidney injury (AKI) is a sudden episode of kidney failure or kidney damage that occurs within a 
few hours or a few days. AKI complicates >500,000 hospitalizations annually in the US, at a cost of 
~$10 billion, and its incidence is rising.1, 2 Patients who develop AKI are at greatly increased risk of 
death acutely, and those who survive have an increased risk of chronic kidney disease (CKD), 
cardiovascular events, and reduced quality of life.1, 3-5 Despite years of investigation, development of 
therapies to prevent and treat AKI has been largely unsuccessful. Investigation of novel therapeutic 
targets is urgently needed. Deferoxamine for the Prevention of Acute Kidney Injury (DEFEAT-AKI) 
is a phase II randomized clinical trial to investigate the effects of iron chelation with 
deferoxamine (DFO) on cardiac surgery-associated AKI. 
 
1.1.2   Role of iron in animal models of AKI 
Iron is essential for many biologic processes, including oxygen transport, DNA repair, and cell 
proliferation. When present in excess and in non-physiologic forms, however, iron is toxic to the kidneys 
and other organs due to its ability to catalyze the Fenton and Haber-Weiss reactions, thereby 
generating hydroxyl radicals and causing cellular oxidative injury.6, 7 Multiple lines of evidence support a 
central role of iron in AKI: exogenous iron infusion exacerbates renal injury;8-10 iron content is markedly 
increased in the kidneys of animals exposed to myriad nephrotoxic insults;11-13 genetic manipulation of 
key proteins involved in iron metabolism, regulation, and transport affect AKI susceptibility;14-16 and 
administration of hepcidin, the master regulator of iron homeostasis, is protective against AKI.17, 18 Most 
notably, iron chelators reliably attenuate AKI in numerous animal models (Table 1). 
 
1.1.3   Principles of iron chelation and potential mechanisms of protection 
An important aspect of chelation therapy in preventing organ injury is the removal from the circulation of 
toxic forms of non-transferrin-bound iron, also known as “catalytic iron,” which is composed primarily of 
iron-citrate and iron-albumin complexes.19 Catalytic iron is taken up by highly vascular organs, such as 
the kidneys and heart, leading to elevated concentrations of intracellular iron. Therapeutic iron 
chelators form a complex with catalytic iron and promote its excretion via the urinary and fecal routes. 
Underlying the protective effects of iron chelators in animal models of AKI are both iron-dependent and 
independent mechanisms. Iron-dependent mechanisms include the prevention of Fenton chemistry 
induced by catalytic iron. This protects against oxidative injury and ferroptosis, a form of iron-dependent 
cell death.20 Iron chelators also act as electron donors to reduce high oxidation states of heme iron, 
such as ferryl (Fe4+) hemoglobin and myoglobin.21, 22 Thus, iron chelators may prevent heme-mediated 
injury independently of their ability to bind catalytic iron. Finally, iron chelators affect cell proliferation 
and survival independently of heme and iron by, for example, upregulating hypoxia-inducible factor 1-
alpha23-25 and direct scavenging of superoxide free radicals.26 
 
1.1.4   Efficacy and safety of iron chelators in humans 
Iron chelators have been used for over half a century to treat patients with genetic hemoglobin 
disorders complicated by iron overload, such as beta thalassemia. Iron chelators in general, and DFO 
specifically, have also been used in human studies to test their ability to prevent acute organ injury, 
including AKI, and have demonstrated promising initial results and an excellent safety profile (section 
1.3). 
 
1.1.5   Rationale for investigation of iron chelation in patients undergoing cardiac surgery 
Cardiac surgery is the ideal setting for investigation of iron chelation for AKI prevention. Cardiac 
surgery results in elevated circulating levels of catalytic iron27 due to multiple factors: exposure of red 
blood cells (RBCs) to non-physiological surfaces and shear stress in extracorporeal circuits, resulting in 

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profound hemolysis; transfusion of RBCs, which become more fragile during storage, resulting in 
additional hemolysis;28-30 ischemia-reperfusion injury (IRI) to the kidneys and other organs due to cross-
clamping of the aorta and intraoperative hypotension;31 and skeletal muscle injury, resulting in the 
release of iron-rich myoglobin into the circulation.32 Consistent with these mechanisms, we found that 
longer duration of cardiopulmonary bypass (CPB) is associated with higher levels of catalytic iron 
postoperatively (section 1.2.2).27 Thus, cardiac surgery exposes patients to an acute iron load 
resulting from hemolysis, transfusion, rhabdomyolysis, and other factors. There are also 
important logistical considerations that favor cardiac surgery. Unlike most clinical settings where AKI 
occurs, cardiac surgery is often planned, and thus allows iron chelation therapy to be initiated 
prophylactically. Accordingly, toxic iron species released into the circulation during cardiac surgery 
can be chelated in real time before AKI has occurred. This feature is critical, since nearly all animal 
models using iron chelators investigated their effect on AKI prevention rather than treatment.33, 34 
 
Finally, cardiac surgery-associated AKI is itself a major public health burden. One multinational 
study conducted among ~30,000 critically ill patients identified cardiac surgery as the second most 
common cause of AKI.35 Over 500,000 cardiac surgeries are performed in the U.S. annually,36 ~80% of 
which are performed with CPB. Depending on the definition, AKI occurs in as many as 72% of patients 
undergoing cardiac surgery,37, 38 with a 6- to 18-fold associated increase in acute mortality compared to 
those without AKI.39-41 AKI requiring RRT occurs less frequently, but is associated with striking (>60%) 
in-hospital mortality.39, 42, 43 
 
1.2   Preclinical and clinical studies supporting the proposed research 
 
1.2.1   Preclinical studies 
Multiple lines of evidence from preclinical studies support a central role of iron in AKI, most importantly 
the finding that iron chelators reliably attenuate AKI in numerous animal models. These studies are 
summarized in Table 1 and are reviewed elsewhere in detail.33 
 

 
Table 1. Animal models demonstrating protective effects of iron chelators in AKI. *Refers to an attenuated rise in BUN and/or Cr compared to sham-treated animals. Abbreviations: AKI, acute kidney injury; AlCl3, 
aluminum chloride; Bi, bilateral; BUN, blood urea nitrogen; Cr, creatinine (serum or plasma); DFO, deferoxamine; DFP, deferiprone; DHB, 2,3- dihydroxybenzoic acid; DXR, doxorubicin; Gent, gentamicin; GFR, glomerular 
filtration rate; GGT, gamma-glutamyl transferase; Hgb, hemoglobin; Hist, histologic; IM, Intramuscular; Inj, injection; IP, intraperitoneal; IRI, ischemia-reperfusion injury; IV, intravenous; NAC, n-acetylcysteine; N/A, Not 
applicable; NR, Not reported; NS, nephrotic syndrome; PO, per os; QD, daily; SC, subcutaneous; Uni, unilateral; UPCR, urine protein-creatinine ratio; Vanc, vancomycin. 
 
Table 1. Animal models demonstrating protection from AKI with iron chelators33 
Reference 
Animal 
Model 
Renal Injury 
Iron chelation regimen 
Demonstration of 
Renal Protection 
Other / Notes 
 
 
 
 
BUN/Cr* 
Hist 
 
Shah et al.,44 1988 
Rats 
Glycerol 
DFO 30 mg/kg IV immediately prior to glycerol inj, then DFO 30 mg/day SC pump x 
24h 
Yes 
Yes 
 
Paller et al.,45 1988 
Rats 
1. Glycerol 
2. Hgb 
3. IRI (Uni) 
1. DFO 25 mg/kg/h IV x 1h concomitantly with glycerol inj, then 12 mg/kg/h x 3h, 
then 6 mg/kg/hr x 3h 
2. DFO 200 mg/kg/h IV x 1h immediately after Hgb inj 
3. DFO 200 mg/kg/h IV x 1h immediately prior to reperfusion 
Yes 
 
Yes 
Yes 
NR 
 
NR 
NR 
 
Paller et al.,8 1988 
Rats 
IRI (Uni) 
DFO 50 or 200 mg/kg/h IV infusion x 60 min starting immediately prior to reperfusion 
Yes 
Yes 
Iron-saturated DFO was not protective 
Walker et al.,46 
1988 
Rats 
Gent 
DFO 20 mg IV immediately prior to gent inj, then 20 mg/day SC pump x 8d 
Yes 
Yes 
Iron-saturated DFO was only partially protective 
Zager et al.,47 1992 
Rats 
Glycerol 
DFO 120 mg/kg IV infusion for 2h immediately after glycerol inj; Mannitol 12.5 ml/kg 
IV infusion for 2h immediately after glycerol inj 
Yes 
 
Yes 
DFO+Mannitol- compared to Mannitol only-treated rats had 
better functional and histologic protection 
Gonzalez-Fajardo 
et al.,48 1994 
Rabbits 
IRI (Bi) 
DFO 25 mg/kg IV immediately prior to clamping and immediately prior to reperfusion 
No 
NR 
 
Ben Ismail et al.,49 
1994 
Rats 
Gent 
DFO 100 mg/kg IM concomitantly with gent inj 
No 
No 
 
Haraldsson et al.,50 
1995 
Rabbits 
IRI (Uni) 
DFO 30 mg/kg IV immediately prior to clamping and immediately prior to 
reperfusion; 
Mannitol 3 ml/kg IV immediately prior to clamping and immediately prior to 
reperfusion 
Yes 
NR 
DFO+Mannitol- compared to Mannitol only-treated rats had a 
higher Cr clearance 
Watanabe et al.,51 
1998 
Rats 
Cisplatin 
DFO 100 mg/kg IP 60 min prior to Cisplatin and continued QD x 10d 
Yes 
NR 
 
Baliga et al.,52 1998 Rats 
Cisplatin 
DFO 30 mg/day SC pump starting 24h prior to Cisplatin and continued daily x 4d 
Yes 
Yes 
 
Saad et al.,53 2001 
Rats 
DXR 
DFO 25, 125, 250, 375, and 500 mg/kg IP x1 administered 30 min prior to DXR inj 
Yes 
Yes 
Only rats treated with DFO at 375 mg/kg or 500 mg/kg had 
histologic protection 
Chander et al.,54 
2002 
Rats 
Glycerol 
DFO 50 and 100 mg/kg SC 30 min prior and 12h after Glycerol inj 
Yes 
Yes 
Higher dose provided better renal protection 
 
Ozdemir et al.,55 
2002 
Mice 
Cisplatin 
DFO 100 and 200 mg/kg IP 60 min prior to Cisplatin and continued QD x 10d 
Yes 
Yes 
GGT (marker of Cisplatin toxicity) reduced by DFO 
De Vries et al.,56 
2004 
Mice  
IRI (Uni) 
Apotransferrin (0.1, 0.25, 0.5, and 5 mg) IP x1 just immediately prior to removal of 
clamps 
Yes 
NR 
 
Naghibi et al.,57 
2004 
Rats 
Vanc 
DHB 50 and 100 mg/kg SC inj starting 30 min prior to Vanc and continued QD x 7d 
Yes 
Yes 
 
Bulucu et al.,58 2008 Rats 
Adriamycin (NS 
model) 
DFO 20 mg/kg IV x1 immediately after Adriamycin inj 
N/A 
NR 
DFO- compared to sham-treated rats had an attenuated rise 
in UPCR (Cr levels were not affected by Adriamycin) 
Petronilho et al.,59 
2009 
Rats 
Gent 
DFO 20 mg/kg SC concomitantly with Gent inj and continued on days 1, 4 and 7; 
NAC 20 mg/kg SC concomitantly with Gent inj and continued q8h X 7d 
Yes 
NR 
Rats treated with DFO+NAC compared with either DFO or 
NAC alone had an attenuated rise in BUN and Cr 
Vlahokos et al.,60 
2011 
Pigs 
Hepatic IRI 
DFO 150 mg/kg IV infusion over 24h starting concomitantly with hepatic artery 
ligation 
N/A 
Yes 
No significant effect of ischemia or DFO on BUN and Cr 
Bernardi et al.,61 
2012 
Rats 
IRI (Bi) 
DFO 20 mg/kg intra-aortic inj immediately prior to induction of ischemia; NAC 20 
mg/kg intra-aortic inj immediately prior to induction of ischemia 
Yes 
NR 
DFO+NAC-treated rats, compared to rats treated with either 
DFO or NAC alone, had an attenuated rise in Cr 
Milona- Jijon et 
al.,62 2012 
Rats 
Chromium 
DFO 100, 200, and 400 mg/kg IP administered 30 min prior to potassium chromium 
inj 
Yes 
Yes 
Dose-dependent renal protection with higher doses of DFO; 
DFO administration after chromium inj was unable to 
attenuate nephrotoxicity 
Sivakumar et al.,63 
2014 
Mice 
AlCl3 
DFP 0.72 mmol/kg PO vs. combo of DFP+DFO; dosing for the latter was 0.89 
mmol/kg IP starting 30 min after AlCl3 and continued QD x 5d 
Yes 
Yes 
Protection was seen in both DFP groups compared to sham-
treated mice; however, the DFP+DFO group had greater 
protection than DFP alone 
Makhdoumi et al.,64 
2018 
Rats 
Cisplatin 
DFP 50, 100, and 200 mg/kg PO starting 5d prior to Cisplatin and continued QD x 
10d 
Yes 
Yes 
Only rats treated with DFP at 100 mg/kg, but not 50 or 200 
mg/kg, were protected from nephrotoxicity 

1.2.2   Clinical studies 
Clinical studies supporting the proposed research include the demonstration of elevated levels of 
catalytic iron in the circulation of patients at risk of AKI, including both cardiac surgery-associated AKI 
and AKI in the setting of critical illness. 
 
Catalytic iron and cardiac surgery-associated AKI 
We measured plasma catalytic iron pre-, intra-, and 
postoperatively in 250 adults undergoing cardiac surgery 
with CPB.27 Catalytic iron levels peaked at the end of CPB, 
and were higher in patients who developed the composite 
endpoint of postoperative AKI requiring RRT or death 
(RRT/death) (Figure 1). In multivariable models, patients 
with catalytic iron levels in the highest versus lowest quartile 
on postoperative day 1 had a 3.99-fold higher odds of AKI 
(95% CI, 1.60 to 9.93) and a 6.71-fold higher odds of 
RRT/death (95% CI, 1.37 to 32.87). Finally, longer duration 
of CPB (P<0.001) and greater number of RBC transfusions 
(P<0.01) each associated with higher catalytic iron 
postoperatively, consistent with hemolysis as an important 
source of catalytic iron in this context.27 
 
Catalytic iron and critical illness-associated AKI 
We measured plasma catalytic iron levels in 121 patients 
within 24h of arrival to the intensive care unit (ICU), and 
found that higher concentrations associated with a greater 
risk of AKI in both univariate and multivariable models 
(adjusted odds ratio per 1-SD higher catalytic iron, 1.67; 
95% CI, 1.04 to 2.67).65 We also measured plasma catalytic 
iron and other iron parameters in 807 patients with AKI 
requiring RRT who enrolled in the Acute renal failure Trial 
Network (ATN) study. Higher quintiles of catalytic iron 
associated with a monotonic increase in the risk of 60-day 
mortality (Figure 2A).66 Other iron markers were also 
associated with death, but the magnitude of association was 
greatest for catalytic iron (Figure 2B).66 
 
Conclusions from these data 
1. Catalytic iron levels are markedly elevated following 
CPB. 
2. Catalytic iron levels are significantly higher among 
patients who develop AKI and RRT/death following CPB. 
3. Catalytic iron levels rise acutely and early in the course 
of AKI following CPB surgery, a setting in which the 
timing of renal injury is known. This establishes CPB 
surgery as an important setting to test the efficacy of iron 
chelation in reducing the risk of AKI, as we now propose. 
4. Higher catalytic iron levels are strongly, monotonically, 
and independently associated with AKI and death in 
settings beyond CPB surgery – namely critical illness – 
establishing a potential role for iron chelation in other 
AKI settings as well. 
 
 
 

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1.3   Rationale for investigation of DFO for AKI prevention in humans 
 
1.3.1   Overview of iron chelators 
Three iron chelators are approved by the Food and Drug Administration (FDA) for the treatment of iron 
overload: deferoxamine (DFO), deferiprone (DFP), and deferasirox (DFX). These agents have 
important differences in their routes of administration, pharmacokinetics, and potential adverse effects 
(Table 2). For multiple reasons described below and elsewhere,33 DFO is the agent best suited for 
use in randomized clinical trials (RCTs) investigating AKI prevention. 
 
1.3.2   Animal models using DFO 
DFO is the agent used in the vast 
majority of animal models 
demonstrating efficacy of iron 
chelation in attenuating AKI (Table 
2). Further, DFO attenuates 
extrarenal acute organ injury in 
numerous models, including 
cardiac ischemia-reperfusion injury 
(IRI) and reperfusion-induced 
arrythmias;67-69 mechanical 
ventilation- and lipopolysaccharide-
induced acute lung injury;70, 71 
endotoxemia-mediated acute liver 
injury;72, 73 and intracerebral 
hemorrhage (Figure 3).74 DFO also 
improves survival in animal models of 
sepsis.75, 76 
 
1.3.3   Favorable biochemical 
properties of DFO 
DFO has the highest iron-binding 
affinity among the chelators, and is the 
only chelator that is available 
parenterally (Table 2). The latter 
property is notable, since parenteral 
administration circumvents the 
limitations associated with enteral drug 
administration in acute illness, 
including concerns related to aspiration 
and impaired gastrointestinal 
absorption. 
 
1.3.4   Preliminary data on DFO and 
prevention of acute organ injury in 
humans 
DFO was the first iron chelator 
approved by the FDA, and thus has the 
longest track record of both efficacy 
and safety in humans for the treatment 
of chronic iron overload conditions. 
DFO is also the only iron chelator that 
is FDA-approved for the treatment of 
acute iron overload (Table 2), and has 
Table 2. Comparison of FDA-approved iron chelators33 
Chelator 
Deferoxamine (DFO) 
Deferasirox (DFX) 
Deferiprone (DFP) 
Brand name 
Desferal 
Exjade, Jadenu 
Ferriprox 
Year of FDA approval 
1968 
2005 
2011 
Route of administration 
IV, IM, SC 
PO 
PO 
Indication 
Acute and chronic iron 
overload 
Chronic iron overload Chronic iron overload 
Iron-binding affinity (pM) 
26.6 
22.5 
19.9 
Adverse effects 
GI,* hypotension,** rash, 
anaphylaxis 
GI,* cytopenias, AKI, 
liver toxicity 
GI,* neutropenia, liver 
toxicity 
Elimination half-life (hrs) 
0.28 
8-16 
1.9 
Dosing frequency 
Continuous 
Once per day 
Three times per day 
Metabolism 
Plasma enzymes 
Liver 
(Glucuronidation) 
Liver (Glucuronidation) 
Excretion 
Urine and feces 
Feces (84%), urine 
(8%) 
Urine (75-90%) 
Contraindications for renal 
impairment 
eGFR<10: contraindicated eGFR<40: 
contraindicated 
None 
*Gastrointestinal (GI) effects include abdominal discomfort, nausea, vomiting, and diarrhea; **Only 
observed at very high doses 

Version Date 11/4/25;  Page 11 
 
been investigated as a therapeutic strategy for preventing acute organ injury in multiple clinical contexts 
(Table 3), including AKI, cardiopulmonary bypass surgery, and intracerebral hemorrhage. 
 
Clinical studies of DFO for prevention of AKI 
Fraga et al.77 investigated the effects of DFO versus placebo on the incidence of AKI in 80 critically ill 
patients with prolonged hypotension. Although the overall incidence of AKI was similar between groups, 
DFO-treated patients had a lower incidence of severe AKI, as well as lower mean SCr on hospital 
discharge compared to placebo-treated patients. 
 
Clinical studies of DFO in patients undergoing cardiopulmonary bypass (CPB) surgery and in patients 
with ST-elevation myocardial infarction (STEMI) 
Several groups studied the effects of DFO in patients undergoing CPB surgery and in patients with 
STEMI.78-81 DFO-treated patients had lower generation of superoxide radicals and plasma markers of 
oxidative stress compared to placebo-treated patients. One RCT found that DFO-treated patients had 
higher left ventricular ejection fraction following CPB surgery compared to placebo-treated patients.80 
 
Clinical studies of DFO in patients with intracerebral hemorrhage (ICH) 
Selim et al.82 performed the largest RCT to date of DFO administration for acute organ injury 
prevention. They enrolled 294 patients with ICH into a phase II trial of DFO versus placebo. DFO-
treated patients had similar neurological outcomes at 90 days compared to placebo-treated patients, 
but had a trend toward improved neurologic outcomes at 180 days. 
 
Importantly, in each of these studies, DFO was well tolerated and did not increase the frequency 
of serious adverse events compared to placebo (Table 3). 
 
Table 3. Randomized, placebo-controlled trials of DFO for acute organ injury prevention33 
REF 
Clinical Setting 
N Iron Chelation Regimen 
Efficacy Findings 
Safety 
Concerns 
Menasche et 
al.78, 1988 
Cardiac Surgery 
24 DFO 30 mg/kg IV during CPB 
DFO-treated patients had lower generation of superoxide radicals 
compared to placebo-treated patients 
None 
Menasche et 
al.,79 1990 
Cardiac Surgery 
20 DFO 30 mg/kg IV during CPB 
DFO-treated patients had an attenuated rise in plasma TBARS 
postoperatively compared to placebo-treated patients 
None 
Paraskev et 
al.80, 2005 
Cardiac Surgery 
45 DFO 57 mg/kg* IV during CPB DFO-treated patients had higher LVEF postoperatively compared to 
placebo-treated patients 
None 
Chan et 
al.,81 2012 
STEMI 
undergoing PCI 
60 DFO 500 mg IV bolus followed 
by 50 mg/kg IV x 12h 
DFO-treated patients had lower plasma iron and F(2)-isoprostane 
levels, but similar infarct size on cardiac MRI 
None 
Fraga et 
al.83, 2012 
Critical illness 
with hypotension 
30 DFO 14 mg/kg† IV + NAC within 
the first 48h of hypotension 
DFO+NAC-treated patients had lower markers of oxidative stress and 
lower SCr on hospital discharge compared to placebo-treated patients 
None 
Fraga et 
al.77, 2016 
Critical illness 
with hypotension 
80 DFO 14 mg/kg† IV + NAC within 
the first 48h of hypotension 
DFO+NAC-treated patients had a similar incidence of AKI, but had a 
lower incidence of severe AKI and a lower SCr at hospital discharge 
None 
Selim et 
al.82, 2019 
ICH 
294 DFO 32 mg/kg per day IV for 3 
days 
Similar neuro outcomes at 3-months, but a trend toward improved 
outcomes at 6-months in DFO-treated patients 
None 
*Actual dose was 4 g, corresponding to 57 mg/kg in a 70-kg adult; †Actual dose was 1 g, corresponding to 14 mg/kg in a 70-kg adult. Abbreviations: 
BUN, blood urea nitrogen; CPB cardiopulmonary bypass; ICH, intracerebral hemorrhage; LVEF, left ventricular ejection fraction; NAC, N-
acetylcysteine; neuro, neurological; PCI, percutaneous coronary intervention; SCr, serum creatinine; STEMI, ST-elevation-myocardial infarction; 
TBARS, thiobarbituric acid reactive substances. 
 
1.4   Rationale for DFO dosing regimen 
We will administer 30 mg/kg (max total dose, 6g) of DFO as a continuous IV infusion beginning 
immediately prior to cardiac surgery (after induction of anesthesia and placement of a central venous 
catheter) and continued intra- and postoperatively for 12h. The determination of this dosing regimen is 
based on several considerations designed to optimize both efficacy and safety. First, 30 mg/kg is 
consistent with the human equivalent doses of DFO that are effective in attenuating AKI in animal 
models (Table 1).33 Second, 30 mg/kg is within the range that exerts anti-inflammatory/anti-oxidative 
effects in human studies of acute organ injury prevention, including patients undergoing CPB surgery 
(Table 3), and was demonstrated to be well tolerated in this patient population. Third, 30 mg/kg is 
within the FDA-recommended dosing range for DFO of 20-40 mg/kg/day for the treatment of chronic 
iron overload. The infusion will be administered over 12 hours based on our findings that catalytic iron 
levels are highest in the immediate perioperative period (Figure 1). 

Version Date 11/4/25;  Page 12 
 
2. SPECIFIC AIMS 
Overview of Study Design 
In Aim 1, we will perform a phase 2, double-blind, randomized, placebo-controlled trial to investigate the 
effects of DFO administration on the incidence of AKI following cardiac surgery. We will randomly 
assign 330 patients undergoing cardiac surgery at three major academic hospitals in Boston to receive 
DFO (30 mg/kg; max total dose, 6g) or an equal volume of normal saline. DFO will be administered as 
a continuous 12h IV infusion starting immediately prior to cardiac surgery (after induction of anesthesia 
and placement of a central venous catheter). We will also collect pre- and postoperative blood, urine, 
and peripheral blood monocytes for exploration of secondary outcomes. 
 
Aim 1 
To test the effects of DFO on the incidence of AKI and extrarenal acute organ injury following cardiac 
surgery, as assessed by KDIGO-defined changes in serum creatinine and urine output over a 7-day 
period, urinary markers of tubular injury (NGAL and KIM-1), and the incidence of postoperative 
myocardial injury, atrial fibrillation, prolonged mechanical ventilation, and sepsis. 
 
Aim 2 
To test the effects of DFO on catalytic iron, oxidative stress, and inflammation following cardiac 
surgery. 
 
 
 
 

Version Date 11/4/25;  Page 13 
 
3. SUBJECT SELECTION 
 
3.1   Inclusion criteria (each of the following) 
1. Age ≥18 years 
2. Undergoing coronary artery bypass graft (CABG) and/or valve 
surgery with CPB. Includes combination surgeries that involve 
CABG and/or valve plus other procedures (e.g., Maze procedure, 
aortic aneurysm repair) 
3. AKI risk score ≥6 at the time of screening (Table 4) 
4. Written informed consent from the patient or surrogate 
 
3.2   Exclusion criteria (at the time of screening) 
1. AKI, defined as any of the following: 
▪ Increase in serum creatinine ≥0.3 mg/dl in 48h 
▪ Increase in serum creatinine ≥50% in 7d (if no value available 
in last 7d, use most recent value in last 3 months) 
▪ Urine output ≤0.5 ml/kg/h x 6 consecutive hours (only 
assessed in patients with hourly monitoring via Foley catheter) 
▪ Receipt of renal replacement therapy (RRT) within 7d 
2. Advanced chronic kidney disease (eGFR <15 ml/min/1.73m2 or 
end-stage kidney disease receiving RRT) 
3. Hemoglobin <8 g/dL (closest value in the prior 3 months) 
4. Fever (temperature ≥38⁰C) in the last 48h 
5. Suspected or confirmed bacteremia, endocarditis, or 
pyelonephritis 
6. Pneumonia, aspiration, or bilateral pulmonary infiltrates from an 
infectious etiology reported on chest x-ray or CT scan in the last 7d 
7. Positive COVID-19 test in the last 10d 
8. Chronic iron overload (including conditions such as 
hemochromatosis and beta thalassemia major) or previous iron 
chelation therapy (including prior participation in DEFEAT-AKI) 
9. Known hypersensitivity to DFO 
10. Taking prochlorperazine 
11. Known severe hearing loss 
12. Pregnant or breastfeeding. Women of childbearing potential will not be included without 
documentation of a negative pregnancy test, unless they have previously undergone hysterectomy or 
bilateral oophorectomy. Women of child bearing potential will be defined as any woman who has begun 
menstruation and not yet reached menopause. Menopause will be defined as any woman over the age 
of 45 who has not had a menstrual period for at least 12 consecutive months. 
13. Prisoner 
14. Concurrent participation in another interventional research study in which the intervention has 
potential interaction with DFO 
15. Surgery to be performed under conditions of circulatory arrest 
16. Receiving extracorporeal membrane oxygenation 
17. Durable ventricular assist device (VAD) prior to surgery (does not include Impella device or intra-
aortic balloon pump) 
18. Any condition which, in the judgement of the investigator, might increase the risk to the patient 
19. Conflict with other research studies 
 
3.3   Source of subjects 
Patients scheduled to undergo cardiac surgery at BWH, MGH, and BIDMC, all located in Boston, MA. 
 
Table 4. Risk factors for cardiac surgery-
associated AKI 
Risk Factor 
Points 
Male sex 
1 
eGFR (ml/min/1.73m2)* 
 
   45-59 
1 
   30-44 
2 
   <30 
3 
Hemoglobin (g/dL)* 
 
   10-11.9 
2 
   <10 
4 
WBC count (per mm3)* 
 
   <4 
1 
   >12 
2 
Platelet count (109/L)* 
 
   <150 
1 
   >400 
2 
Albumin (g/dL)* 
 
   3.6-4.0 
1 
   <3.6 
2 
Hypertension 
1 
Diabetes mellitus 
1 
CHF† 
1 
Chronic liver disease‖ 
1 
Prior cardiac surgery 
2 
Combined CABG/valve 
1 
*Closest value in the last 3 months. 
†Any of the following: CHF; HFrEF; HFpEF; 
NYHA class III or IV; diastolic dysfunction; or 
LVEF≤40%. 
‖Any of the following: chronic liver disease; 
cirrhosis; NAFLD; AIH; chronic viral hepatitis. 
 
Abbreviations: AIH, autoimmune hepatitis; 
CHF, congestive heart failure; eGFR, 
estimated glomerular filtration rate (assessed 
using CKD-EPI equation); HFpEF, heart 
failure with preserved ejection fraction; 
HFrEF, heart failure with reduced ejection 
fraction; LVEF, left ventricular ejection 
fraction; NAFLD, non-alcoholic fatty liver 
disease. 

Version Date 11/4/25;  Page 14 
 
3.4   Recruitment methods 
Patients will be enrolled prior to cardiac surgery, either at their in-person preoperative evaluation 
(typically 7-10 days prior to surgery), by phone/zoom if their preoperative evaluation is conducted 
virtually (due to COVID-19 or other factors), or as inpatients. Additional details on enrollment are 
provided in section 4. No remuneration will be provided for participating. 
 
 

Version Date 11/4/25;  Page 15 
 
4. SUBJECT ENROLLMENT 
 
4.1   Methods of enrollment and procedures for obtaining informed consent 
Consecutive patients scheduled to undergo cardiac surgery at BWH, MGH, and BIDMC will be 
screened on a daily basis by research coordinators at each site using electronic medical records. A 
standardized screening checklist will be used to assess each patient’s eligibility. 
 
4.2.  Procedures for obtaining informed consent 
Overview 
The chiefs of cardiac surgery at BWH, MGH, and BIDMC are supportive of this research study and 
have approved approaching the cardiac surgical patients for screening and consenting. All patients, 
regardless of method of consent, will receive a copy of their consent form signed by both the patient 
and the study staff obtaining consent. Recruitment will take place with the assistance of the 
preoperative evaluation centers at BWH, MGH, and BIDMC, as described further below. 
 
Consent of outpatients at their preoperative visit 
For patients who have an in-person preoperative appointment (typically 7-10 days prior to the date of 
surgery), research study staff will ascertain their willingness to discuss the study at the conclusion of 
their preoperative visit. A member of the patient’s clinical team (e.g., the nurse, nurse practitioner, or 
physician caring for the patient) will initially introduce the study to the patient and obtain the patient’s 
permission to be contacted by study staff before they are approached by study staff. For patients who 
express interest in hearing about the study, research staff will briefly introduce the study, including 
providing patients with a paper handout (attached) that includes an overview of the study. Research 
staff will be able to answer basic questions about the study but will not obtain consent. If the patient 
expresses interest in further discussing the study, a physician investigator will explain the study in 
detail, answer questions, and seek written consent. 
 
Consent of outpatients by phone/zoom 
The preoperative evaluation centers at BWH, MGH, and BIDMC will incorporate a question regarding 
research into their standardized list of preoperative assessment questions (already being done at BWH, 
and in process at MGH and BIDMC). During their remote preoperative appointment (conducted by 
phone or zoom), patients will be asked by their nurse or nurse practitioner if they would like to “opt out” 
of communication about research studies they may be eligible to participate in based on their upcoming 
procedure. The nurse or nurse practitioner will document in the electronic medical record whether the 
patient wishes to opt out of communication about research opportunities. Research study staff will 
check the patient’s appointment notes to identify which patients may be contacted. In a minority of 
cases, if there is no documentation in the patient’s chart regarding whether they would like to “opt out” 
of communication about research studies, eligible patients will be contacted by phone by a member of 
their clinical team (e.g., the nurse or nurse practitioner who saw the patient during their preoperative 
evaluation). The clinical team member will ask the patient if they are willing to be contacted by the 
research team to hear about the study. 
 
Eligible patients who agree to be contacted will be called by a physician investigator to explain the 
study, answer questions, and seek consent. If the patient wishes to consent after the physician 
investigator has explained the study, the patient will be sent an email with an embedded REDCap 
survey link to the electronic Informed Consent (eIC) form, which is 21 CFR Part 11 compliant. On this 
survey page, patients will verify their information is accurate and will read the consent form. Patients 
will acknowledge that they have both read and understood the informed consent form, and that they 
agree to participate in the research study. Consent forms are stored as a PDF in the subjects’ REDCap 
record, and subjects that have provided consent electronically will be notified automatically via email 
when their final consent form is available for download in REDCap. The Informed Consent Process is 
documented in REDCap for each subject with the addition of new fields to capture remote and 

Version Date 11/4/25;  Page 16 
 
electronic consent. No medical content, diagnoses, study descriptors, or other PHI will be present in 
unsecured emails sent to subjects. 
 
As an alternative to the REDCap eIC form, patients who wish to consent after the physician investigator 
has explained the study may receive the consent form by email or fax, and may send the signed copy 
of the consent form back to the research team by email or fax. In such cases, patients will be asked to 
bring in a signed copy of the original consent form on the day of surgery. 
 
Consent of inpatients 
For patients already in the hospital, recruitment and written consent will take place at the bedside, 
typically 1-2 days prior to surgery, by a physician investigator. Potential subjects will be initially 
approached by a member of their clinical team (e.g., their nurse) who has first-hand knowledge of the 
potential subject’s medical history to ascertain their willingness to discuss the study with the physician 
investigator. If the potential subject agrees to discuss the study further, he/she will be introduced to the 
physician investigator by the clinical team member. Patients will be provided a paper handout that 
includes an overview of the study, along with the consent form, and will be given an opportunity to read 
the consent form and ask questions. Patients will then decide if they wish to decline, enroll, or if they 
need additional time to think about it, in which case they will be provided with a business card and 
encouraged to follow-up with any questions. In a minority of cases due to scheduling issues or re-
scheduling, patients may be approached on the day of surgery. Utmost care will be taken, and best 
clinical judgment will be used to determine if a patient is a candidate for same-day enrollment. This will 
include asking the patient’s nurse for input on the suitability for same-day enrollment, talking with the 
patient about their level of anxiety, and discussing the general idea of research with the patient and 
their family. 
 
Consent of inpatients using a hybrid phone/in-person approach 
On rare occasions there may be eligible patients in the hospital, but the physician investigator(s) for 
that site may not be available to consent the patient in-person. Under such circumstances, similar 
consenting procedures will take place as described above under, “Consent of inpatients”, except that 
potential subjects will be approached initially by a non-physician member of the study team (e.g., a 
clinical research coordinator). As above, this initial approach will only occur after a member of the 
potential subject’s clinical team has ascertained their willingness to discuss the research with the study 
team. The non-physician member of the study team will briefly introduce the study. If the patient wishes 
to hear more about the research, a physician investigator will then describe the study further by phone, 
including the purpose of the study, the study activities that will take place, and the risks and benefits of 
participating. The physician-investigator will also answer any questions. Patients will then decide if they 
wish to decline, enroll, or if they need additional time to think about it. For patients who wish to enroll, 
they will sign a paper informed consent form (ICF). A sticker with the patient’s name and MRN will be 
placed on each page of the ICF. The signature page of the ICF that includes a line for the physician-
investigator to sign and date will be scanned and emailed to the physician-investigator, who will then 
sign it and email it back to a member of the study team. This variation of the consent process, when 
employed, will be documented by a note in the study file. 
 
Consent of patients who lack decisional capacity 
It is unusual for patients undergoing cardiac surgery to lack decisional capacity. However, in a minority 
of cases there may be eligible patients who lack decisional capacity due to acute severity of illness 
(e.g., intubation/sedation) or other factors. In these cases, study investigators will follow identical 
procedures as above with the patient’s surrogate if the patient is deemed to lack decisional capacity by 
the clinical team. The Mass General Brigham preferred order of surrogates will be followed, and the 
investigator will document the relationship of the surrogate to the subject in the research record. The 
order of surrogates will be: 
 

Version Date 11/4/25;  Page 17 
 
i) court appointed guardian with specific authority to consent to participation in research or authority 
to make health care decisions for a class of diagnostic and therapeutic decisions inclusive of the 
proposed research; 
ii) health care proxy/person with durable power of attorney with specific authority for making health 
care decisions inclusive of the proposed research; or 
iii) spouse, adult child, or other close family member who knows the subject well and has been 
involved in their care. 
 
For patients deemed to lack decisional capacity who are enrolled by surrogate consent, assent of 
subjects will be required for participation in the research unless the subject is incapable of providing 
assent due to his/her medical condition (e.g., sedation). For patients deemed to lack decisional capacity 
who are enrolled by surrogate consent and who subsequently regain capacity during the study, 
investigators will explain the study (including updating them on what has happened so far as a result of 
being in the study), answer any questions, and ask for written informed consent to continue to 
participate. Alternatively, patients will have the option of withdrawing from the study. 
 
Non-English speaking patients will be eligible for inclusion. We will use official hospital interpreters and 
the Mass General Brigham approved ‘short form’ consent document in the native language of the 
patient and/or their surrogate. 
 
Using a checklist, we will document the following items of the informed consent process: 
 
▪ 
If consent was obtained in person or remotely (if remotely, we will document the method: electronic 
Informed Consent, email, or fax) 
▪ 
If consent was obtained from the subject or the surrogate 
▪ 
If consent was obtained from a subject who was physically unable to talk or write, we will document 
the means by which consent was given by the subject (e.g., orally) 
▪ 
If consent was obtained from the surrogate: 
-Reason why subject lacked decisional capacity 
-Relationship of surrogate to subject 
-Whether the patient was able to assent (if not, document the reason why) 
-Whether the subject regained capacity to consent a later time (if so, document whether the subject 
provided consent to continue to participate or not) 
▪ 
Whether an interpreter was required and the short form used 
▪ 
Confirmation that a copy of the consent form was provided to the subject or surrogate 
▪ 
Confirmation that the patient’s electronic medical record has been updated to reflect that the patient 
has consented to be enrolled in the research study 
 
4.3   Treatment assignment and randomization 
Participants will be randomly assigned in a 1:1 fashion to receive DFO or an equal volume of normal 
saline. Randomization will be stratified by site and by preoperative eGFR (<60 vs. ≥60 ml/min/1.73m2) 
at the time of screening. Treatment assignment lists will be generated centrally by the study 
biostatistician, Wei Wang PhD, using permuted block sizes of 4 and sent to the research pharmacies at 
each site. Patients, physicians, nurses, and study investigators will be blinded to treatment assignment. 
 
 

Version Date 11/4/25;  Page 18 
 
5. STUDY PROCEDURES 
 
5.1   Drugs to be used 
We will administer DFO or an equal volume of normal saline as an IV infusion over 12h. DFO will be 
administered at a total dose of 30 mg/kg (maximum total dose, 6g). The DFO (or normal saline) infusion 
will begin immediately prior to cardiac surgery (after induction of anesthesia and placement of a central 
venous catheter) and will be continued intra- and postoperatively for a total of 12h. The rationale for the 
dose of 30 mg/kg is provided in section 1.4. In preparing the DFO infusion, the research pharmacy at 
each site will follow similar methods used in prior DFO studies80, 81 and according to the manufacturer 
recommendations: the prescribed amount of DFO powder, based on the patient’s weight, will be 
dissolved in sterile water to achieve a concentration of 10%. The solution will then be further diluted in 
normal saline to achieve a final volume of 240mL to standardize the amount of fluid administered in 
both study arms. The DFO (or normal saline) will be delivered from the research pharmacy to the 
operating room by a member of the research pharmacy staff or a clinical research coordinator, and will 
be administered to the patient by the patient’s nurse as a continuous 12h IV infusion through a central 
venous catheter. The DFO or normal saline infusion will begin immediately after induction of anesthesia 
and placement of a central venous catheter, which is typically inserted into an internal jugular or 
subclavian vein in the operating room 1 hour prior to the start of surgery for routine clinical care. 
 
5.2   Data to be collected 
Upon enrollment, the following variables will be recorded: age; sex; race; ethnicity; comorbidities; home 
medications; type of surgery; urgency of surgery (elective, urgent, or emergent); and date of surgery. 
The following data will be recorded postoperatively: 
 
-Cardiopulmonary bypass (CPB) time 
-Aortic cross clamp time 
-Estimated blood loss intraoperatively 
-Requirement for (and number of) red blood cell transfusions intraoperatively and for 7d 
-Requirement for (and volume) of Cell Saver used intraoperatively 
-Duration of invasive mechanical ventilation 
-Myocardial injury, atrial fibrillation, ARDS, and infection/sepsis within 7d 
-Physiologic and vital sign data, including heart rate, blood pressure, and urine output for 7d 
-Daily lab values, including hemoglobin and serum creatinine, for 7d 
-Receipt of renal replacement therapy within 7d 
-Reoperation during hospitalization 
-ICU and hospital length of stay 
-ICU and hospital mortality 
 
5.3   Methods for data collection 
Each site will review electronic medical records and enter patient-level data into a central online 
database using REDCap, a secure, HIPAA-compliant, web-based application for building and 
managing databases. REDCap has many advanced features including multi-site access, audit trails, 
branching logic, and validation ranges for each variable to minimize keystroke errors. Clinical research 
coordinators will enter detailed data on demographics, comorbidities, vital signs, physiologic 
parameters (e.g., hourly urine output), laboratory measures, medications, and clinical outcomes. 
 
5.4   Biological sample collections 
Overview 
We will collect blood and urine samples at five time points: preoperatively (after insertion of an arterial 
line [for blood] and after insertion of a Foley catheter [for urine]); at the end of CPB; on arrival to the 
ICU; and on postoperative days 1 and 2 (Figure 4). Blood will be obtained from arterial or central 
venous catheters, which are inserted preoperatively as part of routine clinical care. If, during the course 
of the study, neither an arterial nor central venous catheter remains in place (e.g., on postoperative day 

Version Date 11/4/25;  Page 19 
 
2), blood will be obtained by peripheral venipuncture by a phlebotomist, in which case all efforts will be 
made to time the blood collection with a clinical blood draw to minimize discomfort. The total volume of 
blood collected will be 80mL. Blood will be collected in serum and heparinized vacutainers, since EDTA 
chelates iron. Urine (12cc) will be obtained from Foley catheters or from a clean catch voided sample if 
the Foley catheter is no longer in place. 
 
 
 
Blood volume 
The blood volumes shown in Figure 4 represent the minimum volume required to perform the 
comprehensive assays for the study. Preoperatively and at the end of CPB we will collect 25mL of 
blood, which will allow us to isolate peripheral blood mononuclear cells (PBMCs) and store them in 
liquid nitrogen for immunophenotyping, including flow cytometry, RNA sequencing (RNA-Seq), and 
qPCR. Specifically, collection of 25mL of blood will be divided as 20mL of plasma and 5mL of serum. 
The 20mL of plasma will allow us to isolate approximately 20 x 106 PBMCs, since each mL of blood 
contains approximately 106 PBMCs. We will aliquot and store these 20 x 106 PBMCs into four aliquots 
of 5 x 106 PBMCs each. Aliquot #1 will be used for flow cytometry studies to assess monocyte 
expression of IL-6, TNFα, HLA-DR, TLR4, PD-L1, IL-1β, IL-10, CD163, heme oxygenase-1, ferroportin, 
transferrin receptor 1, and iron uptake transporters (DMT1, ZIP14). These markers will be used to 
assess the effect of DFO (versus normal saline) on the inflammatory phenotype of monocytes 
postoperatively. Further, they will be used to assess whether the effect of DFO versus normal saline on 
clinical parameters (AKI and extrarenal acute organ injury) differs according to preoperative differences 
in monocyte expression of these markers. Aliquot #2 will be used to quantify intracellular iron 
concentrations using the calcein-AM method.84 Aliquot #3 will be used for RNA-Seq of monocytes to 
facilitate discovery of novel transcripts influenced by DFO. Aliquot #4 will be used for qPCR to validate 
the targets identified by RNA-Seq. 
 
The volume of blood drawn at the other time points will be 10mL, as shown in Figure 4. This will 
include 5mL of blood drawn into a serum vacutainer and 5mL drawn into a heparinized plasma 
vacutainer. The serum and plasma will be centrifuged, subaliquoted, and stored at –80C. 5mL of blood 
contains approximately 2.5mL of plasma/serum (approximately 50% of whole blood is plasma/serum), 
which will allow us to archive eight 300uL plasma and serum aliquots at each time point. These aliquots 
will be used to measure the following parameters, and for storage for future hypotheses and 
mechanistic pathways: catalytic iron, total iron, total iron binding capacity, ferritin, hepcidin, troponin I, 
and oxidative stress parameters (F[2]-isoprostane and myeloperoxidase). Finally, we will collect the 
buffy coat (for DNA isolation) on ICU arrival and on post-operative day (POD) 1 (Figure 4). 

Version Date 11/4/25;  Page 20 
 
 
Patients with a hemoglobin level <8 g/dl are excluded (section 3.2). Additionally, if during the course of 
the study the patient’s clinical team determines that collection of blood is unsafe for the patient (e.g., if 
the patient is experiencing major bleeding postoperatively) then the blood sample will not be collected 
until the clinical team determines that it is safe. Urine will be collected for assessment of markers of 
tubular injury, including NGAL and KIM-1. 
 
Sample processing, cataloging, storing, and monitoring 
We will centrifuge samples as soon as possible and no more than 6h after collection and store the 
plasma, serum, and urine at –80C. At two time points (preoperatively and at the end of CPB) we will 
also isolate PBMCs and store them in liquid nitrogen. We will use screw cap micro tubes for plasma, 
serum, and urine samples, each pre-labeled with a unique barcode and a printed label. Each site will 
catalogue the date and time of collection, processing, and storage at –80C (or in liquid nitrogen, for 
PBMCs) for each sample. Samples will be transported every 3-6 months from MGH and BIDMC to 
BWH, which will serve as the central biorepository for the study. The location of each sample will be 
cataloged using Freezerworks, a sophisticated biorepository management and inventory program. 
 
5.5   Sending biosamples and data outside MGB 
Sending biosamples to research collaborators outside Mass General Brigham 
Pending execution of a Material Transfer Agreement, we will send blood and urine samples to the 
following collaborators: Dr. Mohan Rajapurkar, at the Muljibhai Patel Society for Research in 
Nephrology (Nadiad, Gurajat, India), and Dr. Rajesh Gupta, at the University of Toledo (Toledo, OH). 
The purpose of shipping these samples is for measurement of catalytic iron and other iron parameters, 
such as hemopexin, haptoglobin, and free hemoglobin. These measurements are quite specialized, 
and the collaborators listed above have unique expertise in performing these measurements. Samples 
will be labeled with a study ID only. No patient-level data will be shared with collaborators at the 
Muljibhai Patel Society for Research in Nephrology. 
 
Sending coded data to research collaborators outside Mass General Brigham 
Coded data from RNA-Sequencing of peripheral blood mononuclear cells will be shared with Drs. 
Matthew Sampson and Dongwon Lee at Boston Children’s Hospital, who have expertise in 
bioinformatics and analysis of omics data, including transcriptomics. No protected health information 
will be shared with collaborators at Boston Children’s Hospital. We will also send a limited dataset of 
randomized patients to the bioinformatics company, Telperian, a clinical innovation company that 
integrates machine learning with clinical trial data to identify subgroups of patients who may benefit 
from the intervention. 
 
 
 
 

Version Date 11/4/25;  Page 21 
 
6. BIOSTATISTICAL ANALYSIS 
 
6.1   Primary endpoint definition 
The primary endpoint is the incidence of postoperative AKI, defined according to the KDIGO criteria 
as any of the following: urine output <0.5 ml/kg/h for ≥6 consecutive hours (assessed within the first 
48h or until the Foley catheter is removed, whichever occurs first; an increase in SCr ≥0.3 mg/dl within 
the first 48h; an increase in SCr ≥50% within the first 7 days; or receipt of RRT within the first 7 days.85 
The immediate preoperative SCr will be used as the baseline value for all analyses. SCr is measured at 
least once daily for routine clinical care postoperatively. Assessment of urine output monitoring will 
begin at the start of surgery. 
 
6.2   Statistical analysis for the primary endpoint 
Hypothesis 1: DFO will reduce the incidence of postoperative AKI. We will use the χ2 test to compare 
the proportion of patients in the DFO versus normal saline (placebo) group who develop the primary 
endpoint. We will perform sensitivity analyses to assess the composite outcome of AKI or death, since 
death is a competing risk for AKI. We will use logistic regression to assess for heterogeneity of 
therapeutic response to DFO across the following subgroups: age; sex; race (White vs. non-White); 
preoperative eGFR (<60 vs. ≥60 ml/min/1.73m2); AKI risk score (≤8 vs. >8); duration of CPB (<120 vs. 
≥120 min; <120 vs. 120-180 vs. >180 min)); intraoperative RBC transfusion; and type of surgery 
(elective vs. urgent/emergent). 
 
6.3   Sample size and power 
Based on our preliminary data and prior studies,37, 38 the anticipated AKI event rate in the placebo group 
is 50%. We hypothesize the AKI event rate in the DFO group will be 34%, an effect size that has been 
proposed to be reasonable for studies in AKI.86, 87 A total of 296 patients (n=148 per group) will provide 
80% power to detect the above treatment effect, with a two-sided α of 0.05. Enrollment of 330 patients 
provides a small buffer for potential early withdrawal from the study, which we anticipate will be 
uncommon due to the nature of the study (inpatient and short duration). 
 
6.4   Secondary endpoints 
Other renal endpoints (clinical) 
▪ 
Effect of DFO across all stages of AKI, defined by changes in SCr according to the KDIGO criteria85 
within 7 days of cardiac surgery. 
▪ 
Requirement for loop or thiazide diuretics in the setting of ≥2 hours of oliguria (urine output <0.5 
ml/kg/h for ≥2 consecutive hours) within 48h of cardiac surgery. 
▪ 
Incidence of Major Adverse Kidney Events,88 defined as any of the following within 7 days following 
cardiac surgery: ≥100% increase in SCr, receipt of RRT, or death. 
 
Other renal endpoints (urinary tubular injury markers) 
We will assess the effect of DFO on renal tubular injury using longitudinal measures of urine NGAL and 
KIM-1, each assessed pre- and postoperatively (Figure 4). These injury markers provide 
complementary data to functional markers (e.g., SCr),89 and have been used in multiple RCTs.90-93  
Urine NGAL and KIM-1 will be normalized to the urine creatinine to account for the influence of dilution. 
 
Extrarenal acute organ injury 
We will assess the incidence of postoperative myocardial injury, atrial fibrillation, prolonged mechanical 
ventilation, and sepsis. The consensus definition and anticipated incidence for each endpoint is 
described in Table 5, and each was chosen based on a strong biologic rationale (Table 5). Assessment 
of atrial fibrillation will be limited to patients who do not have it at baseline. For sepsis, we will document 
the suspected or confirmed source of infection: pneumonia, genitourinary, biliary, bacteremia, sternal 
wound infection, or other. We will also document the presence/absence of septic shock, defined as 
sepsis with persistent hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mm 
Hg and having a serum lactate level >2 mmol/L despite adequate volume resuscitation.94 

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We will assess time to liberation from IV vasoactive medications, as well as the Vasoactive-Inotropic 
Score during the first 24 hours. Finally, we will assess the number of ventilator-, hospital-, and ICU-free 
days to day 28, as well as all-cause hospital mortality. Patients who die prior to 28 days will be 
assigned 0 ventilator-, hospital-, and ICU-free days. 
 
Iron and oxidative stress markers 
We will assess the effect of DFO on iron and oxidative stress markers, including catalytic iron, total iron, 
total iron binding capacity, ferritin, hepcidin, F(2)-isoprostane, and myeloperoxidase, each assessed 
pre- and postoperatively (Figure 4). 
 
6.5   Statistical analysis for secondary endpoints 
Hypothesis 2: DFO will attenuate peak postoperative increases in urinary markers of tubular injury 
(NGAL and KIM-1) and iron and oxidative stress, and will reduce the incidence of myocardial injury, 
atrial fibrillation, prolonged mechanical ventilation, and sepsis. For binary variables we will use the χ2 
test to compare the proportion of patients in each group who develop the endpoint. For continuous 
variables we will compare baseline (preoperative)-adjusted peak postoperative levels of each marker in 
DFO- versus placebo-treated patients using the two sample t-test or Wilcoxon rank-sum test depending 
on the distribution. We will also use a Generalized Estimating Equation for repeated measures to 
analyze longitudinal assessments of each marker in DFO- versus placebo-treated patients. For 
analyses of urinary tubular injury markers, we will perform sensitivity analyses using a global rank 
endpoint to account for anuria as a competing risk.101, 102 Finally, we will evaluate a composite endpoint 
of any renal or extrarenal acute organ injury or hospital mortality. 
 
6.6   Modified intention-to-treat analysis 
The final analysis will be limited to patients who are initiated on the study drug, irrespective of whether 
they are able to complete the entire 12h infusion, consistent with a modified intention-to-treat analysis. 
Patients who consent but are subsequently found to be ineligible prior to initiation of the study drug 
infusion (e.g., if a patient develops a new fever several hours prior to surgery) will be withdrawn. In 
such cases, the reason for the withdrawal will be documented and reported, but these patients will not 
be included in the final analysis, nor will they count toward the total enrollment target of 300 analyzable 
patients. Accordingly, we anticipate enrolling up to 330 patients (10% buffer) to obtain 300 analyzable 
patients, accounting for withdrawal prior to receipt of study drug. 
 
 
Table 5. Secondary extrarenal endpoints 
Endpoint 
Definition 
Incidence* Biologic Rationale 
Myocardial 
injury 
Peak postop troponin I† elevation >10 times the 
99th percentile URL, assessed on POD1 and 2.95 
15% 
DFO attenuates cardiac IRI67, 68 and improves myocardial 
contractility in animals.96 In a RCT in 45 adults undergoing 
cardiac surgery, patients treated with DFO had a higher 
LVEF postop compared to placebo.80 
AF 
‡Confirmed on a 12-lead ECG or a rhythm strip, 
confirmed by a healthcare provider, or treated 
(either medically [e.g., amiodarone] or with 
electrical cardioversion). Patients with AF at 
baseline will be excluded. 
40% 
In animal models, DFO prevents CPB-associated 
arrhythmias.69  In patients with chronic iron overload from 
beta-thalassemia major, arrhythmias are an indication for 
DFO treatment intensification.97 
Prolonged 
ventilation 
‡Requirement for mechanical ventilation >24h 
postop. 
20% 
In animal models, DFO attenuates the severity of 
mechanical ventilation- and lipopolysaccharide-induced 
acute lung injury.70, 71 
Sepsis 
‡Life-threatening organ dysfunction caused by a 
dysregulated host response to infection (assessed 
within 7d postop). Organ dysfunction is defined as 
an acute increase in the total SOFA score ≥2 
points consequent to the infection. 
10% 
DFO improves monocyte phagolysosome function in vitro.98  
Moreover, DFO improves survival in animal models of 
sepsis.75, 76, 99   
*Anticipated incidence based on our preliminary data and published literature. †Troponin I is less affected by skeletal muscle breakdown 
than troponin T.100 ‡Defined as per the Third International Consensus Definition (Sepsis-3).94 Abbreviations: AF, atrial fibrillation/flutter; 
DFO, deferoxamine; ICH, intracerebral hemorrhage; LVEF, left ventricular ejection fraction; POD, postoperative day; URL, upper reference 
limit. 

Version Date 11/4/25;  Page 23 
 
7. RISKS AND DISCOMFORTS 
 
Overview of DFO safety profile 
DFO was the first iron chelator approved by the FDA (in 1968), and thus has a long track record of 
safety. DFO is generally very well tolerated, as patients with genetic hemoglobin disorders complicated 
by iron overload often receive DFO on a daily basis for their entire lives.103 Rare but serious potential 
adverse effects of DFO include hypersensitivity reactions, hypotension, acute respiratory distress 
syndrome (ARDS), infection, vision changes, and hearing loss. 
 
7.1   Hypersensitivity reactions 
Hypersensitivity reactions, including anaphylaxis, have very rarely been reported with DFO (less than 1 
in 10,000). In a phase 2 RCT of DFO at 32 mg/kg per day for 3 days in patients with ICH, none of the 
147 DFO-treated patients experienced anaphylaxis.82 
 
7.2   Hypotension 
DFO may cause hypotension if infused very rapidly (>15 mg/kg/h). For example, DFO-induced 
hypotension was initially observed in two of three children with acute iron poisoning who received large 
doses of IV DFO (ranging from 800-1500mg) administered over 15 minutes.104 Accordingly, the FDA-
recommended infusion rate for IV DFO for acute iron intoxication is to not exceed 15 mg/kg/h. Thus, the 
DFO dosing regimen in the current study (30 mg/kg over 12h hours, which equates to 2.5 mg/kg/h) is 6-
fold lower than the maximum FDA-recommended infusion rate. 
 
Regarding dose, the maximum FDA-approved dose for DFO for acute iron intoxication is 6g/day, or ~86 
mg/kg in a 70-kg adult, and doses as high as 150 mg/kg/day for 3 months have been used without 
toxicity.105 Thus, the dosing of 30 mg/kg in the current study is far below the maximum FDA-approved 
dose, and is unlikely to cause hypotension. Supporting this, one study administered DFO as an IV 
bolus of 500mg over 10 minutes in patients with STEMI.81 This infusion rate of 50mg/min, despite being 
more than 15-times higher than the infusion rate in the current study (30 mg/kg over 12h, or ~3 mg/min 
in a 70-kg individual), did not result in any hypotension. Importantly, hypotension was also not observed 
in the studies of IV DFO for acute organ injury prevention in humans, summarized in Table 3. The 
largest such study, a phase 2 RCT of DFO at 32 mg/kg per day for 3 days in patients with ICH, found 
the incidence of hypotension was similar in the DFO-treated patients (1 of 144 [1%]) compared to 
placebo-treated patients (2 of 147 [1%]).82 
 
7.3   ARDS 
DFO may rarely cause ARDS when administered in very high doses. Tenenbein et al. described four 
adult patients with acute iron overdose who developed ARDS after receiving high doses of IV DFO (15 
mg/kg/h) for prolonged periods of time.106 DFO doses received by the four patients ranged from 24 to 
120g delivered over 32 to 72 hours, corresponding with doses 10 to 50-times higher than those that will 
be used in the current study. The High-Dose Deferoxamine in Intracerebral Hemorrhage (HI-DEF) 
study (clinicaltrials.gov NCT01662895), which investigated a continuous IV infusion of DFO at 62 
mg/kg/day for 5 consecutive days versus normal saline placebo in patients with ICH, was stopped early 
due to the observation of 6 cases of ARDS among the DFO-treated patients after enrollment of 42 
subjects. Three modifications to the DFO dosing regimen were subsequently implemented: 1) the 62 
mg/kg/day dose was reduced to 32 mg/kg/day; 2) the 5-day infusion was reduced to 3 days; and 3) the 
continuous infusion was changed to daily interrupted infusions of 12h/day, based on data that DFO-
associated ARDS is more likely to occur in patients treated for longer than 24h.106 These changes to 
the DFO dosing regimen were implemented in a phase 2 RCT of DFO in patients with ICH, and the 
incidence of ARDS was similar in the DFO- (2 of 144 [1%]) compared to placebo-treated patients (1 of 
147 [1%]).82 
 

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7.4   Infection 
In patients with chronic iron overload it has been reported that infections, especially gastroenteritis with 
Yersinia species, may be promoted by DFO. Among dialysis patients receiving DFO, rare cases of 
mucormycosis have also been reported. An increased risk of infection has not been reported with short-
term use of DFO for acute organ injury prevention (Table 3). The largest such study, a phase 2 RCT of 
DFO at 32 mg/kg per day for 3 days in patients with ICH, found the incidence of infection was similar in 
DFO- and placebo-treated patients (35 of 144 [25.0%] and 36 of 147 [24.5%], respectively).82 
 
7.5   Vision changes 
DFO administered in high doses and over long periods of time has rarely been linked to vision changes. 
Effects on the eye were first noted when very high doses (>100 mg/kg/day) were given.107 Symptoms 
may include night-blindness, impaired color vision, impaired visual fields, and reduced visual acuity. 
Severe cases may show signs of retinitis pigmentosa on fundoscopy, whereas milder cases are only 
demonstrable with electroretinography. The main risk factor appears to be high doses of DFO.108 
 
The prevalence of DFO-associated ocular toxicity was evaluated in 84 children who were receiving 
DFO for an average of 6.6 years for transfusion-related iron overload due to thalassemia.109 The DFO 
dosage was 25-50 mg/kg/day. Ophthalmic screening was performed at baseline and on an annual 
basis. Only one patient had abnormal findings, with central blurring, retinal pigmentary changes, and a 
reduced central response on electroretinography. This patient had a 3-year history of poor adherence 
and was temporarily receiving IV DFO at 50 mg/kg/day; all symptoms promptly recovered after 
changing to subcutaneous administration. Notably, vision changes have not been described in any of 
the short-term studies of DFO use for acute organ injury prevention (Table 3). The largest such study, a 
phase 2 RCT of DFO at 32 mg/kg per day for 3 days in patients with ICH, found that none of the 147 
DFO-treated patients experienced vision changes.82 
 
7.6   Hearing loss 
Sensorineural hearing loss has rarely been reported in patients receiving high doses of DFO long-term. 
One study assessed the frequency of hearing loss cross-sectionally in 67 patients receiving regular 
DFO via subcutaneous pump infusion for β-thalassemia.110 Patients received DFO at a mean dose of 
50 mg/kg/day. In five patients, sensorineural hearing loss was detected. The mean exposure time to 
DFO in these five patients was 15 years. Importantly, hearing loss has not been reported with short-
term use of DFO for acute organ injury prevention (Table 3). The largest such study, a phase 2 RCT of 
DFO at 32 mg/kg per day for 3 days in patients with ICH, found the incidence of hearing loss was 
similar in DFO- and placebo-treated patients (1 of 144 [1%] and 1 of 147 [1%], respectively).82 
 
7.7   Summary of all potential adverse effects of DFO, and their frequency 
Very common side effects (affecting more than 1/10 patients): 
-Injection site reaction such as pain, swelling, reddening, itching of the skin 
-Joint or muscle pain 
 
Common side effects (affecting between 1/10 to 1/100 patients): 
-Nausea 
-Headache 
-Fever 
 
Uncommon side effects (affecting between 1/100 to 1/1,000 patients) 
-Vomiting 
-Abdominal pain 
-Disturbances of hearing such as ringing, hearing loss 
 
Rare side effects (affecting between 1/1,000 to 1/10,000 patients): 

Version Date 11/4/25;  Page 25 
 
-Disturbances of vision such as blurred eyesight, abnormal color vision, night blindness, black spots in 
the vision, loss of vision, clouding of the lens of the eye, visual field defects, or decreased sharpness of 
vision 
-Fungal or bacterial infections leading to high fever, shortness of breath, acute diarrhea, abdominal 
pain, general discomfort, or sore throat 
-Dizziness, light-headedness (signs of low blood pressure that can occur when the drug is given too 
rapidly) 
 
Very rare side effects (affecting less than 1/10,000 patients): 
-Diarrhea 
-Sensation of numbness or tingling in fingers and toes 
-Breathlessness due to lung disorders 
-Hives, difficulty breathing or swallowing, feeling of tightness in the chest with wheezing or coughing, 
dizziness, swelling mainly of the face and throat (signs of a severe allergic reaction or asthma) 
-Disturbances of the nervous systems 
 
Unknown frequency: 
-Muscle spasms 
-Abnormal kidney function test results or decreased urine output 
 
Additional information on DFO safety can be found in the attached FDA product label. 
 
7.8   Risks of blood draw 
The total volume of blood collected for this study (assuming that a subject is hospitalized for at least 2 
days postoperatively) is 80mL (about 5 tablespoons). Blood will be obtained from arterial or central 
venous catheters, which are inserted preoperatively as part of routine clinical care. If, during the course 
of the study, neither an arterial nor central venous catheter remains in place, blood will be obtained by 
peripheral venipuncture by a phlebotomist, in which case all efforts will be made to time the blood 
collection with a clinical blood draw to minimize discomfort. There is a very small risk of infection, 
lightheadedness, and/or fainting during blood draws. 
 
7.9   Loss of confidential patient information 
Loss of confidential patient information is a potential risk in any clinical study. To minimize this risk we 
will collect our primary database using REDCap, a secure, HIPAA-compliant, web-based application for 
building and managing databases. REDCap has many advanced features including multi-site access, 
audit trails, and the ability to export data with removal of identifiers. Electronic study documents 
containing protected health information will only be kept on password-protected hospital computers. 
Paper documents containing protected health information will be kept in binders stored in a secure 
location at each hospital site. All research staff are CITI-certified and will receive regular training at lab 
meetings regarding the importance of confidentiality of data. 
 
Biological specimen tubes containing plasma, serum, DNA, and urine will be tagged with study ID#’s 
only and will not include any protected health information. Specimens will be stored in locked freezers 
at each of the three sites, and will be transported every 3-6 months from MGH and BIDMC to BWH, 
which will serve as the central biorepository for the study. No protected health information will be 
shared with collaborators outside of Mass General Brigham. Genetic data will not be placed onto 
publicly available repositories such as the National Institutes of Health (NIH) central repository. 
 
 

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8. POTENTIAL BENEFITS 
 
8.1   Potential benefits to participating individuals 
Individuals assigned to receive DFO may experience lower rates of postoperative AKI following cardiac 
surgery. Our hypothesis that iron chelation with DFO may prevent/attenuate AKI in patients undergoing 
cardiac surgery is supported by ample data from preclinical studies, as well as preliminary data in 
humans (discussed in detail in section 1). 
 
8.2   Potential benefits to society 
This study will help answer a critically important question about the potential pathologic role of iron in 
AKI. If we demonstrate a therapeutic effect of DFO on prevention of AKI or other acute organ injury, the 
findings from this study will lay the groundwork for conducting a larger, phase 3, RCT of iron chelation 
in the setting of cardiac surgery. Even null findings will yield important scientific insights into AKI. We 
will generate novel data on circulating measures of inflammation and oxidative stress in the 
perioperative setting, which we will explore in relation to clinical endpoints such as AKI. Using 
sophisticated translational immunology techniques, including flow cytometry and RNA-Seq, we will 
generate novel data on monocyte immunophenotype in the setting of AKI. 
 
 
 
 

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9. MONITORING AND QUALITY ASSURANCE 
 
9.1   Independent monitoring of source data 
Study investigators collecting the data will be blinded to the treatment group. The key linking the study 
ID with the treatment group will be maintained securely by the study’s biostatistician and by the 
research pharmacies of each of the three participating sites. 
 
9.2   Study team composition, oversight, and governance 
Study team composition 
David E. Leaf, MD, MMSc is the PI, and will be responsible for recruitment of patients at BWH, as well 
as the overall execution of the trial, including all communications with regulatory agencies. Aranya 
Bagchi, MBBS is the site principal investigator (PI) at MGH, and will be responsible for overseeing 
recruitment and all study activities at MGH. Shahzad Shaefi, MD, MPH is the site PI at BIDMC, and will 
be responsible for overseeing recruitment and all study activities at BIDMC. Jochen Muehlschlegel, 
MD, MMSc is a co-investigator and will assist with troubleshooting any enrollment or logistical issues 
that arise over the course of the study. Edy Kim, MD, PhD is a co-investigator and will lead the 
monocyte studies in Aim 2. Wei Wang, PhD is a biostatistician and will conduct the primary analyses for 
the trial. She will also generate randomized treatment assignment lists for the research pharmacies at 
each site. Matthew Sampson, MD, MSCE and Dongwon Lee, PhD are co-investigators and will lead the 
analyses of the monocyte transcriptomics in Aim 2. 
 
Oversight 
Dr. David Leaf is responsible for overseeing the overall conduct of the study across all three sites. Site 
PIs (Dr. David Leaf for BWH; Dr. Aranya Bagchi for MGH; Dr. Shahzad Shaefi for BIDMC) will be 
responsible for oversight of data and sample collection at each site. Drs. Leaf, Bagchi, and Shaefi will 
have regular conference calls and will meet in person at least 4 times per year. Additionally, Dr. Leaf 
will conduct in-person site visits at a minimum of every 6 months to ensure that all study procedures are 
being performed and documented in accordance with the protocol, with corrective actions taken as 
needed to ensure compliance. All data entry into REDCap is expected to be completed no later than 30 
days from the date of hospital discharge or death. 
 
Governance 
Dr. Leaf will lead the study and have responsibility for all study decisions. Major study decisions will be 
made in close consultation with co-investigators, regulatory agencies, and content experts. Study 
decisions will be communicated to co-investigators in writing (by email). Study progress will be reported 
to the single Institutional Review Board through an online portal (Insight), and will be communicated to 
the Food and Drug Administration through 1571 forms, which will be sent via overnight mail. The 
primary mode of communication with members of the DSMB will be via email. 
 
9.3   Safety monitoring and reporting  
Overview 
The patients in this study will be undergoing high risk surgery and will be critically ill postoperatively. It 
is therefore expected that they will have a number of unrelated adverse health events during the course 
of their hospital stay. Therefore, we will limit the scope of our adverse events (AEs) monitoring and 
reporting to the following AEs of special interest (AESI), which will be assessed by review of electronic 
medical records: hypersensitivity reactions (including anaphylaxis); hypotension; ARDS; 
infection/sepsis; and any AE that, in the view of the site PI, is definitely or possibly related to the study 
drug. 
 
Hypersensitivity reaction 
During the 12h study drug infusion, patients will be in the highly monitored setting of the operating room 
or the cardiothoracic ICU. If a patient develops anaphylaxis or any other serious AE during the study 
drug infusion that is related or possibly related to the study drug, the infusion will be discontinued 

Version Date 11/4/25;  Page 28 
 
immediately. If a patient develops anaphylaxis, the patient will be treated as per routine clinical care, 
including IM epinephrine, methylprednisolone, antihistamines, normal saline, albuterol, and other 
therapies as determined by the clinical team. 
 
Hypotension 
Although hypotension has not been reported with the DFO dosing regimen that will be used in the 
current study, we will monitor the frequency and severity of hypotension in the perioperative period by 
calculating the vasoactive-inotropic score during the first 24 hours of the study, beginning with the start 
of the study drug infusion. The vasoactive-inotropic score is a validated method for integrating all 
vasoactive medications and their doses on an hourly basis into a single measure, and has been used in 
multiple settings,111-113 including CPB surgery.114 
 
ARDS 
The incidence of ARDS will be assessed daily during the hospital stay for a maximum of 7 days. ARDS 
will be defined and its severity categorized according to the Berlin criteria115 as follows: 
 
Berlin Definition of ARDS 
Timing 
Within 1 week of a known clinical insult 
Chest imaging (chest radiograph 
or computed tomography) 
Bilateral opacities – not fully explained by effusions, lobar/lung collapse, or nodules 
Origin of edema 
Respiratory failure not fully explained by cardiac failure or fluid overload 
Need objective assessment (e.g., echocardiography) to excluded hydrostatic edema if 
no risk factor present 
Oxygenation 
 
   Mild 
PaO2/FiO2 201-300 mm Hg with PEEP≥5 cm H2O 
   Moderate 
PaO2/FiO2 101-200 mm Hg with PEEP≥5 cm H2O 
   Severe 
PaO2/FiO2 ≤100 mm Hg with PEEP≥5 cm H2O 
Abbreviations: FiO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen; PEEP, positive end-expiratory 
pressure 
 
In addition to monitoring the incidence and severity of ARDS, we will also record the frequency of the 
following respiratory outcomes to further monitor for pulmonary toxicity that may not meet the strict 
criteria for ARDS: 
-Requirement for mechanical ventilation >24h postoperatively 
-Ventilator-free days to day 28 
 
Infection/sepsis 
We will document all suspected or confirmed infections in the first 7 days or until hospital discharge. 
Infections will be categorized according to the source (pneumonia, genitourinary, biliary, bacteremia, 
sternal wound infection, or other) and severity (infection alone, sepsis, or septic shock). Sepsis is 
defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. 
Organ dysfunction is defined as an acute increase in the total SOFA score ≥2 points consequent to the 
infection.94 Septic shock is defined as sepsis with persistent hypotension requiring vasopressors to 
maintain mean arterial pressure ≥65 mm Hg and having a serum lactate level >2 mmol/L despite 
adequate volume resuscitation.94 
 
Classifying AESI according to severity and relatedness to the study intervention 
For each AESI, site PIs will document the severity and relatedness to the study intervention. Severity of 
AESIs will be assessed using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. 
Relatedness will be categorized as definitely, possibly, or not related to the study intervention, 
according to the following definitions: 
 
▪ 
Definitely Related: The adverse event is clearly related to the investigational agent – i.e., an 
event that follows a reasonable temporal sequence from administration of the study intervention, 
follows a known or expected response pattern to the suspected intervention, or that is confirmed 

Version Date 11/4/25;  Page 29 
 
by improvement on stopping the exposure and that could not be reasonably explained by the 
known characteristics of the subject’s clinical state. 
▪ 
Possibly Related: An adverse event that follows a reasonable temporal sequence from 
administration of the study intervention and follows a known or expected response pattern to the 
suspected intervention, but that could readily have been produced by a number of other factors. 
▪ 
Not Related: The adverse event is clearly not related to the investigational agent – i.e., another 
cause of the event is most plausible; and/or a clinically plausible temporal sequence is 
inconsistent with the onset of the event and the study intervention and/or a causal relationship is 
considered biologically implausible. 
 
Reporting of unanticipated problems, including unanticipated AEs 
Site PIs will report all unanticipated problems involving risks to subjects or others to the overall study 
PI, Dr. David Leaf, within 24h of the date they first become aware of the problem. Dr. Leaf will report all 
unanticipated problems involving risks to subjects or others to the Mass General Brigham Institutional 
Review Board (IRB), which is serving as the single IRB for this study, and to the Chair of the Data and 
Safety Monitoring Board (DSMB), within 5 working days/7 calendar days of the date he first becomes 
aware of the problem. Other AEs and minor protocol deviations will be reported to the IRB during 
continuing review. 
 
Unblinding 
Physicians caring for study subjects in an emergency situation may determine that unblinding is 
necessary for clinical care. In such a scenario, physicians may be unblinded. Whenever possible, the 
physician caring for the patient should contact the site PI to notify them of the need to be unblinded to a 
particular subject and communicate any planned intervention so that such interventions can be 
documented. Physicians can be unblinded by contacting the research pharmacy at their site (available 
by phone/pager 24h/day, 7d/week) and requesting to be unblinded for provision of emergency care. 
 
9.4   DSMB 
A multidisciplinary panel of three physician-scientists with expertise in clinical trials, cardiac surgery, 
acute kidney injury, and iron chelation will meet in person or through videoconference prior to study 
launch and after enrollment of 10, 25, 50, and 75% of the total enrollment target. Additional meetings 
will be held more frequently as needed, as determined by the members of the DSMB. Enrollment rates, 
unanticipated problems, and data on AEs will be reviewed at each meeting. The members of the 
committee will have the option to review data on AEs in an unblinded manner. If they choose to 
exercise this option, an honest broker who is not involved in the direct conduct of the research will be 
available to unblind the committee members (study investigators will remain blinded). 
 
The DSMB will submit a written report to the overall study PI (Dr. Leaf) within 3 days of each meeting. 
This report will be submitted to the IRB during Continuing Review, unless the DSMB recommends 
changes to the protocol or other study documents, in which case the report will be submitted to the IRB, 
along with an amendment incorporating the suggested changes, within 14 calendar days from the date 
the PI receives the report. The DSMB will be responsible for determining if the research should be 
altered or stopped. As this is a phase 2 RCT, no interim analyses are planned for potential early 
stopping of the trial for either futility or efficacy. The DSMB consists of the following three individuals, 
none of whom are affiliated with the trial: 
 
 
1. Lorenzo Berra, MD (Chair) 
Medical Director, Respiratory Care, Dept of Anesthesia, Critical Care and Pain Medicine, MGH 
Reginald Jenney Associate Professor of Anaesthesia, HMS 
 
2. Magdy Selim, MD, PhD 
Chief, Division of Stroke and Cerebrovascular Diseases, BIDMC 

Version Date 11/4/25;  Page 30 
 
Vice Chair, Committee on Clinical Investigations, BIDMC 
Professor of Neurology, HMS 
 
3. Maureen M. Achebe, MD 
Clinical Director, Non-Malignant Hematologic Clinic, Dana-Farber Cancer Institute 
Director, BWH Sickle Cell Program 
Assistant Professor of Medicine, HMS 
 
A minimum of two DSMB members (the Chair plus at least one other member) will be required for 
quorum. If there is a disagreement among members of the committee regarding recommendations for 
changes to the protocol, recommendations will be made according to the majority vote. If there are only 
two members present and there is a disagreement, the Chair will make the final decision. 
 
Qualifications of DSMB members 
Dr. Berra is the Medical Director of Respiratory Care and a staff anesthesiologist and intensivist in the 
Department of Anesthesia, Critical Care and Pain Medicine at MGH. He is an NIH-funded physician-
scientist with expertise in RCTs in the setting of cardiac surgery. 
 
Dr. Selim is the Chief of the Division of Stroke and Cerebrovascular Diseases at BIDMC. He is the PI of 
the Intracerebral Hemorrhage Deferoxamine (i-DEF) study, the largest RCT (n=294) of DFO for acute 
organ injury prevention performed to date.82 He has been studying DFO in the context of ICH since 
2009. He is also the Vice Chair for the Committee on Clinical Investigations (the IRB) at BIDMC. 
 
Dr. Achebe is a hematologist with expertise in the clinical use of iron chelators, including DFO, through 
her experience in the management of iron overload in patients with hemoglobinopathies. She also has 
expertise with RCTs as the site PI for several multicenter trials through the Sickle Cell Disease Clinical 
Trials Network and several investigator-initiated and industry-funded trials in sickle cell disease and 
other red cell disorders. 
 
9.5   Single IRB 
In accordance with NIH policy, protection of human subjects will be monitored by a single IRB (the 
Mass General Brigham IRB). 
 
 
 
 

Version Date 11/4/25;  Page 31 
 
10. REFERENCES 
 
1. 
Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, 
length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005; 16(11):3365-70. 
2. 
Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal changes in incidence of dialysis-
requiring AKI. J Am Soc Nephrol. 2013; 24(1):37-42. 
3. 
Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a 
systematic review and meta-analysis. Kidney Int. 2012; 81(5):442-8. 
4. 
Odutayo A, Wong CX, Farkouh M, et al. AKI and Long-Term Risk for Cardiovascular Events and 
Mortality. J Am Soc Nephrol. 2017; 28(1):377-87. 
5. 
Villeneuve PM, Clark EG, Sikora L, Sood MM, Bagshaw SM. Health-related quality-of-life 
among survivors of acute kidney injury in the intensive care unit: a systematic review. Intensive 
Care Med. 2016; 42(2):137-46. 
6. 
Halliwell B, Gutteridge JM. Role of free radicals and catalytic metal ions in human disease: an 
overview. Methods Enzymol. 1990; 186:1-85. 
7. 
Jacob AK, Hotchkiss RS, DeMeester SL, et al. Endothelial cell apoptosis is accelerated by 
inorganic iron and heat via an oxygen radical dependent mechanism. Surgery. 1997; 
122(2):243-53. 
8. 
Paller MS, Hedlund BE. Role of iron in postischemic renal injury in the rat. Kidney Int. 1988; 
34(4):474-80. 
9. 
Zager RA, Johnson AC, Hanson SY. Parenteral iron therapy exacerbates experimental sepsis. 
Kidney Int. 2004; 65(6):2108-12. 
10. 
Wu ZL, Paller MS. Iron loading enhances susceptibility to renal ischemia in rats. Ren Fail. 1994; 
16(4):471-80. 
11. 
Baliga R, Zhang Z, Baliga M, Shah SV. Evidence for cytochrome P-450 as a source of catalytic 
iron in myoglobinuric acute renal failure. Kidney Int. 1996; 49(2):362-9. 
12. 
Baliga R, Zhang Z, Baliga M, Ueda N, Shah SV. In vitro and in vivo evidence suggesting a role 
for iron in cisplatin-induced nephrotoxicity. Kidney Int. 1998; 53(2):394-401. 
13. 
Baliga R, Ueda N, Shah SV. Increase in bleomycin-detectable iron in ischaemia/reperfusion 
injury to rat kidneys. Biochem J. 1993; 291:901-5. 
14. 
Agarwal A, Balla J, Alam J, Croatt AJ, Nath KA. Induction of heme oxygenase in toxic renal 
injury: a protective role in cisplatin nephrotoxicity in the rat. Kidney Int. 1995; 48(4):1298-307. 
15. 
Zarjou A, Bolisetty S, Joseph R, et al. Proximal tubule H-ferritin mediates iron trafficking in acute 
kidney injury. J Clin Invest. 2013; 123(10):4423-34. 
16. 
Wang X, Zheng X, Zhang J, et al. Physiological functions of ferroportin in the regulation of renal 
iron recycling and ischemic acute kidney injury. Am J Physiol Renal Physiol. 2018; 
315(4):F1042-F57. 
17. 
Scindia Y, Dey P, Thirunagari A, et al. Hepcidin Mitigates Renal Ischemia-Reperfusion Injury by 
Modulating Systemic Iron Homeostasis. J Am Soc Nephrol. 2015; 26(11):2800-14. 
18. 
van Swelm RP, Wetzels JF, Verweij VG, et al. Renal Handling of Circulating and Renal-
Synthesized Hepcidin and Its Protective Effects against Hemoglobin-Mediated Kidney Injury. J 
Am Soc Nephrol. 2016; 27(9):2720-32. 
19. 
Evans RW, Rafique R, Zarea A, et al. Nature of non-transferrin-bound iron: studies on iron 
citrate complexes and thalassemic sera. J Biol Inorg Chem. 2008; 13(1):57-74. 
20. 
Dixon SJ, Lemberg KM, Lamprecht MR, et al. Ferroptosis: an iron-dependent form of 
nonapoptotic cell death. Cell. 2012; 149(5):1060-72. 
21. 
Reeder BJ, Wilson MT. Desferrioxamine inhibits production of cytotoxic heme to protein cross-
linked myoglobin: a mechanism to protect against oxidative stress without iron chelation. Chem 
Res Toxicol. 2005; 18(6):1004-11. 
22. 
Reeder BJ, Hider RC, Wilson MT. Iron chelators can protect against oxidative stress through 
ferryl heme reduction. Free Radic Biol Med. 2008; 44(3):264-73. 

Version Date 11/4/25;  Page 32 
 
23. 
Mehrabani M, Najafi M, Kamarul T, et al. Deferoxamine preconditioning to restore impaired HIF-
1alpha-mediated angiogenic mechanisms in adipose-derived stem cells from STZ-induced type 
1 diabetic rats. Cell Prolif. 2015; 48(5):532-49. 
24. 
Choi CW, Lee J, Lee HJ, et al. Deferoxamine Improves Alveolar and Pulmonary Vascular 
Development by Upregulating Hypoxia-inducible Factor-1alpha in a Rat Model of 
Bronchopulmonary Dysplasia. J Korean Med Sci. 2015; 30(9):1295-301. 
25. 
Guo C, Hao LJ, Yang ZH, et al. Deferoxamine-mediated up-regulation of HIF-1alpha prevents 
dopaminergic neuronal death via the activation of MAPK family proteins in MPTP-treated mice. 
Exp Neurol. 2016; 280:13-23. 
26. 
Hoe S, Rowley DA, Halliwell B. Reactions of ferrioxamine and desferrioxamine with the hydroxyl 
radical. Chem Biol Interact. 1982; 41(1):75-81. 
27. 
Leaf DE, Rajapurkar M, Lele SS, et al. Increased plasma catalytic iron in patients may mediate 
acute kidney injury and death following cardiac surgery. Kidney Int. 2015; 87(5):1046-54. 
28. 
Haradin AR, Weed RI, Reed CF. Changes in physical properties of stored erythrocytes 
relationship to survival in vivo. Transfusion. 1969; 9(5):229-37. 
29. 
Donadee C, Raat NJ, Kanias T, et al. Nitric oxide scavenging by red blood cell microparticles 
and cell-free hemoglobin as a mechanism for the red cell storage lesion. Circulation. 2011; 
124(4):465-76. 
30. 
Hod EA, Zhang N, Sokol SA, et al. Transfusion of red blood cells after prolonged storage 
produces harmful effects that are mediated by iron and inflammation. Blood. 2010; 
115(21):4284-92. 
31. 
Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, 
pathophysiology and treatment. Nat Rev Nephrol. 2017; 13(11):697-711. 
32. 
Omar AS, Ewila H, Aboulnaga S, Tuli AK, Singh R. Rhabdomyolysis following Cardiac Surgery: 
A Prospective, Descriptive, Single-Center Study. Biomed Res Int. 2016; 2016:7497936. 
33. 
Sharma S, Leaf DE. Iron Chelation as a Potential Therapeutic Strategy for AKI Prevention. J Am 
Soc Nephrol. 2019; 30(11):2060-71. 
34. 
Sharma S, Leaf DE. Iron Chelation as a Potential Therapeutic Strategy for AKI Prevention. J Am 
Soc Nephrol. 2019 (in press). 
35. 
Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, 
multicenter study. JAMA. 2005; 294(7):813-8. 
36. 
D'Agostino RS, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons Adult Cardiac 
Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg. 2019; 107(1):24-
32. 
37. 
Meersch M, Schmidt C, Hoffmeier A, et al. Prevention of cardiac surgery-associated AKI by 
implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI 
randomized controlled trial. Intensive Care Med. 2017; 43(11):1551-61. 
38. 
Lei C, Berra L, Rezoagli E, et al. Nitric Oxide Decreases Acute Kidney Injury and Stage 3 
Chronic Kidney Disease after Cardiac Surgery. Am J Respir Crit Care Med. 2018; 
198(10):1279-87. 
39. 
Loef BG, Epema AH, Smilde TD, et al. Immediate postoperative renal function deterioration in 
cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc Nephrol. 
2005; 16(1):195-200. 
40. 
Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: a meta-analysis. Clin J Am 
Soc Nephrol. 2013; 8(9):1482-93. 
41. 
Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict 
prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc 
Nephrol. 2004; 15(6):1597-605. 
42. 
Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. 
Circulation. 1997; 95(4):878-84. 
43. 
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal 
failure after cardiac surgery. J Am Soc Nephrol. 2005; 16(1):162-8. 

Version Date 11/4/25;  Page 33 
 
44. 
Shah SV, Walker PD. Evidence suggesting a role for hydroxyl radical in glycerol-induced acute 
renal failure. Am J Physiol. 1988; 255(3 Pt 2):F438-43. 
45. 
Paller MS. Hemoglobin- and myoglobin-induced acute renal failure in rats: role of iron in 
nephrotoxicity. Am J Physiol. 1988; 255(3):F539-44. 
46. 
Walker PD, Shah SV. Evidence suggesting a role for hydroxyl radical in gentamicin-induced 
acute renal failure in rats. J Clin Invest. 1988; 81(2):334-41. 
47. 
Zager RA. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury 
and oxidant tubular stress. Mechanistic and therapeutic implications. J Clin Invest. 1992; 
90(3):711-9. 
48. 
Gonzalez-Fajardo JA, Fernandez L, Alvarez T, Vaquero C. Preservation of cortical 
microcirculation after kidney ischemia-reperfusion: value of an iron chelator. Ann Vasc Surg. 
1995; 9(2):227-8. 
49. 
Ben Ismail TH, Ali BH, Bashir AA. Influence of iron, deferoxamine and ascorbic acid on 
gentamicin-induced nephrotoxicity in rats. Gen Pharmacol. 1994; 25(6):1249-52. 
50. 
Haraldsson G, Sorensen V, Nilsson U, et al. Effect of pre-treatment with desferrioxamine and 
mannitol on radical production and kidney function after ischaemia-reperfusion. A study on 
rabbit kidneys. Acta Physiol Scand. 1995; 154(4):461-8. 
51. 
Watanabe H, Kanno H. [Experimental studies of the protective effect of deferoxamine mesilate 
on cisplatin induced toxicity]. Nihon Jibiinkoka Gakkai Kaiho. 1998; 101(8):967-78. 
52. 
Baliga R, Zhang Z, Baliga M, Ueda N, Shah SV. Role of cytochrome P-450 as a source of 
catalytic iron in cisplatin-induced nephrotoxicity. Kidney Int. 1998; 54(5):1562-9. 
53. 
Saad SY, Najjar TA, Al-Rikabi AC. The preventive role of deferoxamine against acute 
doxorubicin-induced cardiac, renal and hepatic toxicity in rats. Pharmacol Res. 2001; 43(3):211-
8. 
54. 
Chander V, Singh D, Chopra K. Attenuation of glycerol-induced acute renal failure in rats by 
trimetazidine and deferoxamine. Pharmacology. 2003; 67(1):41-8. 
55. 
Ozdemir E, Dokucu AI, Uzunlar AK, et al. Experimental study on effects of deferoxamine 
mesilate in ameliorating cisplatin-induced nephrotoxicity. Int Urol Nephrol. 2002; 33(1):127-31. 
56. 
de Vries B, Walter SJ, von Bonsdorff L, et al. Reduction of circulating redox-active iron by 
apotransferrin protects against renal ischemia-reperfusion injury. Transplantation. 2004; 
77(5):669-75. 
57. 
Naghibi B, Ghafghazi T, Hajhashemi V, Talebi A, Taheri D. The effect of 2,3-dihydroxybenzoic 
acid and tempol in prevention of vancomycin-induced nephrotoxicity in rats. Toxicology. 2007; 
232(3):192-9. 
58. 
Bulucu F, Oktenli C, Kenar L, et al. Efficacy of deferoxamine, N-acetylcysteine and selenium 
treatments in rats with Adriamycin-induced nephrotic syndrome. J Nephrol. 2008; 21(4):576-83. 
59. 
Petronilho F, Constantino L, de Souza B, et al. Efficacy of the combination of N-acetylcysteine 
and desferrioxamine in the prevention and treatment of gentamicin-induced acute renal failure in 
male Wistar rats. Nephrol Dial Transplant. 2009; 24(7):2077-82. 
60. 
Vlahakos D, Arkadopoulos N, Kostopanagiotou G, et al. Deferoxamine attenuates lipid 
peroxidation, blocks interleukin-6 production, ameliorates sepsis inflammatory response 
syndrome, and confers renoprotection after acute hepatic ischemia in pigs. Artif Organs. 2012; 
36(4):400-8. 
61. 
Bernardi RM, Constantino L, Machado RA, et al. N-acetylcysteine and deferrioxamine protects 
against acute renal failure induced by ischemia/reperfusion in rats. Rev Bras Ter Intensiva. 
2012; 24(3):219-23. 
62. 
Molina-Jijon E, Zarco-Marquez G, Medina-Campos ON, et al. Deferoxamine pretreatment 
prevents Cr(VI)-induced nephrotoxicity and oxidant stress: role of Cr(VI) chelation. Toxicology. 
2012; 291(1-3):93-101. 
63. 
Sivakumar S, Khatiwada CP, Sivasubramanian J, Raja B. FTIR study of protective action of 
deferoxamine and deferiprone on the kidney tissues of aluminum loaded mice. Spectrochim 
Acta A Mol Biomol Spectrosc. 2014; 118:488-97. 

Version Date 11/4/25;  Page 34 
 
64. 
Makhdoumi P, Abnous K, Mehri S, et al. Oral deferiprone administration ameliorates cisplatin-
induced nephrotoxicity in rats. J Pharm Pharmacol. 2018; 70(10):1357-68. 
65. 
Leaf DE, Rajapurkar M, Lele SS, Mukhopadhyay B, Waikar SS. Plasma catalytic iron, AKI, and 
death among critically ill patients. Clin J Am Soc Nephrol. 2014; 9(11):1849-56. 
66. 
Leaf DE, Rajapurkar M, Lele SS, et al. Iron, Hepcidin, and Death in Human AKI. J Am Soc 
Nephrol. 2019; 30:493-504. 
67. 
Ambrosio G, Zweier JL, Jacobus WE, Weisfeldt ML, Flaherty JT. Improvement of postischemic 
myocardial function and metabolism induced by administration of deferoxamine at the time of 
reflow: the role of iron in the pathogenesis of reperfusion injury. Circulation. 1987; 76(4):906-15. 
68. 
van der Kraaij AM, Mostert LJ, van Eijk HG, Koster JF. Iron-load increases the susceptibility of 
rat hearts to oxygen reperfusion damage. Protection by the antioxidant (+)-cyanidanol-3 and 
deferoxamine. Circulation. 1988; 78(2):442-9. 
69. 
Bernier M, Hearse DJ, Manning AS. Reperfusion-induced arrhythmias and oxygen-derived free 
radicals. Studies with "anti-free radical" interventions and a free radical-generating system in the 
isolated perfused rat heart. Circ Res. 1986; 58(3):331-40. 
70. 
Zhu W, Huang Y, Ye Y, Wang Y. Deferoxamine preconditioning ameliorates mechanical 
ventilation-induced lung injury in rat model via ROS in alveolar macrophages: a randomized 
controlled study. BMC Anesthesiol. 2018; 18(1):116. 
71. 
Ritter C, da Cunha AA, Echer IC, et al. Effects of N-acetylcysteine plus deferoxamine in 
lipopolysaccharide-induced acute lung injury in the rat. Crit Care Med. 2006; 34(2):471-7. 
72. 
Cermanova J, Kadova Z, Dolezelova E, et al. Deferoxamine but not dexrazoxane alleviates liver 
injury induced by endotoxemia in rats. Shock. 2014; 42(4):372-9. 
73. 
Orfanos NF, Mylonas AI, Karmaniolou, II, et al. The effects of antioxidants on a porcine model of 
liver hemorrhage. J Trauma Acute Care Surg. 2016; 80(6):964-71. 
74. 
Cui HJ, He HY, Yang AL, et al. Efficacy of deferoxamine in animal models of intracerebral 
hemorrhage: a systematic review and stratified meta-analysis. PLoS One. 2015; 
10(5):e0127256. 
75. 
Messaris E, Antonakis PT, Memos N, et al. Deferoxamine administration in septic animals: 
improved survival and altered apoptotic gene expression. Int Immunopharmacol. 2004; 
4(3):455-9. 
76. 
Andrades M, Ritter C, de Oliveira MR, et al. Antioxidant treatment reverses organ failure in rat 
model of sepsis: role of antioxidant enzymes imbalance, neutrophil infiltration, and oxidative 
stress. J Surg Res. 2011; 167(2):e307-13. 
77. 
Fraga CM, Tomasi CD, Damasio DC, et al. N-acetylcysteine plus deferoxamine for patients with 
prolonged hypotension does not decrease acute kidney injury incidence: a double blind, 
randomized, placebo-controlled trial. Crit Care. 2016; 20(1):331. 
78. 
Menasche P, Pasquier C, Bellucci S, et al. Deferoxamine reduces neutrophil-mediated free 
radical production during cardiopulmonary bypass in man. J Thorac Cardiovasc Surg. 1988; 
96(4):582-9. 
79. 
Menasche P, Antebi H, Alcindor LG, et al. Iron chelation by deferoxamine inhibits lipid 
peroxidation during cardiopulmonary bypass in humans. Circulation. 1990; 82(5 Suppl):IV390-6. 
80. 
Paraskevaidis IA, Iliodromitis EK, Vlahakos D, et al. Deferoxamine infusion during coronary 
artery bypass grafting ameliorates lipid peroxidation and protects the myocardium against 
reperfusion injury: immediate and long-term significance. Eur Heart J. 2005; 26(3):263-70. 
81. 
Chan W, Taylor AJ, Ellims AH, et al. Effect of iron chelation on myocardial infarct size and 
oxidative stress in ST-elevation-myocardial infarction. Circ Cardiovasc Interv. 2012; 5(2):270-8. 
82. 
Selim M, Foster LD, Moy CS, et al. Deferoxamine mesylate in patients with intracerebral 
haemorrhage (i-DEF): a multicentre, randomised, placebo-controlled, double-blind phase 2 trial. 
Lancet Neurol. 2019; 18(5):428-38. 
83. 
Fraga CM, Tomasi CD, Biff D, et al. The effects of N-acetylcysteine and deferoxamine on 
plasma cytokine and oxidative damage parameters in critically ill patients with prolonged 
hypotension: a randomized controlled trial. J Clin Pharmacol. 2012; 52(9):1365-72. 

Version Date 11/4/25;  Page 35 
 
84. 
Glickstein H, El RB, Shvartsman M, Cabantchik ZI. Intracellular labile iron pools as direct targets 
of iron chelators: a fluorescence study of chelator action in living cells. Blood. 2005; 
106(9):3242-50. 
85. 
Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO 
clinical practice guideline for acute kidney injury. Kidney Int Suppl 2. 2012:1-138. 
86. 
Chertow GM, Palevsky PM, Greene T. Studying the prevention of acute kidney injury: lessons 
from an 18th-century mathematician. Clin J Am Soc Nephrol. 2006; 1(5):1124-7. 
87. 
Faubel S, Chawla LS, Chertow GM, et al. Ongoing clinical trials in AKI. Clin J Am Soc Nephrol. 
2012; 7(5):861-73. 
88. 
Billings FTt, Shaw AD. Clinical trial endpoints in acute kidney injury. Nephron Clin Pract. 2014; 
127(1-4):89-93. 
89. 
Parikh CR, Moledina DG, Coca SG, Thiessen-Philbrook HR, Garg AX. Application of new acute 
kidney injury biomarkers in human randomized controlled trials. Kidney Int. 2016; 89(6):1372-9. 
90. 
Bansal N, Carpenter MA, Weiner DE, et al. Urine Injury Biomarkers and Risk of Adverse 
Outcomes in Recipients of Prevalent Kidney Transplants: The Folic Acid for Vascular Outcome 
Reduction in Transplantation Trial. J Am Soc Nephrol. 2016; 27(7):2109-21. 
91. 
Gallagher SM, Jones DA, Kapur A, et al. Remote ischemic preconditioning has a neutral effect 
on the incidence of kidney injury after coronary artery bypass graft surgery. Kidney Int. 2015; 
87(2):473-81. 
92. 
Bullen AL, Katz R, Lee AK, et al. The SPRINT trial suggests that markers of tubule cell function 
in the urine associate with risk of subsequent acute kidney injury while injury markers elevate 
after the injury. Kidney Int. 2019; 96(2):470-9. 
93. 
Guerrero Orriach JL, Galan Ortega M, Ramirez Fernandez A, et al. Cardioprotective efficacy of 
sevoflurane vs. propofol during induction and/or maintenance in patients undergoing coronary 
artery revascularization surgery without pump: A randomized trial. Int J Cardiol. 2017; 243:73-
80. 
94. 
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions 
for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-10. 
95. 
Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction 
(2018). Circulation. 2018; 138(20):e618-e51. 
96. 
Bolli R, Patel BS, Zhu WX, et al. The iron chelator desferrioxamine attenuates postischemic 
ventricular dysfunction. Am J Physiol. 1987; 253(6 Pt 2):H1372-80. 
97. 
Pennell DJ, Berdoukas V, Karagiorga M, et al. Randomized controlled trial of deferiprone or 
deferoxamine in beta-thalassemia major patients with asymptomatic myocardial siderosis. 
Blood. 2006; 107(9):3738-44. 
98. 
Pittis MG, Estevez ME, Diez RA, de Miani SA, Sen L. Decreased phagolysosomal fusion of 
peripheral blood monocytes from patients with thalassemia major. Acta Haematol. 1994; 
92(2):66-70. 
99. 
Wang S, Liu C, Pan S, et al. Deferoxamine attenuates lipopolysaccharide-induced inflammatory 
responses and protects against endotoxic shock in mice. Biochem Biophys Res Commun. 2015; 
465(2):305-11. 
100. 
Schmid J, Liesinger L, Birner-Gruenberger R, et al. Elevated Cardiac Troponin T in Patients 
With Skeletal Myopathies. J Am Coll Cardiol. 2018; 71(14):1540-9. 
101. 
Felker GM, Maisel AS. A global rank end point for clinical trials in acute heart failure. Circ Heart 
Fail. 2010; 3(5):643-6. 
102. 
Wilson FP, Shashaty M, Testani J, et al. Automated, electronic alerts for acute kidney injury: a 
single-blind, parallel-group, randomised controlled trial. Lancet. 2015; 385(9981):1966-74. 
103. 
Xia S, Zhang W, Huang L, Jiang H. Comparative efficacy and safety of deferoxamine, 
deferiprone and deferasirox on severe thalassemia: a meta-analysis of 16 randomized 
controlled trials. PLoS One. 2013; 8(12):e82662. 
104. 
Whitten CF, Gibson GW, Good MH, Goodwin JF, Brough AJ. Studies in acute iron poisoning. I. 
Desferrioxamine in the treatment of acute iron poisoning: clinical observations, experimental 
studies, and theoretical considerations. Pediatrics. 1965; 36(3):322-35. 

Version Date 11/4/25;  Page 36 
 
105. 
Silliman CC, Peterson VM, Mellman DL, et al. Iron chelation by deferoxamine in sickle cell 
patients with severe transfusion-induced hemosiderosis: a randomized, double-blind study of 
the dose-response relationship. J Lab Clin Med. 1993; 122(1):48-54. 
106. 
Tenenbein M, Kowalski S, Sienko A, Bowden DH, Adamson IY. Pulmonary toxic effects of 
continuous desferrioxamine administration in acute iron poisoning. Lancet. 1992; 
339(8795):699-701. 
107. 
Davies SC, Marcus RE, Hungerford JL, et al. Ocular toxicity of high-dose intravenous 
desferrioxamine. Lancet. 1983; 2(8343):181-4. 
108. 
Olivieri NF, Buncic JR, Chew E, et al. Visual and auditory neurotoxicity in patients receiving 
subcutaneous deferoxamine infusions. N Engl J Med. 1986; 314(14):869-73. 
109. 
Baath JS, Lam WC, Kirby M, Chun A. Deferoxamine-related ocular toxicity: incidence and 
outcome in a pediatric population. Retina. 2008; 28(6):894-9. 
110. 
Shamsian BS, Aminasnafi A, Moghadassian H, et al. Sensory neural hearing loss in beta-
thalassemia major patients treated with deferoxamine. Pediatr Hematol Oncol. 2008; 25(6):502-
8. 
111. 
Gaies MG, Gurney JG, Yen AH, et al. Vasoactive-inotropic score as a predictor of morbidity and 
mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010; 11(2):234-8. 
112. 
McIntosh AM, Tong S, Deakyne SJ, Davidson JA, Scott HF. Validation of the Vasoactive-
Inotropic Score in Pediatric Sepsis. Pediatr Crit Care Med. 2017; 18(8):750-7. 
113. 
Han J, Pinsino A, Sanchez J, et al. Prognostic value of vasoactive-inotropic score following 
continuous flow left ventricular assist device implantation. J Heart Lung Transplant. 2019; 
38(9):930-8. 
114. 
Yamazaki Y, Oba K, Matsui Y, Morimoto Y. Vasoactive-inotropic score as a predictor of 
morbidity and mortality in adults after cardiac surgery with cardiopulmonary bypass. J Anesth. 
2018; 32(2):167-73. 
115. 
Force ADT, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin 
Definition. JAMA. 2012; 307(23):2526-33.