A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical Trial of Allogeneic Bone Marrow-derived Human Mesenchymal Stromal Cells (hMSCs) for the Treatment of Acute Respiratory Distress Syndrome
Phase: PHASE2
Conditions: Respiratory Distress Syndrome, Adult
Sponsor: Michael A. Matthay

Date: April 19, 2022  
 
Confidential  
 
 
Clinical Study Protocol 
Protocol Title: A Phase 2b, Randomized, Double-blind, Placebo-
controlled, Multi-center Clinical Trial of Allogeneic Bone 
Marrow-derived Human Mesenchymal Stromal Cells for 
the Treatment of Acute Respiratory Distress Syndrome  
Investigationa
l Drug: 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
Protocol 
Number: 
UCSF-hMSC-ARDS-P1P2-14 
IND Number: 15331 
Sponsor-
Investigator: 
Michael A. Matthay, MD 
University of California, San Francisco 
 
 
Signature: 
 
_______________________________________ 
 
 
Original Date: 
 
 
 
 
 
 
 
Confidentiality Statement 
 
This document is confidential and is to be distributed for review only to investigators, potential 
investigators, consultants, study staff, and applicable independent ethics committees or 
institutional review boards. The consents of this document shall not be disclosed to others without 
written authorization from Department of Defense, unless it is necessary to obtain informed consent 
from potential study participants. 
 
 
PROTOCOL Approval 

Michael A Matthay, MD 
 
Page ii 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
 
Protocol:  
UCSF-hMSC-ARDS-P1P2-14 
 
Version/Date: 
April 19, 2022 
IND: 15331 
 
 
Protocol Chair: 
 
Michael A. Matthay, MD 
 
Short Title:  Mesenchymal Stromal Cells For Acute Respiratory Distress Syndrome  
 
 
 
I have read protocol, and I approve it. As the principal investigator, I agree to conduct this 
protocol according to good clinical practices, which are delineated in the International 
Conference on Harmonization (ICH) of Technical Requirements for Registration of 
Pharmaceuticals for Human Use “Guidance for Industry: E6 Good Clinical Practice 
Consolidated Guidance” (May 1996), and according to the criteria specified in this protocol. 
 
Print Name of Principal Investigator [or Protocol Chair]: 
 
 
_______________________________________________ 
 
 
Signature:______________________________________________    
 
 
Date:__________________________________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Date: April 19, 2022  
 
Confidential  
 
 
Table of Contents 
TABLE OF CONTENTS ........................................................................................ I 
1 
PROTOCOL SYNOPSIS ............................................................................... 1 
2 
GLOSSARY OF ABBREVIATIONS .............................................................. 8 
3 
BACKGROUND .......................................................................................... 10 
3.1 SUMMARY .................................................................................................. 10 
3.2 SCIENTIFIC RATIONALE ............................................................................... 10 
3.2.1 Significance of this work to Acute Respiratory Distress Syndrome ... 10 
3.2.2 Significance of this work to Acute Respiratory Distress Syndrome after 
Trauma ........................................................................................................ 11 
3.3 BACKGROUND RELEVANT TO MECHANISM OF ACTION OF MESENCHYMAL 
STROMAL CELLS IN ARDS ................................................................................. 11 
3.3.1 Engraftment and Trans-differentiation .............................................. 11 
3.3.2 Immunomodulatory & Anti-inflammatory Effects ............................... 12 
3.3.3 Anti-Microbial Effects ........................................................................ 13 
3.3.4 Secretion of Paracrine Soluble Factors that Enhance Alveolar Fluid 
Clearance and the Resolution of Alveolar Edema ....................................... 13 
3.3.5 Secretion of Paracrine Soluble Factors that Improve Lung Endothelial 
and Epithelial Permeability .......................................................................... 14 
3.3.6 MSCs for Treatment of Acute Lung Injury after Hemorrhagic Shock and 
Resuscitation ............................................................................................... 15 
3.4 NONCLINICAL SAFETY AND EFFICACY STUDIES ............................................. 16 
3.5 DESCRIPTION OF INVESTIGATIONAL CELLULAR PRODUCT AND DOSE 
SELECTION ....................................................................................................... 18 
3.6 CLINICAL EXPERIENCE ................................................................................ 18 
3.7 POTENTIAL BENEFITS AND RISKS TO HUMAN PARTICIPANTS........................... 25 
3.7.1 Potential Benefits .............................................................................. 25 
3.7.2 Potential Risks .................................................................................. 25 
3.8 STUDY RATIONALE ..................................................................................... 26 
4 
STUDY OBJECTIVES................................................................................. 27 
4.1 PRIMARY OBJECTIVE .................................................................................. 27 
4.2 SECONDARY OBJECTIVES ........................................................................... 27 
5 
STUDY DESIGN ......................................................................................... 27 
6 
ENDPOINTS ............................................................................................... 28 
6.1 PRIMARY STUDY ENDPOINT: PHASE 2B ........................................................ 28 
6.2 SECONDARY ENDPOINTS: PHASE 2B ............................................................ 28 
6.2.1 Efficacy Secondary Endpoints .......................................................... 28 
6.2.2 Safety Secondary Endpoints ............................................................ 30 
6.2.3 Primary and Secondary Endpoints Adjusted for SARS-CoV-2 Infection
 
31 
7 
STUDY POPULATION AND ENROLLMENT ............................................. 32 

Michael A Matthay, MD 
 
Page ii 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
7.1 NUMBER/SOURCE/SCREENING .................................................................... 32 
7.2 INCLUSION CRITERIA ................................................................................... 32 
7.3 EXCLUSION CRITERIA ................................................................................. 33 
7.4 STUDY INITIATION TIME WINDOW ................................................................. 35 
7.5 SUBJECT RECRUITMENT AND INFORMED CONSENT ....................................... 35 
7.6 RANDOMIZATION AND STRATIFICATION .......................................................... 36 
7.7 EARLY WITHDRAWAL OF SUBJECTS ............................................................. 36 
7.7.1 When and How to Withdraw Subjects ............................................... 36 
7.7.2 Data Collection and Follow-up for Withdrawn Subjects .................... 36 
8 
CHEMISTRY, MANUFACTURING AND CONTROLS ................................ 36 
8.1 PRODUCT MANUFACTURING COMPONENTS .................................................. 37 
8.1.1 Source Material Procurement ........................................................... 37 
8.1.2 Donor Screening ............................................................................... 37 
8.1.3 Reagents .......................................................................................... 38 
8.1.4 Qualification Program ....................................................................... 41 
8.2 PRODUCT MANUFACTURING PROCEDURES ................................................... 41 
8.2.1 Cell Processing ................................................................................. 41 
8.3 FINAL INFUSION FORMULATION .................................................................... 44 
8.4 PRODUCT TESTING ..................................................................................... 44 
8.4.1 In-process Testing and Criteria ......................................................... 44 
8.4.2 Description of Assays ....................................................................... 44 
8.5 HMSC FINAL CELLULAR PRODUCT RELEASE CRITERIA/SPECIFICATIONS ........ 44 
8.5.1 Description of Assays ....................................................................... 45 
8.5.2 Final Cellular Product Certificate of Analysis .................................... 46 
8.6 PRODUCT STABILITY ................................................................................... 47 
8.7 PLACEBO PRODUCT .................................................................................... 47 
8.8 OTHER ISSUES ........................................................................................... 47 
8.8.1 Product Tracking............................................................................... 47 
8.8.2 Labeling ............................................................................................ 47 
8.8.3 Container/Closure ............................................................................. 48 
8.8.4 Environmental Impact ....................................................................... 48 
8.8.5 Validation and Qualification of the Manufacturing Process ............... 48 
8.8.6 Cellular Product Preparation ............................................................. 48 
8.8.7 Placebo Product Preparation ............................................................ 48 
8.9 SUBJECT COMPLIANCE MONITORING ........................................................... 48 
8.10 PRIOR AND CONCOMITANT THERAPY ........................................................... 49 
8.11 BLINDING OF CELLULAR PRODUCT ............................................................... 49 
8.12 RECEIVING, STORAGE, DISPENSING AND RETURN ......................................... 49 
8.12.1 Receipt of Cellular Product ............................................................... 49 
8.12.2 Storage ............................................................................................. 49 
8.12.3 Dispensing of Cellular Product ......................................................... 49 
8.12.4 Return or Destruction of Cellular Product ......................................... 50 
9 
STUDY PROCEDURES .............................................................................. 50 

Michael A Matthay, MD 
 
Page iii 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
9.1 PRE-SCREENING ........................................................................................ 50 
9.2 INFORMED CONSENT AND RANDOMIZATION .................................................. 50 
9.3 BASELINE STUDY PROCEDURES .................................................................. 51 
9.4 INVESTIGATIONAL PRODUCT ADMINISTRATION .............................................. 51 
9.5 VENTILATOR MANAGEMENT ......................................................................... 53 
9.6 CONCOMITANT THERAPY ............................................................................ 54 
9.7 RADIOGRAPHIC ASSESSMENT OF LUNG EDEMA (RALE) SCORE ..................... 54 
9.8 BIOSPECIMENS FOR BIOLOGICAL ENDPOINT MEASUREMENTS ........................ 54 
9.9 DAYS 1, 2, AND 3 MEASUREMENTS .............................................................. 55 
9.10 DAY 7 MEASUREMENTS .............................................................................. 55 
9.11 DAY 28 MEASUREMENTS ............................................................................ 55 
9.12 DAY 60 MEASUREMENTS ............................................................................ 56 
9.13 POST-HOSPITALIZATION FOLLOW-UP ............................................................ 56 
10 
DATA COLLECTION............................................................................... 56 
10.1 MEDICAL HISTORY ...................................................................................... 56 
10.2 BASELINE ASSESSMENTS ............................................................................ 57 
10.2.1 To Be Collected From Patient Charts ............................................... 57 
10.3 ASSESSMENT AFTER ENROLLMENT: DETERMINATION OF STABLE BASELINE FOR 
STUDY PRODUCT ADMINISTRATION AND MONITORING DURING AND AFTER INFUSION 
PROTOCOL ....................................................................................................... 57 
10.4 ASSESSMENT AFTER ENROLLMENT: REFERENCE MEASUREMENTS ................. 58 
10.4.1 Reference Measurements (to be collected from patient charts) ....... 58 
10.4.2 Specimen Collection ......................................................................... 59 
10.5 ENDPOINT DETERMINATIONS ....................................................................... 59 
10.6 ASSESSMENTS AFTER HOSPITALIZATION ...................................................... 59 
11 
STATISTICAL PLAN ............................................................................... 59 
11.1 SAMPLE SIZE DETERMINATION .................................................................... 60 
11.2 STATISTICAL METHODS FOR PRIMARY AND SECONDARY ENDPOINTS .............. 60 
11.3 SUBJECT POPULATION(S) FOR ANALYSIS ...................................................... 60 
12 
SAFETY AND ADVERSE EVENTS ........................................................ 61 
12.1 DEFINITIONS .............................................................................................. 61 
12.2 RECORDING OF ADVERSE EVENTS ............................................................... 63 
12.3 REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS . 64 
12.3.1 Investigators’ Reporting Requirements to the Sponsor ..................... 64 
12.3.2 Sponsor Reporting: Notifying the FDA .............................................. 64 
12.3.3 Sponsor Reporting:  Notifying the DSMB .......................................... 65 
12.4 UNBLINDING PROCEDURES ......................................................................... 65 
12.5 STOPPING RULES ....................................................................................... 65 
12.6 MEDICAL MONITORING ................................................................................ 66 
12.6.1 Independent Data and Safety Monitoring Board ............................... 66 
13 
DATA HANDLING AND RECORD KEEPING ......................................... 66 

Michael A Matthay, MD 
 
Page iv 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
13.1 CONFIDENTIALITY ....................................................................................... 66 
13.2 SOURCE DOCUMENTS................................................................................. 67 
13.3 CASE REPORT FORMS ................................................................................ 67 
13.4 RECORDS RETENTION ................................................................................ 67 
14 
STUDY MONITORING, AUDITING, AND INSPECTING......................... 67 
14.1 STUDY MONITORING PLAN .......................................................................... 67 
14.2 AUDITING AND INSPECTING .......................................................................... 68 
15 
ETHICAL CONSIDERATIONS ................................................................ 68 
16 
STUDY FINANCES ................................................................................. 69 
16.1 FUNDING SOURCE ...................................................................................... 69 
16.2 CONFLICT OF INTEREST .............................................................................. 69 
17 
PUBLICATION PLAN .............................................................................. 69 
18 
LIST OF REFERENCES .......................................................................... 70 
19 
APPENDICES ......................................................................................... 79 
APPENDIX A: TIME-EVENTS SCHEDULE ............................................................... 80 
APPENDIX B: LUNG INJURY SCORE ..................................................................... 81 
APPENDIX C: DE-IDENTIFIED DATA ELEMENTS FOR SCREENED, NON-ENROLLED 
SUBJECTS ......................................................................................................... 82 
APPENDIX D: VENTILATOR MANAGEMENT ............................................................ 83 
APPENDIX E: STUDY PRODUCT PREPARATION PROTOCOL .................................... 87 
APPENDIX F: GUIDELINES FOR SYMPTOM MANAGEMENT DURING STUDY PRODUCT 
INFUSION ........................................................................................................ 103 
APPENDIX G.  MINI-BRONCHOALVEOLAR LAVAGE PROCEDURE ........................... 106 
APPENDIX H. PHASE 2B INVESTIGATIONAL PRODUCT INFUSION PROTOCOL .......... 107 
APPENDIX I. BAROTRAUMA ............................................................................... 112 
APPENDIX J. CHILDS-PUGH SCORE FOR LIVER DYSFUNCTION ............................. 113 
APPENDIX K. ORDINAL SCALE FOR CLINICAL IMPROVEMENT (OSCI) .................... 114 
APPENDIX L. RADIOGRAPHIC ASSESSMENT OF LUNG EDEMA (RALE) SCORE....... 115 

Michael A Matthay, MD 
 
Page 1 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
1 Protocol Synopsis 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
Protocol Number: 
UCSF-hMSC-ARD-P1P2-14 
Title: 
A Phase 2b, Randomized, Double-blind, Placebo-controlled, 
Multi-center Clinical Trial of Allogeneic Bone Marrow-Derived 
Human Mesenchymal Stromal Cells for the Treatment of Acute 
Respiratory Distress Syndrome  
Short Title 
Mesenchymal Stromal Cells For Acute Respiratory Distress 
Syndrome  
Clinical Phase 
Phase 2b 
Methodology 
Randomized, double-blind, placebo-controlled  
Study duration 
3-4 years 
IND Sponsor-Investigator 
Michael A. Matthay, MD 
Funding Sponsor 
Department of Defense 
Study Product 
Allogeneic Bone Marrow-derived Human Mesenchymal Stromal 
Cells (hMSCs) 
IND Number 
15331 
Participating Sites 
Intensive Care Units at seven Clinical Centers: Zuckerberg San 
Francisco General Hospital & Trauma Center and UCSF Moffitt-
Long Hospital (San Francisco, CA), University of California 
Davis Medical Center (Sacramento, CA), Harborview Medical 
Center (Seattle, WA), Oregon Health & Science University 
(Portland, OR), Vanderbilt University Medical Center (Nashville, 
TN) and the University of Texas Health Sciences Center at 
Houston/Memorial Hermann-Texas Medical Center (Houston, 
TX) 
Study Objective 
To assess the efficacy of hMSCs in critically ill patients with 
Acute Respiratory Distress Syndrome (ARDS) 
Accrual Objective 
120 patients (60 patients receiving hMSCs and 60 patients 
receiving placebo)  

Michael A Matthay, MD 
 
Page 2 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
Study Design 
Randomized, double-blind, placebo-controlled, multi-center.  
Subjects with ARDS will receive a single infusion of hMSCs or 
placebo. 
Study Product, Dose, Route, 
Regimen 
 
The cellular product is cryopreserved for long-term storage. The 
cryopreserved hMSCs are formulated in CryoStor (90%) and 
DMSO (10%). 
Immediately prior to administration, the product is thawed and 
diluted in 1:1 reconstitution media (1:1 mix of 5% human serum 
albumin and 10% Dextran 40). Additional reconstitution media is 
added to a final product volume of 300 mL. 
Placebo: 300 mL of reconstitution media (1:1 mix of 5% human 
serum albumin and 10% Dextran 40). 
Each dose of the hMSCs or placebo will be administered 
intravenously over approximately 60-80 minutes. All patients will 
receive one dose. × 
10 x 106 cells/kg (n=60); placebo (n=60) 
Primary Endpoint:  
Reduction in the severity of ARDS: Change in the oxygenation 
index (OI) from baseline over 36 hours following the initiation of 
study product infusion (with measurements of OI at 6, 12, 18, 24, 
30 and 36 hours). 
Secondary Endpoints:  
Respiratory physiology endpoints: The 4-point acute lung 
injury score (LIS) at days 1, 2, 3 and 7, or on the last day of 
positive pressure ventilation prior to day 7; pulmonary dead space 
at days 1, 2, 3 and 7; chest radiograph assessment of pulmonary 
edema (RALE score) at days 1, 2, 3 and 7; ventilatory ratio with 
measurements at 6, 12, 18, 24, 30, and 36 hours, and days 2, 3, 
and 7; incidence of barotrauma at days 1, 2, 3 and 7; ventilator 
free-days over 7, 14 and 28 days; duration of assisted ventilation 
over 28 days in the survivors; achieving pressure support 
ventilation equal to 5 cm H20 with positive end-expiratory 
pressure (PEEP) equal to 5 cm H20 for 2 hours. OI will be 
collected (as planned) also on days 2, 3, and 7 if still being 
ventilated with positive pressure as a secondary endpoint. 
Secondary Infection endpoints: Superficial incisional/wound 
infections, deep incisional wound infections, and organ/space 
infections, and ventilator associated pneumonia (all during the 14 

Michael A Matthay, MD 
 
Page 3 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
days after enrollment). 
Systemic illness endpoint: Sequential Organ Failure Assessment 
(SOFA) score at 3, and 7 days; in hospital mortality at 14, 28 and 
60 days; additional prognostic value of neutrophil:lymphocyte 
ratio; ordinal scale for clinical improvement at 7, 14 and 28 days. 
Neurocognitive endpoint: Neurocognitive function measured by 
the Glasgow Outcome Score at hospital discharge  
Thromboembolic: Incidence of thromboembolic events 
measured by ultrasound of the deep venous system or CT-
angiography of the chest ordered for clinical purposes/by treating 
clinicians; additional prognostic value of fibrinogen at baseline. 
Biomarkers:  
Plasma: Change in levels of plasma, urine and genetic biomarkers 
from baseline compared to 6 , 24, 48, and 72 hours including: 
endothelial injury (angiopoietin-2), lung epithelial injury 
(Receptor for Advanced Glycation Endproducts [RAGE]), pro-
inflammatory pathways (interleukin-6 [IL-6], interleukin-8 [IL-8], 
soluble tumor necrosis factor-1 [sTNF-1], intercellular adhesion 
molecule-1 [ICAM-1], interferon gamma-induced protein-10 [IP-
10], interleukin-10 [IL-10], vascular endothelial growth factor 
[VEGF], matrix metalloproteinase-8 [MMP-8], thrombomodulin, 
surfactant protein-D [SP-D], triggering receptor expressed on 
myeloid cells-1 [TREM-1], interleukin-18 [IL-18], plasminogen 
activator inhibitor-1 [PAI-1]), impaired coagulation (protein C), 
pro-resolving lipids (lipoxin A4, Resolvin D1), biomarkers that 
reflect the paracrine activity of the administered hMSCs 
(angiopoietin-1 [Ang-1] and keratinocyte growth factor [KGF]).  
Changes in levels of plasma SARS-CoV-2 viral antigen and 
antibody levels at multiple timepoints; gene expression at baseline 
and on day 2 and 3. 
Alveolar fluid: Lung protein permeability as measured by total 
protein in mini-bronchoalveolar lavage [mBAL] protein at day 2; 
the same biomarkers will also be measured in plasma to compare 
hMSCs versus placebo treated patients.  
Urine:  Microalbumin will also be measured at 24 and 48 hours 
Others: Primary and secondary endpoints will be adjusted by 
SARS-CoV2 infection to better understand the hMSC effects in 
patients with COVID-19 disease.  
 

Michael A Matthay, MD 
 
Page 4 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
Safety endpoints: Tolerability of the hMSCs, defined as the 
incidence of pre-specified infusion-associated events and 
unexpected severe adverse events in ARDS patients treated with 
hMSCs. 
Inclusion Criteria 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients will be eligible for inclusion if they meet all of the below 
criteria within 14 days of initial ICU admission.  Criteria 1-3 
must all be present within a 24-hour time period and at the time 
of enrollment: 
Acute onset (defined below) of: 
1. A need for positive pressure ventilation by an endotracheal or 
tracheal tube with a PaO2/FiO2 ratio <250 mmHg and ≥5 cm 
H2O positive end-expiratory airway pressure (PEEP), as per 
the Berlin Criteria.  
2. Bilateral infiltrates consistent with pulmonary edema (defined 
below) on the frontal chest radiograph, or bilateral ground 
glass opacities on a chest CT scan. 
3. No clinical evidence of left atrial hypertension as a primary 
explanation for the bilateral pulmonary infiltrates. 
4. If the cause of ARDS is trauma, additional inclusion criteria 
will include ONE of the following relevant risk factors for 
developing ARDS: 
a. Hypotension (systolic blood pressure[SBP] < 90 
mmHg) in the field or in the first 24 h after injury, or 
b. Transfusion of 3 units of blood products in the first 24 
hours following injury, or  
c. Meets the new Critical Administration Threshold 
(CAT) criteria with at least 3 units of blood in one 
hour, or 
d. Blunt or penetrating torso trauma, or 
e. Long bone fractures, or 
f. The highest level of institutional trauma activation 
ARDS Diagnostic Criteria Defined: 
 
Acute onset is defined as follows: The duration of the 
hypoxemia criterion (#1) and the chest radiograph 
criterion (#2) must both be present  ≤ 14 days of initial 
ICU admission at the time of enrollment 

Michael A Matthay, MD 
 
Page 5 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
 
Infiltrates considered “consistent with pulmonary edema” 
include any infiltrates not fully explained by mass, 
atelectasis, or effusion or opacities known to be chronic 
(>14 days of initial ICU admission). Vascular 
redistribution, indistinct vessels, and indistinct heart 
borders alone are not considered “consistent with 
pulmonary edema” and thus would not count as qualifying 
opacities for this study. 
 
If a patient meets #1 and #2 inclusion criteria but has an 
echocardiogram with LV ejection < 40% ordered by 
treating clinicians because of a clinical suspicion of acute 
left heart failure, the patient will be excluded. 
 
If the patient meets #1 and #2 inclusion criteria but has a 
Pulmonary Arterial Occlusion Pressure (PAOP), also 
known as the Pulmonary Arterial Wedge Pressure 
(PAWP), that is initially greater than 18 mm Hg, then the 
inclusion criteria must persist for more than 12 hours after 
the PAOP has declined to ≤ 18 mm Hg.  
Exclusion Criteria 
1. Age less than 18 years 
2. Greater than 72 hours since first meeting ARDS criteria per 
the Berlin definition of ARDS 
3. Greater than 14 days since initial ICU admission 
4. Inability to administer study product within 14 days of initial 
ICU admission 
5. PaO2/FiO2 ≥ 250 mmHg after consent obtained and before 
study product is administered 
6. Unable to obtain informed consent/no surrogate available 
7. Pregnant or lactating  
8. In custody of law enforcement officials 
9. Burns > 20% of total body surface area 
10. WHO Class III or IV pulmonary hypertension 
11. History of cancer treatment in the last 2 years except for non-
melanotic skin cancers 
12. Underlying medical condition for which 6-month mortality is 
estimated to be > 50% 
13. Moribund patient not expected to survive 24 hours 

Michael A Matthay, MD 
 
Page 6 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
14. Advanced chronic liver disease (Childs-Pugh Score > 12)  
15. Severe chronic respiratory disease with the use of home 
oxygen 
16. Severe traumatic brain injury - defined as: 
a. A patient who has undergone intracranial 
neurosurgical intervention for monitoring or therapy 
(intracranial pressure monitoring, external ventricular 
drain, craniotomy), or 
b. Intracranial injury by head CT (does not include 
patients with minimal subarachnoid injury and/or 
minor skull fracture), or 
c. Post-resuscitation Glasgow Coma Score (GCS) < 9 
assessed after sedation interruption, or  
d. Non-survivable head injury as assessed by 
neurosurgery 
17. Evidence of anoxic brain injury 
18. History of stroke within the last 3 years 
19. No intent/unwillingness to follow lung protective ventilation 
strategy  
20. Currently receiving extracorporeal life support (ECLS) or 
high-frequency oscillatory ventilation (HFOV) 
21. Anticipated extubation within 24 hours of enrollment 
22. Clinical evidence of left atrial hypertension as measured by a 
pulmonary arterial wedge pressure > 18mmHg or left 
ventricular failure measured by an echocardiogram with a left 
ventricular ejection fraction less than 40%. Clinical 
judgement will determine if either of these measurements 
needs to be carried out. 
Statistical Consideration 
The primary endpoint, Oxygenation Index (OI), will be assessed 
for the change from the baseline measurement (prior to infusion 
of the study product) over 36 hours (with measurements at 6, 12, 
18, 24, 30 and 36 hours), and will be compared between the 
placebo and hMSCs treatment conditions using a linear mixed-
effects regression model. The model will be estimated using 
likelihood estimation which will allow the inclusion of all 
collected data, regardless of the number of assessments available 
for variable. Terms in the model will include the two stratification 

Michael A Matthay, MD 
 
Page 7 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Name of Sponsor – 
Investigator 
Michael A. Matthay, MD 
University of California, San Francisco 
Investigational Product 
Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs) 
variables, treatment condition (active or placebo), time of 
assessment, condition-by-time, recruitment site, and a site-by-
treatment interaction term. A test of the treatment condition will 
directly test the main research question. Covariates identified by 
preliminary analysis as potentially confounding due to baseline 
differences will be added to the model. 
 
Given the sample size of 60 per treatment condition, in this 
multisite, randomized trial using oxygenation index as the 
primary outcome and measures taken at 6 time points, it is 
estimated the study will have 80% power to detect a difference 
between conditions for an effect size as low as 0.43.  Using the 
pilot data from Day 4, for example, this would translate to 
approximately a difference of 1.29 on the oxygenation index. 
 
The primary and secondary endpoints (including clinical and 
biological data) will be adjusted for SARS-CoV-2 infection as a 
cause of ARDS, which is adjudicated by the study physicians. 
 

Michael A Matthay, MD 
 
Page 8 
University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
2 Glossary of Abbreviations 
Abbreviation 
Full Term 
AE 
Adverse Event 
AFC 
Alveolar Fluid Clearance 
ALI 
Acute Lung Injury 
ARDS 
Acute Respiratory Distress Syndrome 
mBAL 
Mini-Bronchoalveolar Lavage 
CFR 
Code of Federal Regulations 
cIRB 
Central Institutional Review Board 
CRF 
Case Report Form 
DoD 
United States Department of Defense 
DSMB 
Data and Safety Monitoring Board 
EAP 
Expanded Access Program 
ECMO 
Extracorporeal Membrane Oxygenation 
EUA 
Emergency Use Authorization 
FDA 
Food and Drug Administration 
GCS 
Glasgow Coma Score 
HFOV 
High-Frequency Oscillatory Ventilation 
HIPPA 
Health Insurance Portability and Accountability Act of 1996 
hMSCs 
Human Mesenchymal Stromal Cells 
HS 
Hemorrhagic Shock 
HSC 
Hematopoietic Stem Cells 
ICH 
International Conference on Harmonization 
ICU 
Intensive Care Unit 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IV 
Intravenous(ly) 
KGF 
Keratinocyte Growth Factor 
LIS 
Lung Injury Score 
mBAL 
Mini Bronchoalveolar Lavage 
MSCs 
Mesenchymal Stromal Cells 
NIH 
National Institute of Health 
NHLBI 
National Heart, Lung and Blood Institute 

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Abbreviation 
Full Term 
NLR 
Neutrophil:Lymphocyte Ratio  
OI 
Oxygenation Index 
OSCI  
Ordinal Scale for Clinical Improvement  
PACT 
Production Assistance for Cellular Therapy 
PAOP 
Pulmonary Artery Occlusion Pressure 
PBW 
Predicted Body Weight 
PEC 
Pulmonary Endothelial Cell 
PEEP 
Positive End-Expiratory Pressure 
PHI 
Protected Health Information 
SAE 
Serious Adverse Event 
SOP 
Standard Operating Procedure 
VR 
Ventilatory Ratio 
 

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3 BACKGROUND 
3.1 
Summary 
We hypothesize that Allogeneic Bone Marrow-derived Human Mesenchymal Stromal Cells 
(referred to hereafter as hMSCs) administered to patients with Acute Respiratory Distress 
Syndrome (ARDS) will be safe and effective in reducing the severity of acute respiratory failure. 
A Phase 2b trial with this cell-based therapy will be used to test the safety and efficacy based on 
potential treatment of the major abnormalities that underlie and accompany/complicate ARDS, 
including oxygenation, carbon dioxide excretion, degree of pulmonary edema on the chest 
radiograph, systemic organ dysfunction, secondary infections, and altered lung endothelial and 
epithelial permeability and inflammation.  
 
COVID-19 (coronavirus disease 2019), a disease caused by SARS-CoV-2, emerged in the United 
States in March 2020 and rapidly became a global pandemic. The vast majority of our enrolled 
patients were COVID-19 patients who developed ARDS. The main motivation for this updated 
protocol is to explicitly include clinical and biologic variables that are relevant to COVID-19 
induced ARDS.  
3.2 
Scientific Rationale 
3.2.1 Significance of this work to Acute Respiratory Distress Syndrome 
Morbidity and mortality have declined only modestly in patients with ARDS in the last decade, 
despite extensive research into its pathophysiology. (1-3) Current treatment remains primarily 
supportive with lung-protective ventilation and a fluid conservative strategy. (4, 5) Pharmacologic 
therapies that reduce the severity of lung injury in vivo and in vitro have not yet been translated to 
effective clinical treatment options. At present, the mortality rate of severe ARDS remains 
unacceptably high, in the range of 30-40%. (6, 7) Therefore, innovative therapies are needed.  
 
Cell-based therapy with mesenchymal stromal cells (MSCs) for the treatment of ARDS is 
attractive as a potential new therapy. MSCs are multi-potent and have the ability to secrete a variety 
of paracrine factors such as growth factors that can enhance tissue repair, anti-inflammatory 
cytokines and also antimicrobial peptides. All of these paracrine factors can potentially treat the 
major abnormalities that underlie ALI, including impaired alveolar fluid clearance, altered lung 
endothelial and epithelial permeability, dysregulated inflammation and ongoing infection. (8, 9) 
 
MSCs, also called marrow stromal stem cells, were first discovered in 1968 by Friedenstein (10) 
who found bone marrow stromal cells that were adherent, clonogenic, and fibroblastic in 
appearance. Adult mesenchymal stromal cells can be isolated from a variety of human tissues, 
including bone marrow, adipose tissue, liver, tendons, synovial membrane, amniotic fluid, 
placenta, umbilical cord blood, and teeth. MSCs are presumed to reside near the sinusoids and 
function as support cells for hematopoietic stem cells (HSC). Although MSCs comprise less than 
0.1% of all bone marrow cells, they can be isolated from whole bone marrow aspirates by their 
ability to adhere to plastic and form colonies. Currently, there are no cell surface markers specific 

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to MSCs. Consequently, in 2006, the International Society of Cellular Therapy defined MSCs by 
three criteria:  
(1) MSCs must be adherent to plastic under standard tissue culture conditions 
(2) MSCs must express certain cell surface markers such as CD105, CD90, and CD73, but 
must not express other markers including CD45, CD34, CD14, or CD11b; and  
(3) MSCs must have the capacity to differentiate into mesenchymal lineages including 
osteoblasts, adipocytes, and chrondoblasts under in vitro conditions. (11)  
 
Use of these cells for therapeutic purposes in a variety of diseases has attracted considerable 
attention due to their low immunogenicity, their immunomodulatory effects, and their ability to 
secrete endothelial and epithelial growth factors.  
3.2.2 Significance of this work to Acute Respiratory Distress Syndrome after Trauma 
ARDS is a common cause of acute respiratory failure after severe trauma that leads to considerable 
morbidity and mortality. (2, 12)  In a recent study of patients receiving mechanical ventilation 
following severe trauma at the Zuckerberg San Francisco General Hospital, the incidence of ARDS 
was 30% (183/621) defined by: (a) bilateral infiltrates on the chest radiograph, and (b) arterial 
hypoxemia (PaO2/FiO2 < 300 mmHg). (13, 14) This incidence is higher than previously reported, 
most likely because prior studies have not included systematic review of serial chest radiographs 
for the presence of bilateral infiltrates. Another study reported an ARDS incidence of 38% 
(148/602) in all patients following trauma and an incidence of 50% in those who required 6 or 
more units of red blood cells. (15) 
  
3.3 
Background Relevant to Mechanism of Action of Mesenchymal Stromal 
Cells in ARDS 
Several mechanisms of action have been established in the literature for the therapeutic effect of 
MSCs in lung injury models.  
3.3.1 Engraftment and Trans-differentiation 
Much of the initial interest in MSC therapy stemmed from the multi-potent properties of the cells. 
Krause et al (16) found that a single bone marrow-derived cell could give rise to cells of multiple 
different organs including the lung. They reported up to 20% engraftment of bone marrow-derived 
cells in the lung, including epithelial cells, from a single hematopoietic precursor. Kotton et al (17) 
reported that plate-adherent cultured bone marrow cells, when given intravenously in wild-type 
mice following bleomycin-induced lung injury, engrafted into the recipient lung parenchyma with 
a morphological and molecular phenotype of alveolar type I pneumocytes. This report gave rise to 
intensive investigation into the possibility that MSCs may be able to regenerate the lung epithelium 
and/or endothelium. (16-20) However, these results were questioned by multiple groups, who 
observed only engraftment of leukocyte lineages (21) and low engraftment rates in lung injury 
models, with observed rates of < 1%. (22-25) Despite initial interest in their multi-potent 
properties, engraftment in the lung does not appear to play a major beneficial role. The beneficial 
effect of MSCs appears to derive more from their capacity to secrete paracrine soluble factors that 

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modulate immune responses, as well as alter the responses of endothelium or epithelium to injury 
through the release of growth factors. (26-33) There may also be important cell-contact dependent 
effects, which may include the transfer of microvesicles and mitochondria to injured recipient host 
cells resulting in restoration of more normal function. (34) 
3.3.2 Immunomodulatory & Anti-inflammatory Effects 
A major characteristic of MSCs has been the immunomodulatory properties of the cells. Multiple 
studies have demonstrated that MSCs possess potent immunosuppressive effects by inhibiting the 
activity of both innate and adaptive immune cells. (28, 29, 35, 36) This immunosuppression has 
been shown to be mediated by cell contact-dependent and -independent mechanisms through the 
release of soluble factors. The list of candidate mediators released or induced by MSCs includes 
TGF-β, PGE2, IDO, TSG, IL-10 and IL-1ra among others. In a model of sepsis following cecal 
ligation and puncture (CLP) in mice, Nemeth et al (26) found that MSCs, activated by LPS or 
TNF-, secreted prostaglandin E2, which reprogrammed alveolar macrophages to secrete IL-10. 
The beneficial effect of MSCs on mortality and improved organ function following sepsis (CLP) 
was eliminated by macrophage depletion or pretreatment with antibodies to IL-10 or the IL-10 
receptor, suggesting a beneficial role for IL-10 in these experiments; IL-10 is a cytokine secreted 
predominantly by monocytes that down-regulates the expression of Th1 cytokines, MHC class II 
antigens, and co-stimulatory molecules on macrophages. IL-10 has also been reported to inhibit 
the rolling, adhesion and transepithelial migration of neutrophils. (37) In co-culture experiments, 
cell contact between MSCs and macrophages was required to stimulate IL-10 production following 
LPS stimulation; MSCs separated by a Transwell plate or MSC conditioned medium could not 
induce IL-10 production. (26) In a model of ALI following intratracheal E. coli endotoxin in mice, 
we found that intra-pulmonary MSCs improved survival and lung injury in association with a 
decrease in MIP-2 and TNF- levels in the bronchoalveolar lavage fluid (BAL) and elevated levels 
of IL-10 in both the plasma and BAL fluids. (38) In bleomycin-induced lung injury and fibrosis in 
mice, Ortiz et al (39) found that MSCs decreased subsequent lung collagen accumulation, fibrosis 
and levels of matrix metalloproteinases in part by IL-1ra secretion; IL-1ra is a cytokine that 
competitively competes with IL-1 for IL-1 receptor binding. IL-1 is one of the major 
inflammatory cytokines in pulmonary edema fluid in patients with ALI/ARDS. (40) These results 
confirmed the anti-inflammatory effects of MSCs in multiple lung injury experiments in mice. (22, 
23, 41-43) There is also new evidence that MSCs release lipoxin A4, an important lipid factor that 
accelerates the resolution of tissue and lung injury. (44) 
 
Despite the well documented immunosuppressive effects of MSCs, recent literature described a 
dual role for MSCs as an immunostimulatory cell as well. (45) As explained above, some studies 
have reported that MSCs can upregulate expression of MHC II when exposed to low levels of 
inflammation and function as antigen presenting cells stimulating the adaptive immune system. 
(46, 47) Recent evidence has also shown that MSCs can secrete IL-6 and induce production of IgG 
by B lymphocytes in an in vitro setting. (48) In addition, MSCs can prevent neutrophil apoptosis 
and degranulation in culture without inhibiting their phagocytic or chemotactic capabilities. (49) 
Thus, these studies have demonstrated that MSCs have more complex effects on the immune 
system than their classical role as immune suppressor cells. Understanding the mechanisms 

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responsible for these apparently paradoxical roles that MSCs play in the immune response is 
important in developing cell-based therapy for clinical use.  
3.3.3 Anti-Microbial Effects  
Bacterial pneumonia and sepsis from a non-pulmonary cause are two of the most common 
etiologies of ARDS. (1) Given the preponderance of literature that describes the 
immunosuppressive effect of MSCs, there might be concern that this effect may impede the host’s 
ability to clear an infection. However, new work describes a dual role for MSCs in regulating the 
immune system and their immunostimulatory effects. Further, a recent report has demonstrated a 
protective effect of systemically administered MSCs in a mouse model of bacterial sepsis (26) and 
data from our own group at UCSF that MSCs are associated with a reduction in the number of live 
bacteria in E. coli pneumonia in mice. The anti-microbial effect with mouse MSCs depended in 
part on the release of lipocalin-2, a well known anti-microbial peptide, from both the MSCs 
themselves and alveolar macrophages. (50) Also, we have found that the release of LL-37 by 
human MSCs reduces the number of bacteria in E. coli pneumonia in mice. (51)  In recent work 
with gram negative peritoneal sepsis in mice, our group has also found that intravenous hMSCs 
improve survival and reduce the number of bacteria in the blood when given after the peritoneal 
sepsis was established. (52) Another study reported better survival following treatment with MSCs 
in a cecal-ligation model of peritonitis in mice. (53) Thus, based on preclinical evidence, treatment 
with MSCs has been associated with a reduction in the number of bacteria in mouse models of 
peritoneal sepsis and pneumonia.  
3.3.4 Secretion of Paracrine Soluble Factors that Enhance Alveolar Fluid Clearance 
and the Resolution of Alveolar Edema 
Impaired alveolar fluid clearance (AFC), or delayed resolution of pulmonary edema, is common 
in patients with ARDS. The level of AFC impairment has significant prognostic value in predicting 
morbidity and mortality. (54, 55) Experimental studies have investigated several mechanisms that 
reduce AFC in ALI. (56, 57) In the alveolar environment, basal AFC is determined predominately 
by amiloride-sensitive and insensitive sodium channels and the activity of the Na-K ATPase. (56, 
58-61) Several stimuli can upregulate AFC including beta-adrenergic agonists via cAMP-
dependent mechanisms. (56, 57) In the mouse and human lung, cAMP-dependent alveolar 
epithelial fluid transport is dependent on CFTR activity, especially in mediating -adrenergic 
receptor-driven alveolar epithelial fluid transport. (62-64) 
 
We and other investigators have reported that pulmonary edema fluid in ARDS contains high 
levels of several pro-inflammatory cytokines, including IL-1, IL-8, TNF- and TGF-1. (65-67) 
Several of these pro-inflammatory cytokines have been studied in experimental fluid transport 
experiments. For example, TNF- decreased the expression of ENaC (-, -, -subunits) mRNAs 
and protein levels, as well as the amiloride-sensitive current and ouabain-sensitive Rb+ uptake in 
rat alveolar epithelial cells. (68) Similarly, IL-1 decreased dexamethasone-induced ENaC 
mRNA and protein levels, and the amiloride-sensitive fraction of the transepithelial current and 
sodium transport across rat type II cell monolayers. (69) More recently, we reported that TGF-1 
decreased the amiloride-sensitive fraction of Na+ uptake and fluid transport across monolayers of 
rat and human type II cells, as well as ENaC mRNA and protein expression. (70) In chronic 

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inflammation associated with nasal polyposis, TGF-1 down-regulated CFTR mRNA and protein 
expression as well as the cAMP-dependent current in human nasal epithelial cells. (71)  
 
MSCs are known to produce several epithelial specific growth factors, specifically keratinocyte 
growth factor (KGF), the seventh member of the fibroblast growth factor family. We have been 
particularly interested in KGF because of work from our group, as well as from other investigators 
who have reported that KGF can reduce lung injury in small animal models of pulmonary edema 
and lung injury. Recombinant KGF pretreatment reduced mortality following intra-tracheal 
instillation of hydrochloric acid (72, 73), bleomycin (74, 75), hyperoxia (76, 77) and Pseudomonas 
aeruginosa. (78)  In rat lungs, KGF improved alveolar fluid transport in part by up-regulating 
ENaC gene expression (79) and Na-KATPase activity (80).  
 
In the ex vivo perfused human lung, the intra-bronchial instillation of hMSCs one hour following 
endotoxin-induced lung injury restored AFC in part by the secretion of KGF. (81) Several 
properties of KGF could explain the therapeutic effect of hMSCs on restoring AFC, including 
alveolar epithelial type II cell hyperplasia and differentiation, surfactant production (82), anti-
apoptotic effects (83) and increased transcription and/or translation of the major sodium and 
chloride transport proteins. (79, 80) Because the effect of MSCs in E. coli endotoxin-induced lung 
injury in the ex vivo perfused human lung model occurred over a 3-hour time period, the 
therapeutic benefit of KGF in these experiments is less likely explained by type II cell hyperplasia 
or transcriptional effects. Alternatively, an increase in vectorial fluid transport across the alveolar 
epithelium can be mediated by an increase in trafficking of sodium transport proteins to the cell 
surface. (84, 85)  
 
We have an established collaboration with the NIH sponsored Production Assistance for Cellular 
Therapy (PACT) Group in the University of Minnesota (Principal Investigator: David McKenna, 
MD) for the production of cGMP clinical grade, cryopreserved hMSCs. In additional experiments 
in the ex vivo perfused human lung, we have found that these hMSCs were effective in both 
endotoxin and live E. coli lung injury models in restoring the rate of AFC over 6 hours whether 
given intravenously or intratracheally. (8, 9) 
 
We also have recently completed experiments with hMSCs in sheep with ALI over 24 hours and 
found evidence of safety and efficacy. We have also completed IND-enabling safety studies in rats 
with ALI. 
3.3.5 Secretion of Paracrine Soluble Factors that Improve Lung Endothelial and 
Epithelial Permeability 
MSCs may be potentially beneficial by therapeutic effects on the injured lung endothelium. The 
integrity of the lung microvascular endothelium is essential to prevent the influx of protein-rich 
fluid from the plasma as well as inflammatory cells, which may further aggravate the ability of the 
lung epithelium to reduce alveolar edema. Several paracrine soluble factors, such as angiopoietin-
1 (Ang-1) and KGF, are potentially important in predicating these effects. Ang-1, a ligand for the 
endothelial Tie2 receptor, is a known endothelial survival (86) and vascular stabilization factor 
that reduces endothelial permeability and inhibits leukocyte-endothelium interactions by 
modifying endothelial cell adhesion molecules and cell junctions. (87-90) Regular MSCs or MSCs 

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(used as a vehicle for gene delivery) transfected with the human Ang-1 gene reduced both 
pulmonary vascular endothelial injury and the recruitment of inflammatory cells into the lungs of 
mice injured by LPS-induced lung injury (41, 43, 91).  In a study by Mei et al (41), the transfection 
of Ang-1 further reduced lung inflammation and nearly completely reversed the LPS-induced 
increase in lung permeability. We recently found that MSCs secrete a significant quantity of Ang-
1. In addition, using siRNA technology, the secretion of Ang-1 produced a therapeutic effect on 
lung epithelial protein permeability in primary cultures of human alveolar epithelial type II cells 
injured by an inflammatory insult. (92) 
 
KGF is one of several epithelial-specific growth factors produced by MSCs. In models of acute 
permeability edema such as -naphthylthiourea (93), P. aeruginosa (78) or ventilator-induced lung 
injury (94), KGF reduced lung edema and bronchoalveolar lavage protein levels. Cultured 
allogeneic hMSCs produced substantial quantities of KGF. The role of KGF is intriguing given 
the previous studies of ALI in animal models. A recent study by Murakami et al. reported that 
fibroblast growth factors (FGF), FGF2, FGF4 and FGF8 are specific for both FGF receptors 1IIIc 
and 3IIIc and are responsible for the maintenance of endothelial barrier homeostasis (95). Another 
epithelial-specific growth factor secreted by MSCs is hepatocyte growth factor (HGF). Previously, 
HGF was found to stabilize the integrity of pulmonary endothelial cells by inhibition of Rho 
GTPase and prevention of actin stress fiber formation and paracellular gaps among pulmonary 
endothelial cells injured by thrombin (96, 97). MSCs have also been reported to produce an 
inflammatory factor called TSG-6, which reduces the size of acute myocardial infarction in mouse 
studies, and also reduces the severity of acid-induced lung injury in mice (98). 
3.3.6 MSCs for Treatment of Acute Lung Injury after Hemorrhagic Shock and 
Resuscitation 
Several mechanisms contribute to the vascular barrier breakdown in multiple organs following 
shock and resuscitation, including inflammation, aberrant clotting, matrix metalloprotease 
activation, and oxidative stress, all described as part of the ischemia-reperfusion syndrome of lung, 
kidney, liver and cardiovascular injury. Dr. Pati’s group was the first to report that MSCs regulate 
pulmonary endothelial cell (PEC) adherens junction stability and permeability after tissue hypoxia. 
(99, 100) To test the effect of intravenous MSCs in an established rat model of fixed pressure 
hemorrhagic shock (HS), rats were treated with MSCs or lactated Ringer’s (control). MSC 
treatment reduced leukocyte infiltration, serum pro-inflammatory cytokine levels (TNF-α, MIP-1 
and MCP-1), and increased the serum anti-inflammatory cytokine IL-10. (99, 101) 
 
In the lungs, MSC treatment reduced the HS-induced increase in lung edema, returning the 
gravimetric measured lung water to normal levels. Rats treated with MSCs following HS and 
trauma also had a significant reduction in lung vascular permeability as measured using the lung 
extravasation of a 70kD infrared tagged dye. Consistent with this finding, treatment with MSC 
preserved adherens junction integrity, as indicated by increases in the barrier proteins VE-
cadherin, claudin-1, and occludin-1 .  
 
Mechanistically, several paracrine factors (KGF, Ang-1,TSG-6, lipoxin A4, Il-1ra, LL-37) account 
for many of the beneficial effects of MSCs in the lung.(101) In addition to the release of these 
paracrine factors, there is also evidence that MSCs can transfer their mitochondria to injured lung 

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epithelium, (34, 102-105) which can reduce lung injury by restoring normal bioenergetics in 
injured alveolar epithelial cells. Also, MSCs release microvesicles that can enhance anti-microbial 
effects by delivery of microvesicles to macrophages that then increase monocyte phagocytosis of 
bacteria. (104) The evidence in laboratory studies indicates that MSCs do not engraft in the lung 
or other organs, but instead provide a therapeutic benefit by the mechanisms. (34, 102-106)   
 
These mechanisms apply to the lung but may also help to explain the beneficial effects of MSCs 
that have been reported on non-pulmonary organ injury. In a mouse sepsis study, there was a 
reduction in serum creatinine as well as bilirubin in the MSC-treated mice. Another group reported 
the beneficial effects of MSCs on reducing acute kidney injury following ischemia-reperfusion. 
(106, 107) Their results indicated that organ recovery might be explained by the release of 
microvesicles from the MSCs that were lodged into the kidney circulation while the majority of 
the MSCs were lodged in the lung circulation. These preclinical studies support the hypothesis that 
MSCs may be beneficial in limiting multiple organ dysfunction as we propose to include in this 
trial since patients who suffer ARDS from medical causes such as pneumonia and aspiration and 
major trauma frequently develop ARDS as well as acute kidney injury and hepatic dysfunction.   
 
The mechanisms of potential benefit have been summarized in two recent reviews by Dr. Matthay 
and his colleagues. (8, 9). In addition, a recent secondary study based on the 60 patient START 
trial demonstrated that there was a reduction in total protein and pro-inflammatory biomarkers in 
the bronchoalveolar lavage of patients who were treated with the MSCs compared to placebo 
(108). We do not have pre-clinical data demonstrating efficacy of MSCs for SARS-CoV-2 lung 
injury.  
3.4 
Nonclinical Safety and Efficacy Studies 
In anticipation of a clinical trial, we established a collaboration with the NIH sponsored Production 
Assistance for Cellular Therapy (PACT) Group in the University of Minnesota (Principal 
Investigator: David McKenna, MD) for the production of cGMP (Current Good  Manufacturing 
Practice) clinical grade, cryopreserved hMSCs. In experiments in the ex vivo perfused human lung, 
these clinical grade hMSCs were effective in both endotoxin and live E. coli lung injury models in 
restoring the rate of AFC over 6 h when given by intra-venous or intra-tracheal administration.  
 
We completed safety studies in rats with ALI. Rats were injured with a standard non-infectious 
model of lung injury (hydrochloric acid instillation) and then randomized to placebo and three 
different doses of intravenous hMSCs from the University of Minnesota. The studies were carried 
out over 6 h. There were no respiratory or hemodynamic adverse effects in the rats treated with 
intravenous hMSCs (doses of 1, 5, and 10 x 106 cells/kg). 
 
We have completed a study with hMSCs in sheep with ALI over 24 hours (Sheep Study 1 in 2011, 
n=18). The sheep were injured with inhalation of hot cottonwood smoke and instillation of live P. 
aeruginosa bacteria in both lungs. Sheep were treated with intravenous hMSCs (either 5 or 10 x 
106 cells/kg) that had been washed to remove all of the DMSO and reconstituted in Plasma-Lyte 
A or with Plasma-Lyte A in the control sheep. The treatment was given 1 hour after the injury. 
There was a significant improvement in oxygenation (PaO2/FiO2 mm Hg) at 24 hours in the sheep 

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treated with hMSCs compared to the control sheep. Also the post-mortem extravascular lung water 
was lower in the sheep treated with the higher dose (10 x 106 cells/kg) compared to controls. The 
hMSCs were well tolerated with no infusion related changes in pulmonary or systemic 
hemodynamics or oxygenation in Sheep Study 1.  
 
We also completed a second sheep study (Sheep Study 2 in 2012, n=12) in which ALI was again 
induced with inhaled cottonwood smoke and instillation of live P. aeruginosa bacteria in both 
lungs to test the safety of giving two doses of hMSCs (1 hour and 18 hours after the injury). In 
contrast to Sheep Study 1, in this second sheep study the hMSCs were administered with 2.5% 
DMSO (i.e., cells not washed to remove the DMSO) and the sheep were pre-treated with 
diphenhydramine and low dose hydrocortisone.  
 
In the 2012 sheep experiments, the results from the first six sheep (each one paired with a control) 
indicated that the severity of sepsis was greater in these sheep than in the prior sheep studies from 
2011, as reflected by higher levels of lactate, lower systemic blood pressure, and lower urine 
output. Five of these 6 sheep died before 24 hours, 2 sheep even before 18 hours. There was a 
protocol of euthanasia guided by a low level of systemic blood pressure and low oxygenation.  
 
In addition to the high observed mortality rate described above, there was no evidence of 
improvement in the oxygenation (PaO2/FiO2 ratio) in the first 12 hours after the first dose of 
hMSCs in the first six treated sheep. This raised some concern that perhaps administering the 
hMSCs with DMSO decreased the efficacy of the hMSC therapy.Consultation was then obtained 
with the FDA after the results of the first 6 sheep. It was mutually agreed upon that we should 
carry out the next 6 sheep experiments with a systematic approach to determine the tolerability of 
the hMSCs, the possible contribution of DMSO to the reduced efficacy, and trying to reduce the 
bacterial injury so that it more closely resembled the experiments from 2011 with the group 1 
sheep.  
 
Thus, in the next two sheep (hMSC-treated and Plasmalyte control-treated), the dose of 
Pseudomonas aeruginosa bacteria was reduced from 2.5 to 1.8 x 1011 for instillation into the lungs. 
The result was a pattern of acute lung injury and sepsis that more closely resembled the sheep 
studies from 2011. These experiments were carried out with the same protocol of DMSO treatment 
and two doses of hMSCs at one and eighteen hours after onset of acute lung injury. Even with the 
lower dose of bacteria, the hMSC-treated sheep died at ≥ 20 h, suggesting again that the second 
dose of hMSCs at this time interval after lung injury was not tolerated in terms of systemic 
hypotension. Also, there was no evidence of efficacy after the first dose of hMSCs, as we had 
observed consistently in the 2011 group 1 sheep.  
 
Thus, for the last four sheep, we continued to use this more moderate dose of bacteria, but returned 
to the original approach of administration of the hMSCs after washing them to remove all the 
DMSO and without any pre-treatment with Benadryl or hydrocortisone. In the final four sheep 
(MSC-treated and control-treated pairs), there was evidence of efficacy of improved oxygenation 
(PaO2/FiO2 ratio) as in the prior group 1 experiments from 2011. However, there was still evidence 
that the second dose of hMSCs given at eighteen hours was not tolerated, because one of the 
hMSC-treated sheep died prior to 24 hours.  

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We previously concluded from these studies that (1) DMSO should not be used in our clinical trial 
and (2) that we could not demonstrate preclinical safety for a second dose of hMSCs in this severe 
model of ALI when the hMSCs were given only 18 hours after the lung injury following an initial 
dose of hMSCs at 1 hour following the injury.  
 
As discussed further in this clinical protocol, based on the results of the phase 2a clinical trial in 
60 patients (START trial), the process of removing DMSO with an extra wash step did reduce 
hMSC viability.  Therefore, in this phase 2b trial, we will simplify the bone marrow transplant 
procedures and not remove the DMSO after thawing the hMSCs product for clinical 
administration. The product will be thawed and diluted  with 1:1 mix of 5% human serum albumin 
and 10% Dextran 40 (see Study Product Preparation Protocol in Appendix E). 
3.5 
Description of Investigational Cellular Product and Dose Selection 
The investigational cellular product is Allogeneic Bone Marrow-derived Human Mesenchymal 
Stromal Cells (hMSCs). The investigational product is manufactured at University of Minnesota’s 
Molecular & Cellular Therapeutics (MCT) Facility.  
 
The hMSCs are formulated in CryoStor (90%) and DMSO (10%), and cryopreserved and stored 
in bags suspended in liquid nitrogen. Immediately prior to administration, the product is thawed 
and diluted in 1:1 with reconstitution media (1:1 mix of 5% human serum albumin and 10% 
Dextran 40). Additional reconstitution media will be added to a final product volume of 300 mL.  
 
The placebo group will be treated with 300 mL of reconstitution media (1:1 mix of 5% human 
serum albumin and 10% Dextran 40). 
 
Pre-clinical safety data has been generated from the ex vivo perfused human lung as well as small 
animals (mouse and rat) and large animal (sheep) safety studies.  In the sheep safety studies, 
animals have been treated with intravenous hMSCs at doses of either 5 x 106 cells/kg or  
10 x 106 cells/kg. 
 
The placebo-controlled Phase 2b study will evaluate the single-dose treatment of 10 x 106 cells/kg. 
The number of MSCs to be administered will be based on viable cell counts at the time of MSC 
preparation by the PACT facility at the University of Minnesota as determined by acridine 
orange/propidium iodide (AO/PI), rather than based on the total number of cells prepared.  
3.6 
Clinical Experience  
There are currently more than 200 clinical trials listed in clinicaltrials.gov using other preparations 
of human mesenchymal stromal cells for therapy for a wide variety of indications, including graft 
versus host disease, acute myocardial infarction, acute kidney injury, diabetes, transplant allograft 
rejection, lower extremity ischemia and, more recently, lung disease. The most relevant  trials for 
this application are: 

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Date: April 19, 2022  
 
 
Confidential  
 
 
 
Studies Focused on Lung Disease 
1) A Phase 2 trial evaluating Prochymal (Adult allogeneic mesenchymal stem cells, Osiris 
Therapeutics) for the treatment of moderate to severe chronic obstructive pulmonary 
disease (COPD, Osiris Therapeutics) involving 62 patients in a randomized, double-
blinded, placebo controlled trial (NCT00683722). The six-month interim data analyses 
demonstrated that Prochymal significantly decreased the level of C-reactive protein in 
patients compared to placebo, but did not improve pulmonary function. The primary 
endpoint was safety, and secondary endpoints included changes in pulmonary function 
tests, exercise capability and quality of life. Subjects received 100 x 106 cells/infusion and 
received 4 weekly infusions (D. Weiss, personal communication). No safety concerns were 
identified between the placebo and treated groups. 
 
2) Two Phase 1 trials involving the use of human umbilical cord derived mesenchymal stem 
cells for the treatment of severe bronchopulmonary dysplasia in neonates up to 6 months 
or 14 days respectively, one randomized and the other open-labeled, single-center 
(NCT01207869 and NCT01297205). Both trials involved the intra-tracheal administration 
of hMSCs (3 x 106/kg for NCT01207869 and 10 or 20 x 106/kg for NCT01297205). The 
primary outcomes measured included the number and severity of adverse reactions and/or 
the relationship between the cytokine concentrations in the BAL fluid and pulmonary 
artery pressure. The intratracheal transplantation of allogeneic hUCB-derived MSCs in 
preterm infants is safe and feasible, and warrants a larger and controlled phase II study 
(NCT01297205). (109) 
 
3) A Phase 1 trial evaluating the treatment of idiopathic pulmonary fibrosis (IPF) with human 
placental derived mesenchymal stem cells (NCT01385644). This was an open-label, single 
center, non-randomized dose-escalation evaluation of the safety and feasibility of 
mesenchymal stem cell treatment for subjects diagnosed with IPF. A total of up to eight 
subjects were enrolled in the study. The first 4 patients received a dose of 1 x 106 placenta-
derived mesenchymal stem cells/kg. The Data Safety Management Board (DSMB) carried 
out an interim safety analysis when these first 4 patients had all undergone their 3-month 
study visit. Because no serious adverse events were documented due to the infusion of 
mesenchymal stem cells, a subsequent 4 patients received IV infusions of 2 x 106 placenta-
derived mesenchymal stem cells/kg. The results of this Phase 1 trial suggested that 
intravenous MSC administration is feasible and has a good short‐term safety profile in 
patients with moderately severe IPF. At six months after treatment, the patients showed no 
worsening in their condition. (110) 
 
4) A Phase 1 trial to test the safety and feasibility of intravenous administration of autologous 
human bone marrow derived mesenchymal stem cells after one-sided lung volume 
reduction surgery (LVRS) and prior to a second LVRS procedure for patients with severe 
pulmonary emphysema (NCT01306513). The study design was an open label, non-
randomized, non-blinded, prospective clinical trial. Subjects would undergo two operations, 
initially on one lung without pre-surgical infusion of bone marrow derived hMSCs, 
followed by a second surgical procedure on the contralateral lung, which was preceded by 
two intravenous infusions of hMSCs one week apart, 4 and 3 weeks prior to the second 

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lung surgery. The dose was not specified in the published protocol. The primary endpoint 
is the safety and feasibility of the intravenous infusion of the two doses of hMSCs with 1 
week interval after the first LVRS and prior to a second LVRS. Toxicity criteria  were 
evaluated by grade according to World Health Organization (WHO). This trial suggests 
that autologous MSC treatment in severe emphysema is feasible and safe. The increase in 
CD31 expression after LVRS and MSC treatment suggests responsiveness of 
microvascular endothelial cells in the most severely affected parts of the lung. (111) 
 
5) Recently, a prospective phase 1b trial of allogeneic adipose-derived MSCs for acute 
respiratory distress syndrome was completed in China. There were no reported serious 
adverse events related to MSC administration, as well as no infusion toxicities. There was 
not a significant difference in the overall number of adverse events between the treatment 
and control groups. There were also no significant differences between length of hospital 
stay, VFDs, and ICU-free days at day 28. Biomarker analysis showed significantly lower 
serum SP-D levels at day 5 in the MSCs group (p=.027). IL-6 levels showed a trend toward 
lower levels from day 0 to day 5, however this was not statistically significant (p=.06). 
Changes in IL-8 were not significant. There were no biomarker changes observed in the 
placebo group. The investigators concluded that the use of allogeneic adipose-derived 
MSCs was both safe and feasible in the treatment of ARDS. (112)  
 
6) Dr. Matthay received this IND (#15331) from the FDA to carry out a dose escalation phase 
1 clinical trial of allogeneic human MSCs for ARDS in critically ill (no-trauma) patients, 
with the plan to advance to a phase 2a clinical trial if the phase 1 trial demonstrated safety. 
Funding was obtained from the NHLBI (U01HL108713) to carry out the trial in five 
university medical centers. The clinical grade, allogeneic bone marrow-derived human 
MSCs were provided by the University of Minnesota NHLBI Production Assistance for 
Cellular Therapeutics (PACT) program (David McKenna, MD, Principal Investigator).  
 
The initial phase 1 and 2a trials were designed to test MSCs for medical causes of ARDS, 
with a planned exclusion of trauma-related ARDS. Dr. Matthay and his co-investigators 
reasoned that the trauma population should be included in a subsequent trial because the 
mechanisms of lung injury in trauma-related ARDS have several common pathways to 
medical causes of lung injury.  Some trauma patients have additioInnal risk factors for 
ARDS that are distinct from the medical population, including hypovolemic shock from 
penetrating or blunt trauma, ischemia-reperfusion following fluid resuscitation, multiple 
blood product transfusions, pulmonary contusion and long bone fractures.  However, it is 
not clear that the biological pathways resulting in lung injury after these specific risk 
factors represent novel pathogenic mechanisms of ARDS.  Because the biology resulting 
in ARDS after trauma likely shares similar common mechanisms of ARDS with medical 
causes of ARDS, we reasoned that this phase 2b trial should include trauma patients. 
Subsequently emerging evidence suggests  that the incidence of ARDS following trauma 
has declined, probably related to changes in resuscitation practices with the reduced use of 
crystalloid fluids and balanced transfusion of blood products. (113).   
   

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Therefore, the inclusion criteria for this trial have been broadened to include all causes of 
ARDS. This is the rationale for this requested amendment to the current IND of testing 
MSCs for both trauma and medical causes of ARDS.  
 
In 2014, Dr. Matthay’s group completed the phase 1 dose escalation trial of bone-marrow 
derived human MSCs in 9 critically ill patients with moderate to severe ARDS from non-
traumatic etiologies, including pneumonia, non-pulmonary sepsis and aspiration 
(NCT01775774). (114) Exclusions included trauma within the prior 5 days, a history of 
pulmonary hypertension, thromboembolic disease, moderate to severe liver disease 
(Childs-Pugh > 11), more than 96 hours since the onset of ARDS, history of treatment for 
cancer within the last 2 years, pregnancy and age < 18 years old. The design was to test the 
safety of doses of 1, 5, and 10 x 106 hMSC/kg predicted body weight (PBW) in three 
patients at each dose level for a total of nine patients, and is described in detail in two 
publications. (114, 115) Dr. Marc Moss served as a medical monitor for the DSMB 
protocol. In consultation with FDA, they defined stopping criteria for the trial based on 
pre-specified infusion-associated adverse events. 
 
The primary endpoint of the phase 1 trial was safety. MSCs had not been previously 
administered to critically ill patients, including those with acute respiratory failure from 
ARDS or with hemodynamic instability (shock). Because these patients were critically ill, 
the trial required a baseline period of 2 hours of hemodynamic and respiratory stability. 
Patients were monitored for pre-specified infusion-associated adverse hemodynamic or 
respiratory events within 6 hours of the MSC infusion. The MSCs were administered 
intravenously over one hour. A coordinator and physician investigator were present at the 
bedside during the infusion and for the subsequent monitoring period. The results were 
reported in 2014. (114) There were no pre-specified associated adverse hemodynamic or 
respiratory events. Heart rate and systemic blood pressure were no different between the 
two hour baseline and the six hour post-infusion monitoring period among the three groups. 
 
The 4-point lung injury score (oxygenation, level of positive end-expiratory pressure, static 
respiratory compliance, and extent of infiltrates on the chest radiograph) (see Appendix 
B) was measured and calculated in all patients (116) at baseline, 6 hours, day 1, day 2 and 
day 3. The lung injury score declined in each of the three dosing groups with the highest 
dose showing the lowest lung injury score; statistical analysis of this data was not done 
because there were only 3 patients in each group and there was no placebo group. Overall, 
there were no serious adverse events attributable to the MSC treatment in this phase 1 trial 
of 9 patients. The DSMB then approved advancing to the phase 2a trial, which retained the 
primary endpoint of safety as measured by the same safety endpoints as in the phase 1 trial. 
 
Dr. Matthay and his group then conducted a phase 2a safety trial with 60 patients with 
ARDS with the same inclusion and exclusion criteria as in the phase 1 trial described above. 
The 2a trial was carried out at the same five university medical centers as the phase 1 trial, 
UCSF, Stanford, Ohio State, University of Pittsburgh and Massachusetts General Hospital 
(NCT02097641).  
 

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
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The trial was reviewed by the DSMB after 20 and 40 patients, and the DSMB found no 
safety isssues and recommended continuing the trial and it was completed recently 
(NCT02097641). The primary endpoint of the trial was safety, thus randomization was 2:1 
for MSC to placebo.  
 
In terms of the primary endpoint, safety, there were no pre-specified infusion related 
adverse events within the 6 hours following infusion.  One patient died within 24 hours 
(hour 22) in the hMSC group related to acute coronary ischemia and infarction during a 
fiberoptic bronchoscopy. This case was reviewed by the DSMB, who concluded that the 
death was not related to the study infusion.  
 
There was a numerically higher mortality over 28 days in the hMSC treated group (30%) 
compared to the 20 patients in the placebo group (15%); this difference was not statistically 
significant (p=0.24). Several imbalances in the MSC vs. placebo group at baseline likely 
contributed to this numerical difference. For example, as an index of severity of illness, the 
mean of APACHE III score was numerically higher at baseline in the MSC patients 
compared to the placebo patients (104±31 versus 89±33, p=0.10). Also, there was a higher 
minute ventilation in the MSC patients compared to the placebo patients (11.1±3.2 versus 
9.6±2.4 L/min, p=0.06), likely reflecting higher pulmonary dead space and potentially 
more severe lung disease. When mortality was adjusted by the APACHE III baseline score, 
the hazard ratio for 28 day mortality was 1.43 (confidence interval [CI]: 0.40 – 5.12, p 
=0.58).   
 
The placebo mortality of 15% was particularly low for ARDS trials, especially considering 
that the entry criteria required moderate to severe hypoxemia (PaO2/FiO2 < 200 mmHg) 
which has an expected mortality of 33-49%. (14) The recent large international LUNG 
SAFE study of ARDS reported a 28 day mortality of 35%. (117) 
 
In terms of signals for potential efficacy, there was a numerical, non-significant  
improvement in the oxygenation index at days 1, 2 and 3 in the MSC treated group 
compared to the placebo patients. On day 1, the median oxygenation index numerically 
improved in the MSC versus placebo group from the baseline (2.7 versus 1.1, p=0.32). On 
day 2, the median oxygenation index numerically improved in the MSC versus the placebo 
group (4.0 versus 2.6, p=0.29) and on day 3, the median oxygenation index numerically 
improved in the MSC versus placebo group (3.0 versus 1.9, p=0.29).  However, this phase 
2a trial of 60 patients with 2:1 MSC to placebo randomization was not powered for any 
efficacy endpoints, whereas this new Phase 2b trial for ARDS from medical and traumatic 
causes of ARDS outlined in this clinical protocol will enroll 120 patients and is powered 
to test for efficacy for respiratory endpoints with 1:1 randomization.  In addition, further 
post hoc analysis of the earlier phase 2a trial showed that there was variability in the 
viability of the MSCs administered from 36 to 85%. This data was available to the 
investigators only after the trial was completed. By tertiles, the viability was 36-56% 
(n=14), 57-69% (n=13), and 71-85%, (n=13).  Because of this wide range of MSC viability, 
we carried out a post hoc analysis to determine whether there were any significant 
differences in the levels of the biologic markers in the plasma according to the MSC 

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viability.  There were no differences in the levels of IL-6, IL-8 or RAGE at baseline. 
However, after adjustment for baseline differences, angiopoietin-2, a marker of vascular 
leak associated with more severe lung in jury in ARDS, was significantly and progressively 
lower in the intermediate and the highest tertiles of MSC viability. Thus, there appeared to 
be a viability-dependent effect on plasma angiopoietin-2 levels based on the MSC viability. 
In addition, analysis of the change in oxygenation index from baseline over two days was 
carried out in these cell viability subgroups. This analysis showed a non-significant trend 
for improved oxygenation index in the intermediate and highest tertile MSC viability 
groups on day 2. The results of this trial have been published recently in Lancet Resp Med. 
(118) 
 
7) Recently, a prospective phase 1 trial of MSCs for sepsis has been completed in Canada 
which did not show any safety issues in the treated patients compared to a historical control 
group. (119) Dr. Matthay has published an editorial commenting on this trial (120). Two 
recent reviews of MSCs co-authored by Dr. Matthay (8, 9) provide an update on MSCs in 
the field of ARDS and sepsis, as well as other critical care conditions. 
 
 
Studies Using hMSCs for Therapy for Graft versus Host Disease, Crohn’s Disease, Acute Myocardial 
Infarction, Acute Kidney Injury and Diabetes 
8) Two Phase 3 trials using Prochymal (Adult allogeneic mesenchymal stem cells, Osiris 
Therapeutics) in severe refractory graft vs. host disease (GvHD): one that was not steroid 
responsive and another that received hMSCs as part of first line therapy (NCT00366145 
and NCT00562497). Both trials were placebo controlled and did not meet their endpoints. 
However, in the steroid refractory trial, there was a statistically significant improvement 
over placebo in patients with gastrointestinal and liver GvHD. The dosing regimen for the 
hMSCs was 2 x 106 cells/kg intravenously twice a week for 4 weeks. These trials were 
inspired by positive Phase 2 results (121), which showed an overall response rate of 94% 
and complete remission rate of 77% among 32 patients who received hMSCs for acute 
GvHD. 
 
9) A Phase 3 trial using Prochymal (Osiris Therapeutics) for the induction of remission in 
subjects 
experiencing 
treatment-refractory 
moderate-to-severe 
Crohn's 
disease 
(NCT00482092). The primary outcome measured will be disease remission (Crohn’s 
Disease Activity Index at or below 150) within a 28-day timeframe. A low dose (600 x 106 
cells total over four intravenous infusions in two weeks) and a high dose (1200 x 106 cells 
delivered intravenously in four infusions over two weeks) will be tested. 
 
10) A Phase 2 trial using Prochymal (Osiris Therapeutics) in patients following an acute 
myocardial infarction (NCT00877903). The study is currently enrolling patients (220 
patients, randomized, double-blinded, placebo controlled). The primary endpoint is left 
ventricular systolic volume; secondary endpoints are measurements of left ventricular 
ejection fraction, infarct size and major adverse cardiovascular events. Subjects receive a 
single intravenous infusion within 7 days following an acute myocardial infarction. Note 

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that this group completed a double blind, placebo-controlled, dose-ranging (0.5, 1.6, and 5 
million cells/kg) study of 53 patients. Left ventricular ejection fraction improved by 
echocardiography in patients treated with hMSCs vs. placebo. There were similar rates of 
adverse events (5.3/patients post hMSCs vs. 7/patient in placebo, n = 53 total). (122) 
 
11) A Phase 1/2 trial studying the efficacy of intramyocardial injections of autologous human 
mesenchymal stem cells in patients undergoing cardiac surgery (Prometheus, NHLBI 
Sponsored, NCT00587990). This randomized, double-blinded, placebo controlled study is 
currently enrolling patients (planned enrollment 45 patients). Primary outcomes are 
incidence of serious adverse events at 6 months including the incidence of sustained 
ventricular arrhythmias, ectopic tissue formation or sudden unexpected death. Dosage used 
will be 10 to 20 intramyocardial injections of 2 to 20 million hMSCs for a total of  
2 x 107 to 2 x 108 cells total. 
 
12) A randomized, multi-center, double-blind, placebo-controlled study of AC607 (hMSCs) 
for the treatment of acute kidney injury in cardiac surgery subjects (AlloCure Inc, 
NCT01602328). Dosage was a single injection of 2 x 106 hMSCs/kg. The primary endpoint 
was time to kidney recovery, defined as a post-operative serum creatinine return to pre-
operative baseline values within 30 days of dosing. This trial was terminated due to futility 
after the final DSMB meeting with 75% patient accrual. The primary analysis showed no 
significant difference in time to recovery of kidney function. There were no significant 
differences between groups in the secondary outcomes of all-cause mortality or provision 
of dialysis. (123) 
 
13) There are >10 clinical trials underway for the treatment of Diabetes, both type 1 and 2, 
with mesenchymal stem cells. One relevant  trial is a Phase 2, multicenter, randomized, 
double-blind, placebo controlled study to evaluate the safety and efficacy of Prochymal 
(Osiris Therapeutics) for the treatment of recently diagnosed Type 1 Diabetes Mellitus 
(NCT00690066). The dosage is not specified. The primary endpoint will be the 
measurement of C-peptide AUC response (mixed meal tolerance test). Secondary 
outcomes will be the measurements of peak C-peptide response, basal C-peptide response, 
total daily insulin dose, glycosylated hemoglobin (HbA1c), number of severe and 
documented hypoglycemic events and changes in levels of GAD or IA-2 autoantibodies. 
 
The safety record for hMSCs prepared by conventional methods has been favorable in clinical 
trials to date, according to published literature and information available on clinical trials.gov. 
Serious infusion-related or delayed toxicities have not been associated with either autologous or 
allogeneic hMSCs in adult and pediatric recipients of allogeneic hematopoietic transplantation, the 
patient population most studied to date. (124) Osiris Therapeutics has sponsored clinical trials of 
Prochymal (allogeneic unrelated donor hMSCs) that have included over 2000 patients to date. In 
a randomized, placebo-controlled, dose-escalation safety study of Prochymal in patients with acute 
myocardial infarction, adverse events were comparable for the hMSC- and placebo-treated groups, 
and no adverse events were attributable to hMSCs administration. (122) Up to 5 x 106 cells/kg 
were administered in this study.   

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3.7 
Potential Benefits and Risks to Human Participants 
3.7.1 Potential Benefits 
The benefits from hMSCs in the treatment of ARDS remain unknown. The benefit of participation 
in this study is the knowledge gained for the benefit of future patients. The mortality rate of 
moderate-to-severe ARDS (the target population for this trial) is approximately 25-40%. 
Administration of hMSCs may have a benefit on mortality in this patient population. Furthermore, 
if hMSCs have benefit in patients with ARDS, this will have a major benefit to society given the 
high mortality rate associated with this condition. 
3.7.2 Potential Risks 
3.7.2.1 Overview 
The main potential risks of participation in this study are those associated with administration of 
the investigational agent. There are additional minor risks associated with study-related procedures 
as detailed below. 
3.7.2.2 Cardiovascular and Respiratory 
Transient occlusion of the pulmonary microcirculation with intravenously administered hMSCs 
could be associated with a fall in systemic blood pressure, rising vasopressor dose, a rise in heart 
rate, an increase in arterial carbon dioxide concentration, or a fall in oxygenation. As detailed 
below, patients will be monitored continuously during the infusion for these signs/symptoms and 
the infusion will be terminated if certain clinical criteria are met or there is concern for worsening 
hemodynamics or oxygenation on the part of the study investigators. 
3.7.2.3 Risks of Transfusion Reaction 
Known potential side effects of blood product transfusion include transient fever or chills. As per 
established regulatory requirements, bone marrow donors are prescreened for infection, reducing 
the risk of infection with HIV or hepatitis B or C from the hMSC cell product. Patients may 
experience more severe or life-threatening transfusion reactions, but these are exceedingly rare. 
Patients will be monitored during the infusion for signs of a transfusion reaction (urticaria or rash, 
bronchospasm) and medications will be readily available to treat a life-threatening transfusion 
reaction, should such a reaction occur.  
3.7.2.4 Risks of blood draws 
All patients will have blood drawn for research purposes. Most blood will be drawn through 
indwelling catheters. Risks of drawing blood percutaneously are minor and include bleeding, 
bruising and infection. 
3.7.2.5 Reproductive risks 
There may be an unexpected risk to an unborn or nursing child. Pregnant and breastfeeding women 
will be excluded from participation in the study.  

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3.7.2.6 Mini-bronchoalveolar lavage (Mini-BAL) 
In the Phase 2b clinical trial, we will obtain mini-bronchoalveolar lavage (mini-BAL) on day 2 
after the infusion of hMSCs. The known potential risk of mini-BAL includes transient 
deterioration of oxygenation or respiratory compliance, requiring an increase in ventilator settings. 
The exclusion of study subjects who require high levels of ventilatory support from this procedure 
will minimize the risk of this complication. We will also exclude patients at risk for complications 
of the mini-BAL procedure, including patients with significant bleeding disorders or elevated 
intracranial pressure using clear, predetermined criteria that are used in clinical practice. In over a 
decade of use at UCSF Medical Center using even less restrictive criteria for exclusion, mBAL 
has not resulted in any safety concerns.  The mini-BAL at day 2 will allow us to test the efficacy 
of hMSCs within the airspaces, which is a primary proposed biological site of action. 
3.8 
Study Rationale  
Pre-clinical data from the ex vivo perfused human lung as well as small animal (mouse and rat) 
and large animal (sheep) studies support the potential efficacy and safety of hMSCs administration 
for the treatment of ALI/ARDS. We completed phase 1 and 2a trials of allogeneic hMSCs in 
moderate-to-severe ARDS, using a hMSCs product derived from bone marrow by conventional 
methods. The trial were designed to test safety endpoints, but included secondary efficacy 
endpoints but the trial was not powered for these secondary efficacy endpoints. (114) (118) 
 
In the Phase 1 trial, we enrolled 9 patients in a 3-dose escalation phase (1 x 106 cells/kg, 5 x 106 
cells/kg and 10 x 106 cells/kg).  
 
A. In Phase 1, we used an open label standard dose escalation model, with a plan for safety 
assessments. 
 
B. The initial dose was 1 x 106 cells/kg given intravenously to 3 patients. After approval from 
the DSMB, we progressed to the next dose. The second dose delivered was 5 x 106 cells/kg 
given intravenously to 3 patients. The third dose level was 10 x 106 cells/kg given 
intravenously to 3 patients. 
 
In the Phase 2a trial, we enrolled 60 patients in a 2:1 blinded randomized placebo-controlled 
design with the dose of 10 x 106 cells/kg (40 patients treated with hMSCs and 20 controls). Safety 
analyses was conducted by the independent DSMB, and the sponsor and investigators were 
blinded.  
The initial phase 1 and 2a trials were designed to test hMSCs for medical causes of ARDS, with a 
plan to exclude trauma-related ARDS. Dr. Matthay and his co-investigators reasoned that the 
trauma population should be included in a subsequent trial because the mechanisms of lung injury 
in trauma-related ARDS have several common pathways to medical causes of lung injury, 
although some trauma patient have hypovolemic shock from penetrating or blunt trauma, 
ischemia-reperfusion following fluid resuscitation, multiple blood product transfusions, 
pulmonary contusion and long bone fractures. This is the rationale of testing hMSCs for both 
trauma and medical causes of ARDS.  
 

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Based on these studies, we propose a Phase 2b randomized, double-blind, placebo-controlled 
clinical trial of hMSCs for the treatment of moderate-to-severe ARDS after medical and traumatic 
causes of ARDS. 
 
4 Study Objectives 
4.1 
Primary Objective 
The primary objective of this study is to assess whether an intravenous infusion of hMSCs in 
patients with ARDS will lead to a reduction in the severity of acute respiratory failure from ARDS 
as measured by the oxygenation index. 
4.2 
Secondary Objectives 
The secondary objectives of this study are to assess the potential efficacy of intravenous infusion 
of hMSCs in patients with ARDS including (1) an improvement in several physiologic and 
functional endpoints of respiratory failure, (2) a reduction in the incidence of secondary infections, 
(3) a reduction in systemic organ failure and in-hospital mortality, (4) improved neurocognitive 
function at hospital discharge, (5) incidence of thromboembolic events, as well as (6) to acquire 
mechanistic data regarding the activity of hMSCs in ARDS patients from biologic samples of 
plasma, urine and mBAL. In addition, safety will monitored as defined by the incidence of pre-
specified infusion associated events and of unexpected severe adverse events in ARDS patients 
treated with hMSCs. Because the vast majority of patients enrolled in this trial will have had ARDS 
secondary to COVID-19, all of the objectives will be analyzed according to whether the patient 
developed ARDS from COVID-19 or another etiology.  
 
5 Study Design 
This clinical study design is a randomized, double-blinded, placebo-controlled Phase 2b clinical 
trial using a 10 x 106 cell/kg dose of hMSCs. Subjects will be randomized in a 1:1 randomization 
scheme to receive hMSCs or cell reconstitution media (1:1 mix of 5% human serum albumin and 
10% Dextran 40) as the placebo; the study will enroll 120 patients who achieve a stable clinical 
baseline and receive study product (either hMSCs or the placebo) as described in Section 9.4.  
 
The DSMB will review adverse outcomes and protocol compliance. A pre-specified interim review 
will occur after 60 subjects have been enrolled and received study product; enrollment will 
continue during DSMB review. All pre-specified clinically important events and unexpected 
serious adverse events including death through day 28 from study product administration will be 
reported to the DSMB on an ongoing basis; the study will be stopped for a safety evaluation by 
the DSMB if they have any concerns or if three subjects have pre-specified clinically important 
events or unexpected serious adverse events EXCEPT death since death will be common in this 
critically ill population due the nature of the underlying illness (e.g., ARDS).  
 

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6 Endpoints  
Analyses of the primary and secondary endpoints will be conducted primarily as an intention-to-
treat analysis plan and also an as-treated analysis as described in detail in Section 11.3. A Statisical 
Analysis Plan has been written according to this protocol. There is the potential for subjects to be 
consented for study participation but to not receive treatment because of clinical instability due to 
the severity of their underlying medical conditions or due to clinical improvement in ARDS.  
6.1 
Primary Study Endpoint: Phase 2b 
The primary study endpoint will assess whether an intravenous infusion of hMSCs in patients 
with ARDS will lead to a reduction in the severity of ARDS as measured by a decrease in the 
oxygenation index (OI) compared to baseline OI (prior to administration of the study product) 
over the first 36 hours after the initiation of study product infusion (with measurements of OI at 
6, 12, 18, 24, 30 and 36 hours). (125, 126) 
 
6.2 
Secondary Endpoints: Phase 2b 
6.2.1 Efficacy Secondary Endpoints 
We will test six categories of efficacy endpoints in the Phase 2b trial: respiratory physiology, 
secondary infection, systemic illness, neurologic, thromboembolic events, and biomarker profiles 
related to potential mechanism of hMSC activity in ARDS.  
 
1. Respiratory Physiology: Respiratory efficacy endpoints will include: 
 Reduction in the 4-point acute lung injury (LIS) score after enrollment in the trial at days 
1, 2, 3 and 7, or on the last day of positive pressure ventilation prior to day 7. The LIS is 
a composite scoring system including the PaO2/FiO2, the level of positive end-expiratory 
pressure, static respiratory compliance, and the quadrants of frontal chest radiograph with 
opacification. 
 Reduction in the pulmonary dead space on days 1, 2, 3 and 7. 
 Reduction in chest radiograph assessment of the extent of pulmonary edema (RALE score) 
at days 1, 2, 3, and 7. 
 OI will be collected (as planned) also on days 2, 3, and 7 if still being ventilated with 
positive pressure as a secondary endpoint. 
 Reduction in ventilatory ratio with measurements at 6, 12, 18, 24, 30, 36 hours, and days 
2, 3 and 7. 
 Incidence of barotrauma on days 1, 2, 3, and 7. 
 Achieving pressure support ventilation with 5 cmH20 and positive end-expiratory pressure 
equals to 5 cmH20 for 2 hours 
 Ventilator free-days over 7, 14 and 28 days; duration of assisted ventilation over 28 days 
in the survivors. Ventilator Free Days (VFDs) to day 28 are defined as the number of days 
from the time of initiating unassisted breathing to day 28 after study product 

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administration, assuming survival for at least two consecutive calendar days after initiating 
unassisted breathing and continued unassisted breathing to day 28. If a patient returns to 
assisted breathing and subsequently achieves unassisted breathing to day 28, VFDs will 
be counted from the end of the last period of assisted breathing to day 28. A period of 
assisted breathing lasting less than 24 hours and for the purpose of a surgical procedure 
will not count against the calculation of VFDs. If a patient was receiving assisted breathing 
at day 27 or dies prior to day 28, VFDs will be zero. Patients transferred to another hospital 
or other health care facility will be followed to day 28 to assess this endpoint.  
 
2. Secondary Infection: Infection efficacy endpoints will include:  
 Superficial incisional/wound infections during the 14 days after enrollment. 
 Deep incisional wound infections during the 14 days after enrollment. 
 Organ (such as lung, liver) or space (such as peritoneum or pleural) infections during the 
14 days after enrollment. 
 Ventilator associated pneumonia (VAP) during the 14 days after enrollment. 
 
3.  Systemic Illness: Systemic illness efficacy endpoints will include: 
 Mean SOFA score (127) at days 3, and 7.  
 In hospital mortality at 14 days, 28 days, and 60 days.  
 Additional prognostic value of neutrophil:lymphocyte ratio.  
 Ordinal Scale for Clinical Improvement (OSCI) at days 7, 14 and 28. 
 
To assess organ failure, we will measure serum creatinine (renal function), bilirubin (hepatic 
function), and platelet count (hematology) at days 0, 3, and 7.  
 
4. Neurologic: Neurocognitive efficacy endpoints will include: 
 Neurocognitive function at hospital discharge by the Glasgow Outcome Score (6 points) 
 
5. Thromboembolic: Thromboembolic safety endpoints will include:  
 Incidence of thromboembolic events: Measured by ultrasound of the deep venous system 
or CT-angiography of the chest when clinically indicated. 
 Additional prognostic value of fibrinogen at baseline.  
 
6. Biologic: Biomarker analysis will include: Changes in levels of plasma, urine, and genetic 
biomarkers at baseline compared to 6, 24, 48, and 72 hours, including:  
o Endothelial injury (angiopoietin-2 [Ang-2])  
o Lung epithelial injury (Receptor for Advanced Glycation Endproducts [RAGE])  
o Pro-inflammatory markers (interleukin-6, interleukin-8, soluble tumor necrosis 
factor-1 [sTNF-1], intercellular adhesion molecule-1 [ICAM-1], interferon 
gamma-induced protein-10 [IP-10], interleukin-10 [IL-10], vascular endothelial 
growth factor [VEGF], matrix metalloproteinase-8 [MMP-8], thrombomodulin, 
surfactant protein-D [SP-D], triggering receptor expressed on myeloid cells-1 
[TREM-1], interleukin-18 [IL-18], plasminogen activator inhibitor-1 [PAI-1])  

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o Protein C (marker of impaired coagulation) 
o Pro-resolving lipids (lipoxin A4, resolvin D1) 
o Biomarkers that reflect the paracrine activity of the administered hMSCs 
(angiopoietin-1 [Ang-1], keratinocyte growth factor [KGF])  
o We will use the levels of the baseline plasma biomarkers (IL-8, Protein C, and 
serum bicarbonate ± vasopressor use at randomization) to classify patients as hyper- 
or hyper-inflammatory subphenotypes as we have described and test for higher 
mortality in the hyper-inflammatory group. Also, we will test for an interaction 
between MSC therapy and the subphenotypes for the outcomes of oxygenation 
index over 36 hours and 28 day mortality. 
 Lung protein permeability as measured by total protein in mini-bronchoalveolar lavage 
[mBAL] protein at day 2; the same biomarkers will also be measured in plasma to compare 
MSC versus placebo treated patients.  
 Measurements of urine microalbumin and urine creatinine 
 Changes in levels of plasma SARS-CoV-2 viral antigen and antibody at multiple 
timepoints.  
 Gene expression at baseline and on days 2 and 3. 
6.2.2 Safety Secondary Endpoints 
Because the infusion of hMSCs could theoretically, as described above, cause transient occlusion 
of the pulmonary microcirculation which could be associated with a fall in systemic blood 
pressure, rising vasopressor dose, a rise in heart rate, an increase in arterial carbon dioxide 
concentration, or a fall in oxygenation, patients will be monitored closely during the study infusion 
for changes in these parameters. These events will be considered pre-specified infusion associated 
events if they occur within 6 hours of the initiation of study product infusion. 
 
Pre-specified infusion associated events will be defined as: 
 
(a) Within 6 hours of the initiation of study product infusion:  
1. An increase in vasopressor dose greater than or equal to the following: 
o Norepinephrine: 10 mcg/min 
o Phenylephrine: 100 mcg/min 
o Dopamine: 10 mcg/kg/min 
o Epinephrine: 0.1 mcg/kg/min 
o Addition of a third vasopressor 
2. New ventricular tachycardia, ventricular fibrillation or asystole 
3. New cardiac arrhythmia requiring cardioversion 
4. Hypoxemia requiring an increase in FiO2 of 0.2 or more and an increase in PEEP 
of 5 cmH20 or more to maintain Sp02 in the target range of 88-95% that is not 
related to respiratory care/suctioning or ventilator dyssynchrony and persists for 
more than 30 minutes 
5. Clinical scenario consistent with transfusion incompatibility or transfusion-related 
infection (e.g. urticaria, rash, new bronchospasm) 
 

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(b) Within 24 hours of the study product infusion: 
1. Any cardiac arrest or death 
 
We will also systemically collect and review the incidence and nature of serious adverse events 
that are different from what is expected in the clinical course of a critically ill patient with ARDS 
for the duration of the clinical trial (through day 28 from study product administration).   
 
Expected events for ARDS are untoward clinical occurrences that are perceived by the investigator 
to occur with reasonable frequency in the day to day care of patients with ARDS treated in an 
intensive care unit with mechanical ventilation. Examples of adverse events that are expected in 
the course of ARDS include transient hypoxemia, agitation, delirium, nosocomial infections, skin 
breakdown, and gastrointestinal bleeding.  Such events, which are often the focus of prevention 
efforts as part of usual ICU care, will not be considered reportable adverse events unless the event 
is considered by the investigator to be associated with the study drug or procedures, or 
unexpectedly severe or frequent for an individual patient with ARDS.  Examples of unexpectedly 
frequent adverse events would be repeated episodes of unexplained hypoxemia.  This would be in 
contrast to an isolated episode of transient hypoxemia (e.g. Sp02 ~85%), related to positioning or 
suctioning. This latter event would not be considered unexpected by nature, severity or frequency.   
 
For this Phase 2b study, the secondary safety endpoint will be the incidence of pre-specified 
infusion associated events occurring within 6 hours of study product administration and any 
cardiac arrest or death occurring within 24 hours of study product administration, as well as any 
unexpected severe adverse events in ARDS patients (not including death because it is expected in 
ARDS) treated with hMSCs compared to patients treated with placebo through day 28 from study 
product administration.   
6.2.3 Primary and Secondary Endpoints Adjusted for SARS-CoV-2 Infection 
In addition, to better understand the hMSC effects in patients with COVID-19 disease, we will 
conduct the following analyses: 
 The primary and secondary endpoints (specified in Section 6.1, 6.2.1, 6.2.2) as stratified 
in separate analyses by the following binary variables of intersest prior to randomization: 
SARS-CoV-2 Infection status, viral antigen level (greater or less than median value), 
dexamethasone (or equivalent steroid therapy) and other immunomodulatory agents. 
 WHO Scale for Clinical Improvement outcome at baseline, day 7, day 14, and day 28 
adjusted by COVID-19 status.  
 Gene expression profiles compared by treatment arm and adjusted for or stratified by 
SARS-CoV-2 Infection, dexamethasone (or equivalent steroid therapy) and other 
immunomodulatory agents. 
 Changes in levels of protein biomarker measurements by treatment arm and adjusted for 
or stratified by SARS-CoV-2 infection, dexamethasone (or equivalent steroid therapy), 
and other immunomodulatory agents. 
 Analysis of primary and secondary endpoints by latent class analysis (LCA) 
subphenotype and adjusted for or stratified  by SARS-CoV-2 Infection. 

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 Analyses of primary and secondary endpoints adjusted for or stratified by anticoagulation 
and antiplatelet treatments. 
 Analyses to be adjusted for measures of MSC viability.  
 
7 Study Population and Enrollment 
7.1 
Number/Source/Screening 
This Phase 2b trial will enroll 120 patients over a 3-4 year interval. Patients with ARDS from 
medical causes (pneumonia, sepsis, aspiration) or trauma will be recruited from Medical and 
Surgical Intensive Care Units at seven medical centers, Zuckerberg San Francisco General 
Hospital & Trauma Center and UCSF Moffitt-Long Hospital (San Francisco, CA), University of 
California Davis Medical Center (Sacramento, CA), Harborview Medical Center (Seattle, WA), 
Oregon Health & Science University (Portland, OR), Vanderbilt University Medical Center 
(Nashville, TN) and the University of Texas Health Sciences Center at Houston/Memorial 
Hermann-Texas Medical Center (Houston, TX). 
 
Study coordinators will screen ICUs daily to identify potential candidates for enrollment. 
Permission to approach patients and/or their families will be requested from the attending 
physicians. All patients meeting the inclusion criteria will be entered into a screening log. If the 
patient is not enrolled, the screening log will include information explaining why enrollment did 
not occur (exclusion criteria, attending physician denial, patient refusal, no surrogate available; 
see Appendix C for a listing of the de-identified data to be collected on screened, non-enrolled 
subjects). 
7.2 
Inclusion criteria 
Patients with the presence of ARDS within 14 days of initial ICU admission.  ARDS is defined by 
presenting the following Criteria 1-3 within a 24-hour time period and at the time of enrollment: 
1. A need for positive pressure ventilation by an endotracheal or tracheal tube with a 
PaO2/FiO2 ratio < 250 mmHg with ≥5 cm H2O positive end-expiratory airway pressure 
(PEEP), as per the Berlin Criteria, and  
2. Bilateral infiltrates consistent with pulmonary edema on frontal chest radiograph, or 
bilateral ground glass opacities on a chest CT scan, and  
3. No clinical evidence of left atrial hypertension as the explanation for the bilateral 
pulmonary infiltrates.  
4. If the cause of ARDS is trauma, additional inclusion criteria will include ONE of the 
following relevant risk factors for developing ARDS: 
a. Hypotension (systolic blood pressure[SBP] < 90 mmHg) in the field or in the first 
24 h after injury, or 
b. Transfusion of 3 units of blood products in the first 24 hours following injury, or  
c. Meets the new Critical Administration Threshold (CAT) criteria with at least 3 
units of blood in one hour, or 

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d. Blunt or penetrating torso trauma, or 
e. Long bone fractures, or 
f. The highest level of institutional trauma activation 
 
ARDS diagnostic criteria defined: 
 “Acute onset” is defined as follows: the duration of the hypoxemia criterion (#1) and the chest 
radiograph criterion (#2) must both be present ≤ 14 days  of initial ICU admission at the time 
of enrollment. 
 Infiltrates considered “consistent with pulmonary edema” include any patchy or diffuse 
opacities not fully explained by mass, atelectasis, or effusion or opacities known to be chronic 
(>14 days of initial ICU admission). The findings of vascular redistribution, indistinct vessels, 
and indistinct cardiac borders alone are not considered “consistent with pulmonary edema” and 
thus will not count as qualifying opacities for this study. 
 If a patient meets #1 and #2 inclusion criteria but has an echocardiogram with LV ejection < 
40% that ordered by treating clinicians because of clinical suspicion of left heart failure, the 
patient will be excluded. 
 If a patient meets the #1 and #2 inclusion criteria but has a PAOP (Pulmonary Arterial 
Occlusion Pressure, also known as the Pulmonary Arterial Wedge Pressure) that is initially 
greater than 18 mm Hg, then the inclusion criteria must persist for more than 12 hours after the 
PAOP has declined to ≤ 18 mm Hg.  
7.3 
Exclusion Criteria 
1. Age less than 18 years 
2. Greater than 72 hours since first meeting ARDS criteria per the Berlin definition of ARDS 
3. Greater than 14 days since initial ICU admission 
4. Inability to administer study product within 14 days of initial ICU admission  
5. PaO2/FiO2 ≥250 mmHg after consent obtained and before study product is administered 
6. Unable to obtain informed consent/no surrogate available 
7. Pregnant or lactating  
8. In custody of law enforcement officials 
9. Burns > 20% of total body surface area 
10. WHO Class III or IV pulmonary hypertension 
11. History of cancer treatment in the last 2 years except for non-melanotic skin cancers 
12. Underlying medical condition for which 6-month mortality is estimated to be > 50% 
13. Moribund patient not expected to survive 24 hours 
14. Advanced chronic liver disease (Childs-Pugh Score > 12) (See Appendix J) 
15. Severe chronic respiratory disease with the use of home oxygen 
16. Severe traumatic brain injury - defined as a patient who: 
a.  Has undergone intracranial neurosurgical intervention for monitoring or therapy 
(intracranial pressure monitoring, external ventricular drain, craniotomy), or 

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b. Has an intracranial injury by head CT (does not include patients with minimal  
subarachnoid injury and/or minor skull fracture) , or 
c. Has a post-resuscitation Glasgow Coma Score (GCS) < 9 assessed after sedation 
interruption, or 
d. Has non-survivable head injury as assessed by neurosurgery 
17. Evidence of anoxic brain injury 
18. History of stroke within the last 3 years 
19. No intent/unwillingness to follow lung protective ventilation strategy  
20. Currently receiving extracorporeal life support (ECLS) or high-frequency oscillatory 
ventilation (HFOV) 
21. Anticipated extubation with 24 hours of enrollment 
22. Clinical evidence of left atrial hypertension as measured by a pulmonary arterial wedge 
pressure > 18mmHg or left ventricular failure measured by an echocardiogram with a left 
ventricular ejection fraction less than 40%. Clinical judgement will determine if either of these 
measurements need to be carried out. (If the pulmonary arterial wedge pressure declines to less 
than 18 mmHg, then the patient would qualify if ARDS criteria persist for at least 12 hours.) 
 
Rationale for Exclusions 
Criteria 1: Patients less than 18 years old are excluded because of limited clinical trial data with 
hMSCs in subjects younger than 18 years. 
Criteria 2: ARDS that develops more than 72 hours  not likely to be related primarily to the acute 
insult, but rather to a nosocomial complication. The efficacy of hMSCs is likely to be greater if 
given in the early phase of ARDS. 
Criteria 3 and 4: By increasing the enrollment window from within 120 hours to within 14 days of 
initial ICU admission, we want to increase the opportunity to recruit more medical and surgical 
patients into this trial.  
Criteria 5: By increasing the PaO2/FiO2 from 200 to 250 mmHg, we want to increase the 
opportunity to recruit more COVID-19 patients into this trial.  
Criteria 6: Informed consent required for enrollment in this trial. 
Criteria 7 and 8: Standard exclusion of vulnerable patient populations. 
Criteria 9: Burns > 20% constitute a different clinical entity than major trauma alone. 
Criteria 10: Intended to exclude patients at increased risk in case pulmonary arterial pressures 
increase after administration of hMSCs and hypoxemia from pulmonary hypertension could 
attenuate efficacy signal. 
Criteria 11: Those with active malignancies within the past 2 years are excluded because of 
uncertainty regarding the possibility that hMSCs might enhance the growth of tumors (though no 
evidence for this from any clinical trial to date). 
Criteria 12, 13 and 14: Intended to exclude patients unlikely to survive because of their underlying 
medical conditions that have a greater impact on clinical outcomes than ARDS. 
Criteria 15: Chronic severe lung disease causing baseline hypoxemia may attenuate assessments 
of efficacy of hMSCs in ARDS 
Criteria 16: Patients with severe traumatic head injury are not ideal candidates for testing hMSCs 
therapy, in part because severe traumatic head injury is a more important factor in poor clinical 

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outcomes in the setting of ARDS, and also because lung protective ventilation may not match well 
with the need for hyperventilation and maintaining hypocapnia in some patients with traumatic 
brain injury. 
Criteria 17: Anoxic brain injury will have an overriding influence on secondary outcomes 
including death and multiple organ dysfunction and thus these subjects would not be good 
candidates for testing hMSCs therapy.  
Criteria 18: Stroke in the last years could make assessment of hMSCs therapy for ARDS difficult 
to interpret, especially since acute stroke is another target for hMSCs therapy that is being tested 
in clinical trials currently.  
Criteria 19: Intended to exclude patients with the use of ventilation strategies other than lung 
protective ventilation delivered by assist control because these alternative ventilation strategies 
would complicate assessment of the primary and secondary endpoints.  
Criteria 20: Those on ECLS are excluded because the effect of the ECLS circuit on hMSCs half-
life is unknown. HFOV is a ventilator strategy shown not to be effective in adults with ARDS. 
Criteria 21: Anticipated extubation within 24 hours would make it difficult to assess the impact of 
the hMSCs therapy given the primary endpoint of oxygenation index. 
Criteria 22: The presence of an elevated pulmonary arterial wedge pressure > 18mmHg or an 
echocardiogram that show decreased left ventricular function less than 40% would mean that the 
patient most likely had a cardiogenic mechanism for the pulmonary edema and should not be 
included in this trial. 
7.4 
Study Initiation Time Window 
All ARDS criteria must occur within the same 24-hour period. The onset of ARDS is when the 
last criterion is met. See Section 9.4 for further clarification on the timelines.   
 
Information for determining when these time window criteria were met may come from either the 
recruitment hospital or reports from a referring hospital. Following randomization, the low tidal 
volume protocol for mechanical ventilation must be initiated within one hour (if not already being 
utilized).  
7.5 
Subject Recruitment and Informed Consent 
Study subjects will be recruited in the ICU by a study investigator or study coordinator. Because 
these study subjects may be unable to consent for themselves, written informed consent will be 
obtained from a surrogate when appropriate. Written informed consent will be obtained by one of 
the study investigators or study coordinators before enrollment in the trial. No study procedures 
will be conducted before obtaining informed consent. If surrogates are not available at bedside, 
study investigators will reach them by phone to seek study recruitment, and a signed electronic 
consent form will be obtained through HIPAA compliant REDCap platform prior to conducting 
study procedures. The signed consent forms can also be scanned and sent to secured fax if 
surrogates prefer. If consent is obtained from a surrogate, the study participant will be asked to re-
consent to study participation when they regain the ability to consent for themselves.  

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7.6 
Randomization and stratification 
For this Phase 2b trial, after informed consent is given, an assignment will be made by computer-
generated randomization to administer either hMSCs therapy or placebo with a 1:1 allocation to 
the hMSCs:placebo arms. Randomization will occur during the 2 hour planned baseline stability 
period and must occur in time to allow the study team to initiate the study product infusion within 
14 days of initial ICU admission. The study participant must have an arterial blood gas with a 
PaO2/FiO2 ratio < 250 with PEEP ≥ 5 cm H2O within 6 hours of randomization.  
 
Since oxygenation index is the primary endpoint, we would like to minimize imbalances in the 
hMSC and placebo groups in their initial levels of arterial hypoxemia. Therefore, the 
randomization plan at each site will be designed to randomize patients by those with a PaO2/FiO2 
< 150 mmHg into equal numbers into the hMSC versus placebo arms. The randomization will also 
be stratified by the presence or absence of trauma.   
7.7 
Early Withdrawal of Subjects 
7.7.1 When and How to Withdraw Subjects 
Since the study treatment is a single infusion of study product, a subject is unlikely to be withdrawn 
by investigators due to safety concerns because there is only a single treatment to be administered. 
However, a surrogate or subject may withdraw consent for study participation either before, during 
or after study product administration. As described below, if a subject or surrogate withdraws 
consent for study participation after study product administration, we will work with them to allow 
collection of follow-up data to ensure safety. 
7.7.2 Data Collection and Follow-up for Withdrawn Subjects 
If a subject or surrogate withdraws consent for the study, we will discuss with the subject or 
surrogate the importance of complete data follow-up for the purposes of our safety analyses and 
determine if they are at least willing to participate in a follow up telephone call to ascertain 
survival. 
 
8 CHEMISTRY, MANUFACTURING AND CONTROLS  
Allogeneic, human bone marrow-derived mesenchymal stem cells (hMSCs) are isolated from fresh 
bone marrow of healthy donors procured by the AllCells, LLC (Alameda, CA).   Following a 
density gradient separation, mononuclear cells containing a population of hMSCs are placed into 
culture.  The cells are continued through a single passage. At this point, the hMSCs are harvested, 
washed in 5% human serum albumin (HSA), and cryopreserved using a controlled rate freezer 
[40% fetal bovine serum, 50% HSA (5%), and 10% DMSO] and stored at ≤ -150°C.   hMSCs 
frozen at passage 1 are subsequently thawed and expanded through a second passage.  Following 
harvest, wash, sampling for lot release testing, and cryopreservation in an optimized 
cryopreservation solution [CryoStor, BioLife Solutions, Bothell, WA; 10% DMSO final 
concentration], the final hMSC product is stored at ≤ -150°C for eventual shipment in a liquid 
nitrogen dry shipper to the clinical site for patient administration.   

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Immediately prior to administration, the product is thawed and diluted in 1:1 reconstitution media 
(1:1 mix of 5% human serum albumin and 10% Dextran 40). Additional reconstitution media is 
added to a final volume of 300 mL. The product is not further cultured or propagated prior to 
administration. 
 
hMSCs Manufacturer: 
University of Minnesota Medical Center (UMMC)  
Clinical Cell Therapy Laboratory (AABB-accredited, FACT-accredited, CAP #18060-01, CLIA 
#24D0688128)  
Molecular and Cellular Therapeutics (MCT)  
1900 Fitch Avenue 
Saint Paul, MN 55108 
 
MCT Facility Description: 
Cross reference is made to CBER Type V Drug Master File #12975. 
See Appendix A1 of CMC (Chemistry, Manufacturing and Controls) for cross-reference letter 
from MCT authorizing FDA to cross-reference DMF 12975 on behalf of this IND. 
 
8.1 
Product Manufacturing Components 
8.1.1 Source Material Procurement 
For hMSCs derived from allogeneic, unrelated donors, the source bone marrow is collected 
through AllCells (Alameda, CA). 
Bone Marrow Procurement: 
 
AllCells, LLC 
1301 Harbor Bay Pkwy #200 
Alameda, CA 94502 
 
Allogeneic bone marrow will be harvested using standard bone marrow harvest procedures at 
AllCells. 
The typical volume of bone marrow collected is approximately 100 mL.  Cells are not mobilized 
or activated in vivo.  Marrow is transported in a validated shipping container by a designated 
courier to the Clinical Cell Therapy Laboratory at the MCT facility, University of Minnesota.   
8.1.2 Donor Screening 
The standard health screen questionnaire and tests for donor infectious diseases are performed by 
AllCells on each marrow donor per 21 CFR 1271.  Testing includes assays for the detection of: 
 Antibody HIV-1, HIV-2, group O 
 HBsAg 
 Antibody HBcore 

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 Antibody HCV 
 HIV-1 NAT 
 HBV NAT 
 HCV NAT 
 Antibody HTLV-I/II 
 Antibody T. pallidum (syphilis serology) 
 Antibody CMV 
 West Nile Virus NAT 
 
Testing is performed by certified Clinical Laboratory Improvement Ammendment (CLIA) 
laboratory using FDA-approved/cleared test kits for donor infectious disease screening.  
Additional testing and screening deemed necessary by regulations and/or institutional policy 
including screening for Zika Virus and Trypanosoma cruzi will be performed. Standard (universal) 
precautions are practiced throughout processing. Standard operating procedures for the prevention 
of cross-contamination have been established.  
8.1.3 Reagents 
See Table 8.1-1 and Table 8.1-2 for summary of reagents used. All reagents with the exception 
of human serum albumin (HSA), and dextran 40 are not approved by the FDA for infusion into 
humans.  Information regarding the source, safety, and performance of these reagents can be found 
in the included sample certificates of analysis (Appendix A2 of CMC). 
 
Standard operating procedures are in place at University of Minnesota Medical Center (UMMC) 
to assure that no recalled lots of HSA are used in the production of the hMSC.  HSA is FDA-
approved and is only obtained from suppliers producing product derived from plasma collected in 
countries considered free of variant Creutzfeldt-Jakob disease (vCJD) risk. 
 
Animal- or human-derived raw materials include fetal bovine serum (FBS) and human serum 
albumin (HSA).  FBS is obtained from qualified herds from USDA inspected abattoirs located in 
the United States of America. HSA is FDA approved for human use. 
 
Table 8.1-3 lists the excipients used to formulate the final frozen product.  Prior to infusion of the 
hMSC product, the cells are thawed, diluted (dextran 40/5% HSA) and sent to the patient for 
administration.  

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Table 8.1-1 Summary of Animal/Human-Derived Reagents 
Reagent/Excipient 
Description 
COA1 
Requirements 
Supplier 
Concentration 
in Final 
(Frozen) 
Product 
Justification 
Fetal bovine serum 
(FBS) 
Sterile, 
nonpyrogenic 
Viral 
(9CFR113.53) 
Mycoplasma, 
Endotoxin, 
Sterility 
Hyclone 
Minimal 
(washed) 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
Human serum 
albumin 
(HSA), 5% 
Sterile, 
nonpyrogenic 
Sterility, 
Endotoxin, 
HBsAg,  
HIV-1/2 
HCV 
Grifols 
 
Minimal 
(washed) 
Supplier Review, 
specifications, 
FDA approved 
for human use 
       1COA (Certificate of Analysis): samples provided in Appendix A2. 
 
 
Table 8.1-2 Summary of Reagents 
Reagent 
Description 
COA1 
Requirements 
Supplier 
Concentration 
in Final 
(Frozen) 
Product  
Justification 
alpha-MEM 
Sterile, 
nonpyrogenic 
Osmolality, 
pH, 
Endotoxin, 
Sterility 
Gibco/ 
Invitrogen 
Minimal 
(washed) 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
DPBS 
Sterile, 
nonpyrogenic 
Endotoxin, 
Sterility 
Life 
Technologies 
Minimal 
(washed) 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
GlutaMax 
Sterile, 
nonpyrogenic 
Osmolality, 
pH, 
Sterility 
Life 
Technologies 
Minimal 
(washed) 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
Hanks’s 
Balanced Salt 
Solution 
Sterile, 
nonpyrogenic 
Osmolality, 
pH, 
Toxicity, 
Endotoxin, 
Sterility 
Lonza 
Minimal 
(washed) 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
 Ficoll Paque 
Premium 
Sterile, 
nonpyrogenic 
Density, 
osmolality, 
GE-
Healthcare 
Minimal 
(washed) 
Supplier Review, 
specifications, 

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Reagent 
Description 
COA1 
Requirements 
Supplier 
Concentration 
in Final 
(Frozen) 
Product  
Justification 
endotoxin, 
sterility 
MD approved for 
use under IND 
TrypLE Select 
Sterile, 
nonpyrogenic 
Sterility, 
Endotoxin 
Gibco/ 
Invitrogen 
Minimal 
(washed) 
 
Supplier Review, 
specifications, 
MD approved for 
use under IND 
Human serum 
albumin 
(HSA), 5% 
Sterile, 
nonpyrogenic 
Sterility, 
Endotoxin, 
HBsAg,  
HIV-1/2 
HCV 
Grifols 
 
Mininal 
(washed) 
Supplier Review, 
specifications, 
FDA approved 
for human use 
        1COA (Certificate of Analysis): samples provided in Appendix A2. 
 
 
 

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Table 8.1-3 Summary of Excipients 
Excipient 
Description 
COA1 
Requirements 
Supplier 
Concentration 
in Final 
(Frozen) 
Product 
Justification 
CryoStor10/CryoStor 
Buffer 
Sterile, 
nonpyrogenic 
Sterility, 
Endotoxin, 
Osmolality 
BioLife 
Solutions 
Primary 
excipient 
Supplier 
Review, 
specifications, 
MD approved 
for use under 
IND 
DMSO (additional 
amount added to 
CryoStor10 to attain 
final concentration of 
10%) 
Sterile, 
nonpyrogenic 
Specific 
gravity, 
Sterility, 
Endotoxin 
Bioniche 
Pharma 
10% 
 
Supplier 
Review, 
specifications, 
MD approved 
for use under 
IND 
Human serum 
albumin 
(HSA), 5% 
Sterile, 
nonpyrogenic 
Sterility, 
Endotoxin, 
HBsAg,  
HIV-1/2 
HCV 
Grifols 
Minimal 
(washed) 
Supplier 
Review, 
specifications, 
FDA 
approved for 
human use 
1COA (Certificate of Analysis): samples provided in Appendix A2. 
 
8.1.4 Qualification Program 
Studies performed during the validation demonstrated sufficient removal of media components.  
Measurement of bovine transferrin pre-wash and post-wash (prior to freezing) served as the marker 
for media component removal in the validation studies performed at UMMC.   
 
8.2 
Product Manufacturing Procedures 
8.2.1 Cell Processing  
A summary of the cell processing is provided in Figure 8.2-1. 
Bone marrow aspirates from AllCells are tested for nucleated cells (NC), differential, viability, 
and sterility, and a sample is saved for cytogenetics testing should the final hMSCs product be 
found to have a chromosomal abnormality. 
 

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Enrichment of the mononuclear cell (MNC) fraction of the marrow is accomplished using an 
automated separation method involving ficoll hypaque density gradient medium, specific gravity 
1.077 g/dl (Ficoll Paque Premium, GE Healthcare). A wash with Hank’s Balanced Salt Solution 
(without phenol red, calcium or magnesium) follows.   
Enriched samples are tested for NC, differential, viability, flow cytometry (CD105, CD73, CD90, 
CD45, CD34, CD14, CD19, HLA-DR). 
For cell culture, cells are seeded at 1.0-1.5 x 105 viable cells/cm2 at a media depth of 1.6 mm in an 
appropriately sized T-flask and placed in a 5% CO2/37°C incubator.  Media consists of MEM, 
16.5% fetal bovine serum (FBS) and GlutaMax (1%  200 mM).  On days one and two, non-
adherent cells are removed, and media is changed.  Fresh media is exchanged every 2-4 days until 
70-90% confluence.   
Cells are washed with Dulbecco’s phosphate buffered saline (DPBS) and detached. Cells are 
cryopreserved at passage one and are held at ≤ -150°C for subsequent expansion. hMSCs frozen 
at passage one are inoculated into a cell factory at 40-50 viable cells/cm2.  Media is exchanged 
every 2-4 days.   
At 70-90% confluence, cells are washed, harvested and resuspended in CryoStor Buffer before 
they are cryopreserved (controlled rate) in freezer bags.  This is performed by adding an equal 
volume of CryoStor10 supplemented with additional DMSO to attain 20% DMSO to the 
resuspended cells. The final formulation hMSC product will contain 10% DMSO in CryoStor 
Buffer.  
The frozen hMSC final cellular product is shipped to the clinical site in a validated liquid nitrogen 
dry shipper with continuous temperature monitoring device to assure shipping temperature   -
150° C.  On receipt, the hMSC cellular product is inspected and placed in a controlled, 
continuously monitored liquid nitrogen storage tank at the clinical site.   
See flow diagram in Figure 8.2-1 for summary of processing and testing.  
Figure 8.2-1 Summary of hMSC Processing at UMMC Cell Therapy Laboratory 
Process Step 
Testing 
Bone Marrow Aspirates from AllCells 
Cell count, Differential, Viability, 
Sterility, 
Cytogenetics (hold sample)  
↓ 
 
MNC Enrichment 
Automated Density Gradient Separation 
Cell count, Differential, Viability, Flow 
Cytometry (CD105, CD73, CD90, 
CD45, CD34, CD14, CD19, HLA-DR) 
↓ 
 
Culture 
 

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University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Process Step 
Testing 
Media = MSC CM (16.5% FBS) 
Initial seeding density (passage 1) = 1.0E+05 
VNC/cm2;  
↓ 
Cells cryopreserved after passage 1  
↓ 
Thaw single vial and seed for Passage 2 
Passage 2 seeding density = 40 -50 VNC/cm2 
↓ 
 
Passage 2 
 
↓ 
 
Harvest 
70 – 90% Confluent with Tryple Select 
Final Product Release Testing: 
Cell count, Differential, Viability 
(AO/PI), Sterility, 
Mycoplasma, Flow Cytometry (CD105, 
CD73, CD90, CD45, CD34, CD14, 
CD19, HLA-DR), Endotoxin, 
Cytogenetics (send T75flask), KGF (for 
information only) 
↓ 
 
Freeze 
1 – 10E+06 NC/mL,  
 
CryoStor10, DMSO final (10%) 
 
↓ 
 
Store frozen at 1-10 million cells/mL  
 
↓ 
 
Ship frozen to clinical site 
 
↓ 
 
On day of infusion: Thaw/dilute  (dextran 40/5% 
HSA) and infuse at bedside 
Sample for: Cell count, Viability 
 

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University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
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Confidential  
 
 
 
8.3 
Final Infusion Formulation  
On the day of infusion, the hMSC final cellular product is thawed, diluted with dextran 40/5% 
HSA and infused into the patient.   
Samples will be taken for cell count and viability. 
See Appendix E for the Study Product Preparation Protocol to be performed at the clinical sites.   
 
8.4 
Product Testing 
8.4.1 In-process Testing and Criteria 
The in-process testing performed is described in Table 8.4-1. 
 
Table 8.4-1 In-process Testing 
Test 
Manufacturing 
Step Where 
Performed 
Method 
Criteria 
Sterility (14-day) 
Bone marrow 
aspirate 
Bactec (UMMC Clinical 
Microbiology Laboratory) 
 
No growth 
Identity 
Immunophenotype 
MNC Enrichment 
UMMC Clinical Flow 
Cytometry Lab 
 
Report: CD90+, 
CD105+ 
CD45+, HLA-DR+ 
CD73+, CD14+, 
CD19+, CD34+ 
Other:  
Cell count 
Bone marrow 
aspirate; 
MNC Enrichment 
UMMC Cell Therapy Lab 
Report Results 
Other: 
Viability 
Bone marrow 
aspirates; 
MNC Enrichment 
UMMC Cell Therapy Lab 
(AO/PI) 
 
Report Results 
8.4.2 Description of Assays 
See Section 8.5. 
 
8.5 
hMSC Final Cellular Product Release Criteria/Specifications 
The hMSCs final cellular product testing (see Table 8.5-1) and release will be performed prior to 
the hMSCs being transported to the clinical site for administration. All samples will be drawn from 
the pre-freeze final product. 
 
 

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University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Table 8.5-1   hMSCs Final Cellular Product Specifications 
Test 
Method 
Criteria 
Results 
Available  
Prior to 
Release 
Sterility (14-day) 
Bactec (UMMC Clinical 
Microbiology Laboratory) 
 
No growth 
yes 
Mycoplasma 
PCR; Apptec protocol 
 
Negative 
yes 
Endotoxin 
 
LAL, chromogenic 
 
<5.0 EU/kg/dose 
yes 
Identity/Purity 
Immunophenotype 
UMMC Clinical Flow 
Cytometry Lab 
 
> 85.0%: CD90+, CD105+ 
< 15.0%: CD45+, HLA-
DR+ 
Report Results: CD73+, 
CD14+, CD19+, CD34+ 
yes 
Potency 
KGF Expression by ELISA 
Report Results 
no 
Other: 
Karyotype 
UMMC Clinical 
Cytogenetics Lab 
 
No clinically significant 
abnormality  
yes 
Other: Cell count 
Manual enumeration 
Report Results 
yes 
Other: Viability 
UMMC Cell Therapy Lab 
(AO/PI) 
 
> 70% 
yes 
 
8.5.1 Description of Assays 
An aliquot for release testing will be removed upon completion of the final product prior to 
freezing.   
8.5.1.1 Sterility 
Sterility testing will be performed using the Bactec System (Becton, Dickinson and Company, 1 
Becton Drive, Franklin Lakes, NJ). Final sterility testing results will be available prior to release 
of the product for patient infusion.  The lot release criterion will be ‘no growth’. 
8.5.1.2 Mycoplasma 
Mycoplasma testing will be performed by a contract laboratory (AppTec) for the PCR based assay. 

Michael A Matthay, MD 
 
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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
8.5.1.3 Endotoxin 
Endotoxin testing is performed using the LAL chromogenic-based EndoSafe-PTS (Charles River 
Laboratories International, Inc., Wilmington, MA). Endotoxin value will be determined for each 
bag and will be included on the certificate of analysis. Clinical centers will determine total 
endotoxin level based upon cell dose/total bags needed. The lot release criterion will be <5.0 
EU/kg/total product.   
8.5.1.4 Identity/Purity 
Analysis by flow cytometry will be used to characterize the cell types within the final product, as 
hMSCs have a unique phenotype signature. Positive markers include CD73 (report), CD90 
(>85%), and CD105 (>85%); negative markers include CD14 (report), CD19 (report), CD34 
(report), CD45 (<15%), and HLA-DR (<15%).   
Identity will also be assured through established standard operating procedures outlining labeling 
and segregation of product practices (i.e., dedicated processing space and medical technologist) 
within the laboratory. Donor HLA type will be known, and this may serve as an additional means 
of identity.  
8.5.1.5 Potency 
KGF content will be used as the early stage potency assay. A sample of each lot will be lysed and 
the lysate tested for KGF content (ELISA, R& D system, Minneapolis, MN, Cat: DKG00). 
 
Additional testing will be performed and analyzed to determine relevance as a potency assay.  This 
will include immunophenotype/flow cytometry (see above) and G-banded karyotype analysis on 
20 metaphase cells.  The cytogenetic testing will be performed to rule out presence of any 
numerical or structural chromosomal abnormality.  If one cell is abnormal, additional cells will be 
analyzed to rule out the presence of a clonal abnormality. Documented benign heritable 
heteromorphisms, such as 9ph, would not be considered as an abnormality. Pre-culture samples of 
marrow will be stored and available for cytogenetic analysis should such a comparison be needed. 
8.5.1.6 Viability 
Viability testing (AO/PI) will be performed on a sample drawn from the final product. A pre-freeze 
viability of >70% will serve as a lot release criterion.  Viability by AO/PI will be used to freeze 
cells in a viable dosing strategy.   
 
8.5.1.7 Cell Count 
Cell number (i.e., NC count) will be determined on a sample of the hMSCs prior to 
cryopreservation using a manual enumeration method (hemacytometer) or automated hematology 
analyzer (Sysmex XS1000i, Lincolnshire, IL) as per standard operating procedure.  
 
8.5.2 Final Cellular Product Certificate of Analysis 
See Appendix A4 of CMC for a sample of the certificate of analysis.  

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
8.6 
Product Stability 
Following processing and successful lot release testing, frozen hMSCs will be transported in a 
validated container (liquid nitrogen dry shipper) with continuous temperature monitoring to the 
clinical site where the cells will be stored in validated, continuously monitored liquid nitrogen 
storage tanks. A small aliquot will be cryopreserved and stored for potential further testing.  
Limited post-thaw stability studies were performed to support use of the cells. 
8.7 
Placebo product 
The placebo is treated with a reconstitution media (1:1 mix of 5% human serum albumin and 10% 
Dextran 40). Both are FDA approved for human use. 
8.8 
Other Issues 
8.8.1 Product Tracking 
A standard operating procedure for product labeling per Foundation for the Accreditation of 
Cellular Therapies (FACT) standards has been established at UMMC.  Labels with appropriate 
identifiers (unique identification number, etc.) will be provided to the collection staff. In-
processing labels and final product labels will have these same identifiers to assure product identity 
throughout production and administration. Confirmation of identity of product and intended 
patient by two parties will take place prior to administration by review of product labeling and 
patient identification. 
8.8.2 Labeling 
Product labeling follows American Associatoin of Blood Banks (AABB) and FACT standards and 
includes unique patient identifiers, product name, storage conditions, and expiration date/time (if 
applicable), as well as collection and manufacture date/time, product volume, identification and 
address of processing lab.   
 
Warning labels, as required per 1271.90 are applied for those donors determined to be ineligible.  
The label also contains the following statement: “Caution: New Drug – Limited by Federal Law 
to Investigational Use” per 21 CFR 312.6.   
 
 
 

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Sample Label   
 
8.8.3 Container/Closure 
Marrow will be collected and processed using syringes, anticoagulant, transfer bags, tubing sets, 
and vials and freezing bags (for samples and products being cryopreserved).  Compatibility of all 
containers and sets with the product has been established with practice and validation runs.  
8.8.4 Environmental Impact 
The sponsor claims categorical exclusion [under 21 CFR 25.31(e)] for the study under this IND.  
To the sponsor’s knowledge, no extraordinary circumstances exist. 
8.8.5 Validation and Qualification of the Manufacturing Process 
See Type V Drug Master File (#12975) describing the MCT Facility.   
8.8.6 Cellular Product Preparation 
Just prior to use, the cellular product will be thawed and diluted in in 1:1 reconstitution media (1:1 
mix of 5% human serum albumin and 10% Dextran 40) for intravenous administration in the 
clinical site’s clinical bone marrow transplant (BMT) facility (or equivalent) by facility 
technicians. See Appendix E for cellular product preparation instructions. 
8.8.7 Placebo Product Preparation 
The placebo will be the same volume of reconstitution media (1:1 mix of 5% human serum albumin 
and 10% Dextran 40).  See Appendix E for study product preparation instructions. 
8.9 
Subject Compliance Monitoring 
The study product will be administered as a single intravenous dose over 60-80 minutes within 14 
days of initial ICU admission. Study personnel will be on site for safety and compliance monitoring 
for the 2 hour baseline stability period, as well as for 6 full hours starting from the time the study 
product infusion is initiated. 

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
8.10 Prior and Concomitant Therapy 
Rescue therapies for severe ARDS, including prone ventilation, corticosteroids, inhaled 
vasodilators, and neuromuscular blockade will be permitted. We will record whether these 
therapies were administered prior to or concomitantly with hMSCs. Patients on ECLS or HFOV 
will be excluded from this trial.  Co-enrollment in randomized clinical trials of supportive therapies 
such as proning will be allowed after approval from the Scientific Review Committee (includes 
the Principal Investigator and two other study investigators) and the Chair of the DSMB. With 
respect to patients with SARS-CoV-2 infection, co-enrollment in randomized clinical trials of 
other interventions such as pharmacologic therapies and convalescent plasma will be considered 
on a trial by trial basis in concert with the Scientific Review Committee and the Chair of the 
DSMB. The use of treatments through Emergency Use Authorization (EUA) and Expanded 
Access Program (EAP) studies shall not be considered an exclusion. The consideration of co-
enrollment with other experimental therapy trials that target patients requiring ICU level of 
care must be evaluated by the Scientific Review Committee and request approval from the Chair 
of the DSMB.  Patients who are enrolled in clinical trials targeting outpatients or patients admitted 
to the acute care floor with trial endpoints assessed before admission to the Intensive Care Unit 
will be eligible for participation.   
8.11 Blinding of Cellular Product 
As in prior studies of hMSCs (122), the infusion bag will be covered with aluminum foil at the 
time of product preparation in the clinical site’s bone marrow transplant laboratory so that the 
product is not visible to the investigators or to the clinicians who are administering the product. 
Personnel in the bone marrow transplant laboratory who will be preparing the study infusion will 
not be blinded to treatment allocation. 
8.12 Receiving, Storage, Dispensing and Return 
8.12.1 Receipt of Cellular Product 
The hMSCs will be shipped using temperature monitored shippers to the clinical site’s clinical 
bone marrow transplant laboratory (or equivalent) from UMMC. Upon receipt of the study cellular 
product, an inventory must be performed and a receipt log filled out and signed by the person 
accepting the shipment. Any damaged or unusable study product in a given shipment will be 
documented in the study files. The investigator must notify the study sponsor of any damaged or 
unusable study treatments that were supplied to the investigator’s site.  
8.12.2 Storage 
The hMSCs will be stored under controlled conditions in liquid nitrogen tanks in the clinical bone 
marrow transplant laboratory.  
8.12.3 Dispensing of Cellular Product 
The study product will be administered as a single dose following randomization; the clinical bone 
marrow transplant laboratory will be responsible for preparing the cellular product or placebo and 
for dispensing the product to study investigators for administration (Appendix E).  

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
The study log for each patient will include treatment assignment, assigned dose of hMSCs, lot and 
bag number for each frozen bag of cellular product used. 
8.12.4 Return or Destruction of Cellular Product 
At the completion of the study, there will be a final reconciliation of cellular product shipped, 
cellular product consumed, and cellular product remaining. This reconciliation will be logged on 
the cellular product log, signed and dated. Any discrepancies noted will be investigated, resolved, 
and documented prior to return or destruction of unused study cell product. Cellular product 
destroyed on site will be documented in the study files. 
 
 
APPENDICES FOR CMC 
 
A1.  Cross reference authorization letter:  UMMC DMF 12975 
 
A2.  Sample certificates of analysis for raw materials/reagents 
 
A3.  Study Product Preparation Protocol for the Clinical Site 
 
A4.  hMSCs product certificate of analysis 
  
 
 
9 Study Procedures 
See Appendix A for the Time-Events Schedule. 
9.1 
Pre-Screening 
All patients in the Intensive Care Unit will be screened for potential study eligibility by trained 
study personnel under a waiver of consent for screening purposes approved by the Institutional 
Review Board. When eligible study subjects are identified, the attending physician caring for the 
patient will be asked if we have permission to approach the patient or their surrogate for potential 
study participation. 
9.2 
Informed Consent and Randomization  
Informed consent will be obtained from each surrogate before enrollment in the trial. No study 
procedures will be conducted before obtaining informed consent. Randomization will occur after 
informed consent as described in Sections 7.5 and 7.6. An arterial blood gas must be obtained to 
confirm a PaO2/FiO2 < 250 mmHg on PEEP ≥ 5 cm H2O within 6 hours of randomization. The 
randomization plan at each site will be designed to randomize patients by those with a PaO2/FiO2 
< 150 mmHg and by those with trauma into equal numbers into the hMSCs versus placebo arms 
in order to minimize the possibility of imbalance at baseline. 
 
If a pregnancy test is not available before informed consent, a blood or urine pregnancy test will 
be obtained in women of childbearing age (50 or younger) after informed consent but before 

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Confidential  
 
 
 
randomization to ensure eligibility. Patients excluded on the basis of tests obtained in this manner 
will not be included in the as-treated population.  
9.3 
Baseline Study Procedures  
If not obtained within the past 24 hours as part of clinical care, patients will have serum creatinine, 
platelet count, total bilirubin and alanine aminotransferase (ALT) measured before the infusion of 
the study product. Blood and urine samples for biomarker measurements will be obtained before 
the infusion of study product as well. 
 
We will measure pulmonary dead space at baseline, as well as on days 1, 2, 3 and 7. This is a non-
invasive test that measures exhaled carbon dioxide from the endotracheal tube. 
9.4 
Investigational Product Administration  
The investigational product will be administered intravenously according to the following dose 
schedule. The investigational product (h MSCs or placebo) will be administered intravenously 
over approximately 60-80 minutes. 
We will enroll 120 patients in a 1:1 blinded, randomized, placebo-controlled design with the dose 
of 10 x 106 viable cells/kg (60 patients treated with hMSCs and 60 controls), with viability 
determined at the time of cell preparation at UMMC. Safety analyses will be conducted by the 
independent DSMB, and the sponsor and investigators will remain blinded. The safety reviews 
will be conducted after treatment of 60 patients, and the trial will continue during these analyses.  
Critically ill patients often experience minute-to-minute changes in vital signs. Investigators 
will begin the infusion of hMSCs after a stable baseline for 2 hours has been observed.  
 
A. Stable baseline will be defined as: 
 
a. Transcutaneous oxygen saturation in the target range of 88-95% without any 
increase in ventilator settings AND 
b. Stable vasopressor use if the patient requires vasopressors for blood pressure 
support. The dose of vasopressor may be increased a small amount during this 2-
hour period, predefined as: no more than a 5 mcg/min increase in norepinephrine 
dose; no more than a 50 mcg/min increase in phenylephrine dose; no more than a 5 
mcg/kg/min increase in dopamine dose; and no more than a 0.05 mcg/kg/min 
increase in epinephrine dose.  
 
B. The following patients will be considered clinically unstable and will NOT receive the 
study product: 
 
a. Patients requiring an increase in FiO2 of 0.2 or more and an increase in PEEP of 5 
or more to maintain Sp02 in the target range of 88-95% 
OR 
b. Patients who require 3 vasopressors for blood pressure support and/or the use of > 
0.1 mcg/kg/min of epinephrine for blood pressure support, 

Michael A Matthay, MD 
 
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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
OR 
c. Patients who do not meet stability criteria in the supine or prone position,  
OR 
d. Patients who have evidence of ongoing bleeding by the requirement of more than 
3 units of packed red blood cells during the prior 24 hours prior to randomization. 
 
C. Patients who are clinically unstable will be monitored closely; if they achieve a stable 
baseline within 14 days of meeting the entry criteria for the study and, at the time of the 
stable baseline, still meet criteria for ARDS (PaO2/FiO2 < 250 with bilateral infiltrates and 
no evidence of left atrial hypertension) with a PEEP of ≥ 5, they can receive the study 
product if the study product can be initiated within 14 days of initial ICU admission.  
D. To confirm study product eligibility, an arterial blood gas will be obtained within 90 
minutes prior to beginning the baseline stability period. Patients will not receive the study 
product infusion if the PaO2/FiO2 ratio is equal or greater than 250 mmHg on this pre-
infusion arterial blood gas. Subjects who do not initiate the infusion of study product (e.g., 
not obtain 2 hours of stable baseline, increased PaO2/FiO2 ≥250, study withdrawn, et al.) 
will be excluded from patient accruals and from the data analyses. They will not be 
included in an intention to treat analysis. Arterial blood gases will also be obtained at the 
end of the study product infusion (~1 hour) and at 6, 12, 18, 24, 30 and 36 hours (+/- 1 hour 
for all timepoints) after the initiation of study product infusion.  
 
E. To summarize the timelines for eligibility for the trial, see these key criteria and the 
timeline:  
 
 Eligibility for the trial - ARDS develops less than 72 hours since first meeting ARDS 
criteria per the Berlin definition of ARDS.   
 Eligibility for the trial - Must begin to administer study product within 14 days of initial 
ICU admission  
 Eligibility - The PaO2/FiO2 remains less than 250 mmHg after consent obtained and within 
90 minutes prior to beginning the baseline stability period. 

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
 
 
 
 
F. During infusion of study product, patients will have continuous monitoring of arterial blood 
pressure, heart rate, rhythm, and oxygen saturation. Study personnel will be available for the 
duration of the infusion to monitor the patient. Body temperature will be monitored at a 
minimum at the start, midway through, and at the end of the infusion. Patients will be 
monitored closely for other signs of transfusion reaction, e.g., rash, urticaria or wheezing. If 
there are any signs of a transfusion reaction, the infusion of study product will be stopped 
immediately. Similarly, if a patient has a pre-specified infusion associated event, the infusion 
will be stopped. The infusion can also be stopped at the discretion of the study investigator if 
there is any concern about the patient’s status. 
9.5 
Ventilator Management  
Ventilator management, including weaning, will follow the modified ARDS Network lower tidal 
volume (6 mL/kg PBW) protocol (Appendix D) which will require assist volume control (not 

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University of California, San Francisco  
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
pressure control) as the mode of ventilation. Using this ventilator management protocol will 
standardize the application of PEEP, which is a component of the primary endpoint, oxygenation 
index, thus reducing the potential for bias. If not already being used, this low tidal volume protocol 
for mechanical ventilation must be instituted with assist control mode (not pressure control or any 
other ventilator modality) within one hour of randomization. Because recent evidence-based 
consensus recommendations have identified a best practice for weaning, weaning strategy will also 
be controlled by protocol rules in accordance with these evidence-based recommendations. This 
will assure similar weaning methods and provide potential benefit to both study groups. This newer 
weaning strategy is a simplified version of the weaning strategy protocol used in ARDS Network 
studies (see Appendix D). 
9.6 
Concomitant Therapy 
We will record the use of other pharmacologic agents that are sometimes used by clinicians in the 
treatment of ARDS, including glucocorticoids (dexamethasone or equivalent steroids therapy), and 
inhaled vasodilators or neuromuscular blockade, anticoagulant and antiplatelet treatment, 
immunomodulatory agents and any COVID-19 related therapies. We will also record if patients 
are in a prone position, receive recruitment maneuvers or extracorporeal membrane oxygenation 
(ECMO), or if patients are enrolled in other experimental therapy trials or treatment.   
9.7 
Radiographic Assessment of Lung Edema (RALE) Score 
Radiographic Assessment of Lung Edema (RALE) score (128) will be used to evaluate the extent 
and density of alveolar opacities on chest radiographs at baseline, and days 1, 2, 3 and 7. To 
determine the RALE score, each radiograph will be divided into quadrants, defined vertically by 
the vertebral column and horizontally by the first branch of the left main bronchus. Each quadrant 
will be assigned a consolidation score from 0 to 4 to quantify the extent of alveolar opacities, based 
on the percentage of the quadrant with opacification and a density score from 1 to 3 to quantify 
the overall density of alveolar opacities, unless the consolidation score for that quadrant is 0. The 
density score allows for more quantitative assessment of the density of opacification by quadrant 
(see Appendix L). We will obtain the de-identified chest x-ray graphs at baseline and on days 1, 
2, 3, 7, and evaluate the RALE scores. We will concurrently systematically evaluate for and record 
evidence of barotrauma including pneumothorax, pneumomediastinum, subcutaneous 
emphysema, and the presence of tube thoracostomy on the same set of radiographs. 
9.8 
Biospecimens for Biological Endpoint Measurements 
Blood samples will be obtained at 6 timepoints (before the infusion of study product, and then at 
6 hours, 12 hours, 24 hours, and on days 2, 3 after the initiation of the study product infusion) for 
biomarker measurements, which include measurements of epithelial injury, inflammation and 
hMSC activity. Plasma obtained from two 6.5 ml EDTA anti-coagulated blood samples will be 
divided immediately after centrifugation into 0.5 mL and 1 mL aliquots and frozen at –80°C.  
 
Urine samples from the patients will be obtained at 3 timepoints (before the infusion of study 
product, then at 24 hours and on day 2 after the initiation of study product infusion). Before the 
infusion of study product, urine will be collected in a 40 ml sterile cup; 30 mL will be frozen 
immediately, and 8 mL will be centrifuged prior to dividing into 4 equal aliquots and freezing at 

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Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14  
 
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Confidential  
 
 
 
–80°C. For 24 hours and day 2, only 8 mL of urine samples will be collected and centrifuged and 
divided into 4 equal aliquots and freezing at –80°C. 
 
A mini-BAL will be performed 2 days (48 hours +/- 4 hours) after the initiation of the study product 
infusion (See Appendix A, Time-Events Schedule) for total protein measurement, a marker of 
lung epithelial permeability, as well as the same biomarkers measured in the plasma.  
 
Finally, 5 mL of blood specimen prior to study product infusion and 5 mL of blood specimen on 
day 2 will be collected in Paxgene tubes for future RNA and DNA extraction.  
 
Biospecimens collected at 6 hours, 12 hours, and 24 hours after the initiation of study product 
infusion can be obtained +/- 1 hour of the indicated timepoint. Day 2 biospecimens will be 
collected at 48 hours  (+/-  4 hours) after the initiation of study product infusion and day 3 
biospecimens can be collected anytime. 
9.9 
Days 1, 2, and 3 Measurements 
If not obtained as part of clinical care, patients will have platelets, serum creatinine, total bilirubin, 
and alanine aminotransferase (ALT) measured on day 3 (+/- 1 day) after administration of the 
study product.  
Arterial blood gases will be obtained at baseline and at hours 6, 12, 18, 24, 30, and 36 (+/- 1 hour 
for all timepoints) after the initiation of the study product infusion in order to assess the primary 
endpoint of oxygenation index. Subsequently, arterial blood gases will be obtained on days 2 (48 
hours +/- 4 hours) and day 3 (anytime). In the unusual circumstance that a patient does not have 
an arterial line for ABG monitoring on day 3, the ABG will not be obtained for study purposes 
alone. If an arterial blood gas is collected +/- 1 hour of an indicated timepoint for clinical purposes, 
another arterial blood gas does not need to be collected for research.  
9.10 Day 7 Measurements 
Arterial blood gases will be obtained anytime on days 7 if patient still has arterial line. If not 
obtained within the past 24 hours as part of clinical care, patients will have platelets, serum 
creatinine, total bilirubin and alanine aminotransferase (ALT) measured on day 7 (+/- 1 day) after 
administration of the study product if they are still hospitalized. 
9.11 Day 28 Measurements 
Patients will be followed daily for adverse events through day 28 after study product 
administration, death or hospital discharge, whichever occurs first. If a patient is discharged from 
hospital before day 28, investigators will follow-up by phone interview with the patient, family 
member or caregiver after day 28 to ensure that no adverse events have occurred through day 28. 
Mechanical ventilation history (on or off ventilator support), ICU history and the need for dialysis 
through day 28 after study product administration will also be collected. Decisions about hospital 
discharge will not be made by study personnel; rather such decisions will be made by clinicians 
caring for the study subject based on the underlying condition that led to the hospitalization.  Also, 
we will assess neurologic status by the 6 point Glasgow Outcome Score at hospital discharge. 

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9.12 Day 60 Measurements 
Vital status and the need for dialysis will be collected at day 60 after study product infusion. If 
patients are discharged from the hospital prior to day 60, we will collect this data through telephone 
interviews with care-givers at the outside facility, or family members, or the patient. 
9.13 Post-hospitalization Follow-up  
Hospital mortality and discharge location will be collected if patient is discharged from hospital 
alive after study enrollment.  Also, vital status at 6 month after study enrollment will be collected 
via a structured telephone interview.  
 
10 Data Collection  
10.1 Medical History  
To be collected from patient charts and patient/surrogate, where applicable. 
1. Demographic and admission data 
2. Pertinent medical history with comorbidities and physical examination 
3. Height, gender, measured body weight, calculated predicted body weight 
4. Pre-hospital times and interventions 
5. Time on ventilator prior to enrollment 
6. High flow nasal oxygen (HFNO) and non-invasive ventilation (NIV) use for the 3 
calendar days prior to meeting ARDS criteria 
7. Mechanisms of Injury if the primary cause of ARDS due to trauma: 
a. Abbreviated injury score by region 
b. Injury severity score 
c. Presence of hypotension on admission (SBP < 90 within 24 hours of 
admission) 
d. Need for blood transfusion, as well as volume of blood and components 
transfused during the 1st 24 hours after injury. 
e. Volume of crystalloid resuscitation transfused during the 1st 24 hours after 
injury. 
f. Procedures performed prior to randomization 
g. Intubated on arrival or time to intubation after admission 
h. Base deficit (lowest level in each 24 hour period) 
8. Acute or chronic renal failure and use of dialysis 
9. History of lung disease 
10. History of solid organ transplant 
11. History of bone marrow transplant 
12. COVID-19 vaccination status prior to enrollment (number, type, and date of doses) 
13. Etiology of ARDS 
14. Outpatient medications 

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10.2 Baseline Assessments  
The following information will be recorded during the 24-hour interval preceding randomization. 
If more than one value is available for this 24-hour period, the value closest to the time of 
randomization will be recorded. If no values are available from the 24 hours prior to randomization, 
then values will be measured post randomization but prior to initiation of study drug. 
10.2.1 To Be Collected From Patient Charts 
1. APACHE III Score  
2. Vital signs: Heart rate, systolic and diastolic blood pressure, body temperature, 
mean arterial pressure, central venous pressure (if available) 
3. Ventilator mode, tidal volume, FiO2 and PEEP, inspiratory plateau pressure, and 
mean airway pressures. If on a pressure-targeted mode, peak pressure during 
inspiration will be assumed to be the plateau pressure 
4. Arterial PaO2, PaCO2, pH and transcutaneous oxygen saturation and base deficit 
5. Date and time of all creatinine determinations in the 96 hours prior to enrollment. 
6. Frontal chest radiograph – radiographic lung injury score (# of quadrants) 
7. Vasopressors or inotropes (epinephrine, norepinephrine, phenylephrine, 
vasopressin, dopamine > 5 μg/kg/min, dobutamine, phosphodiesterase inhibitors) 
8. Suspected or known site of infection 
9. Baseline platelet count and kidney/liver function tests: creatinine, total bilirubin, 
alanine aminotransferase. Make laboratory measurements as specified in Study 
Procedures Section 9.3 if not available from testing obtained as part of clinical care 
10. Baseline assessments must include all data needed for the 4-point acute lung injury 
score, SOFA score, Ordinal Scale of Clinical Assessment (OSCI) and trauma 
registry index (if applicable) 
11. COVID-19 test results (if applicable) 
10.3 Assessment after Enrollment: Determination of Stable Baseline for Study 
Product Administration and Monitoring During and After Infusion Protocol 
 
The following parameters will be measured and recorded every 15 minutes for the two hour period 
used to establish the stable baseline prior to the study product infusion: 
 
1. Respiratory: FiO2, PEEP, transcutaneous oxygen saturation; additional ventilator 
parameters will be recorded if clinically available. 
2. Cardiovascular: Heart rate, systolic and diastolic blood pressure, vasopressor doses. 
 
The same clinical parameters will be recorded every 15 minutes for the duration of the infusion 
and every hour for the next 5 hours.  
 
An arterial blood gas will be obtained within 90 minutes prior to beginning the baseline stability 
period, at the end of the study product infusion (~1 hour), and 6 hours (+/- 1 hour) after the 
initiation of the study product infusion; additional blood gases will be recorded at 12, 18, 24, 30 

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and 36 hours (+/- 1 hour for all timepoints) after the initiation of the study product infusion. If an 
arterial blood gas is collected +/- 1 hour of an indicated timepoint for clinical purposes, another 
arterial blood gas does not need to be collected for research. 
10.4 Assessment after Enrollment: Reference Measurements 
The following data will provide the basis for assessing protocol compliance and safety as well as 
between-group differences in several efficacy variables. Data for each of the variables will be 
recorded on the days shown in the Time-Events Schedule (Appendix A) or until death, discharge 
from the ICU, or unassisted ventilation for 48 hours. 
10.4.1 Reference Measurements (to be collected from patient charts) 
The following parameters will be measured and recorded at the time of Randomization as well as 
on subsequent dates using values closest in time to 8:00 A.M. on the days specified in the Time-
Events Schedule (Appendix A). The following conditions will be ensured prior to measurements: 
no endobronchial suctioning for 10 minutes; no invasive procedures or ventilator changes for 30 
minutes. All vascular pressures will be zero-referenced to the mid-axillary line.. 
1. If receiving assisted ventilation, record daily up to day 7: 
a. Tidal volume, FiO2, PEEP, inspiratory plateau pressure, and mean airway pressures 
b. Pressure during inspiration if on a pressure targeted mode (PSV, PCV, etc) 
c. Arterial PaO2, PaCO2, pH and transcutaneous oxygen saturation 
2. Fluid intake and output 
3. Vital signs: Heart rate, systolic and diastolic blood pressure, body temperature, CVP 
4. Modified Brussels Score data on days 0 through 14 
a. Vasopressor use (Y/N), lowest systolic blood pressure, creatinine, bilirubin, and 
platelet count for the day  
5. The date and value of the highest creatinine between days 15 and 28 
6. Safety laboratory studies: all creatinine and bilirubin measurements will be recorded as 
above. Creatinine, bilirubin and ALT will be measured and recorded as safety labs on day 
7 if not obtained as part of clinical care.  
7. Data regarding infections, including: 
a. Surgical site and wound infections by CDC criteria 
b. Ventilator associated or nosocomial pneumonia as diagnosed by CDC criteria 
c. Culture-proven bacteremia 
d. SARS-CoV-2 virus infection  
8. Blood product transfusions 
9. On-study procedures and surgical interventions 
10. Co-enrollment in randomized clinical trials of other interventions and treatments related to 
SARS-CoV-2 infection 
11. Inpatient medications (selected) 
12. Must include all data needed for the 4-point acute lung injury score (including frontal chest 
radiograph), SOFA score, OSCI score and trauma registry index (if applicable) 
13. D-dimer, lymphocyte count, neutrophil count, fibrinogen, ferritin and serum C-reactive 
protein (if applicable) 

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10.4.2 Specimen Collection 
1. Date and time of specimen collection 
2. Time of specimen processing and storage 
 
10.5 Endpoint Determinations 
1. Vital status at 60 days  
2. Brussels Organ dysfunction failures at days 0-14 
3. SOFA score at 3 and 7 days 
4. Oxygenation index (PaO2/FiO2 and mean airway pressure) at 6, 12, 18, 24, 30 and 36 hours 
after the initiation of study product infusion as well as on days 2, 3, and 7 if still being 
ventilated with positive pressure (cannot be calculated if patient is on pressure support, as 
the mean airway pressure is not reliable) 
5. Ventilatory ratio at 6, 12, 18, 24, 30, 36 hours after the initiation of study product infusion, 
and on days 2, 3, 7 
6. Incidence of barotrauma on days 1, 2, 3 and 7 
7. Time when patient achieves pressure support ventilation with 5 cmH20 and 5 cmH20 
positive end-expiratory pressure for 2 hours 
8. Time of initiation of unassisted breathing (assuming a patient achieves 48 consecutive 
hours of unassisted breathing) 
9. Need for re-instituting assisted or mechanical ventilation after achieving 48 consecutive 
hours of unassisted breathing 
10. Status 48 hours after initiation of unassisted breathing 
11. Need for, timing, and duration of dialysis; change in renal function as measured by 
creatinine 
12. ICU length of stay in calendar days including ICU days after readmission to ICU 
13. Hospital length of stay in calendar days  
14. Discharge diagnoses and discharge disposition (home, other facility, with or without 
assisted ventilation) 
15. WHO Ordinal Scale of Clinical Assessment at days 7, 14 and 28 
 
10.6 Assessments After Hospitalization 
A health status questionnaire will be conducted at 28 days, 60 days and 6 months through telephone 
interviews. 
 
11 Statistical Plan   
The Statistical Analysis Plan has been written along with this Protocol and provides the details of 
the statistical methodologies applied to this Phase 2b trial.  

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11.1 Sample Size Determination  
The sample size for this trial will be 60 patients in the hMSCs arm and 60 patients in the placebo 
arm, for a total of 120 patients with a balanced randomization of patients with PaO2:FiO2 <150 
mmHg and patients with trauma. This sample size was determined on the basis of feasibility.  
 
Given the sample size of 60 per treatment condition, in this multisite, randomized trial using 
oxygenation index as the primary outcome and measures taken at 6 time points, it is estimated the 
study will have 80% power to detect a difference between conditions for an effect size as low as 
0.43.  Using the pilot data from Day 4, for example, this would translate to approximately a 
difference of 1.29 in the oxygenation index. 
11.2 Statistical Methods for Primary and Secondary Endpoints 
Descriptive summary statistics (e.g. means and standard deviations, or median with inter-quartile, 
as appropriate) will be used to summarize the primary and secondary endpoints by study treatment. 
The primary and secondary efficacy endpoints will also be analyzed using appropriate models.   
  
The primary endpoint, change in the oxygenation index over time, will be compared between 
treatment conditions using a linear mixed-effects regression model.  The model will be estimated 
using likelihood estimation which will allow the inclusion of all collected data, regardless of the 
number of assessments available for assessment. Terms in the model will include the two 
stratification variables, treatment condition (active or placebo), time of assessment, condition-by-
time, recruitment site and a site-by-treatment interaction term.  A test of the treatment condition 
will directly test the main research question. Covariates identified by preliminary analysis as 
potentially confounding due to baseline differences will be added to the model. 
 
The data analysis plan for secondary efficacy and safety endpoints has been provided in the 
Statistical Analysis Plan.  
 
The primary and secondary endpoints (including clinical and biological data) will be adjusted for 
COVID-19 infection as a cause of ARDS, which is adjudicated by the study physicians.  
11.3 Subject Population(s) for Analysis 
A total of three populations will be used for all summaries and analyses. Subjects who have 
satisfied the population criteria will be classified in the designated population and will only be 
included in analyses for which they have available data.  
Intent-to-Treat (ITT) Population 
The primary analysis for this trial will be an intention-to-treat (ITT) analysis based on 
randomization to either hMSCs or placebo.  
 
Since the study treatment is a single infusion of study product, a subject is unlikely to be withdrawn 
by investigators due to safety concerns because there is only a single treatment to be administered. 
However, a surrogate or subject may withdraw consent for study participation either before, during 

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or after study product administration. For subjects who are withdrawn prior to the initiation of 
study product infusion, they will not be included in ITT population. For subjects who are 
withdrawn during or after study product administration, they will be included in ITT population.  
The ITT population will be used to present primary efficacy endpoint and secondary efficacy 
endpoints by allocated randomization. Subjects will be summarized according to the treatment to 
which they were randomized, regardless of which treatment they actually received.  
Per Protocol Population 
It is possible that there will be a number of deviations from the trial protocol (e.g. non-compliance 
with the allocated intervention, non-adherence to other elements of the protocol, et al.)   The Per 
Protocol (PP) population is defined as all patients who will complete the study without major 
protocol deviations. The PP population will be fixed following clinical review of all protocol 
deviations at the end of the study and prior to unblinding and data locking. Due to the blinding 
feature of the study, the analyses of endpoints using PP population will not feasible in the interim 
report to DSMB. However, as a sensitivity analysis, the analysis of efficacy and safety endpoints 
using PP population will be included in the final study report.    
Safety Population 
The Safety population will be used for the analysis of safety, including adverse events, toxicity 
and safety laboratory evaluation. In this study, the Safety population is defined as all randomized 
who started the study product administration, regardless of infusion completion.  
Due to the blinding feature of the trial, the safety and adverse events will be summarized using 
ITT population in the interim report for 60 patients to the DSMB. However, in the final report, 
the safety summaries and adverse events listings will be grouped by actual treatment received.  
12 Safety and Adverse Events  
12.1 Definitions 
Investigators will determine daily if any clinical adverse experiences occur during the period from 
enrollment through study day 28 after investigational product administration. The investigator will 
evaluate any changes in laboratory values or physical signs, and will determine if the change is 
clinically important and different from what is expected in the course of treatment of patients with 
ARDS. 
For this trial, a reportable adverse event is defined as: 
Any clinically important untoward medical occurrence in a patient receiving study product which 
is different from what is expected in the clinical course of a patient with ARDS, or:  
1. Any clinically important, untoward medical occurrence that is thought to be associated with 
the study product, regardless of the “expectedness” of the event for a patient with ALI, or 
2. The following pre-specified infusion associated events occurring within 6 hours from the start 
of study product will always be reported as adverse events: 

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 If on a vasopressor, an increase in vasopressor dose greater than or equal to the 
following: 
o Norepinephrine: 10 mcg/min 
o Phenylephrine: 100 mcg/min 
o Dopamine: 10 mcg/kg/min 
o Epinephrine: 0.1 mcg/kg/min 
o Addition of a third vasopressor 
 New cardiac arrhythmia requiring cardioversion OR ventricular tachycardia, 
ventricular fibrillation or asystole 
 Hypoxemia requiring an increase in FiO2 of 0.2 or more and an increase in PEEP 
of 5 cmH20 or more to maintain Sp02 in the target range of 88-95% that is not 
related to respiratory care/suctioning or ventilator dyssynchrony and persists for 
more than 30 minutes 
 Clinical scenario consistent with transfusion incompatibility or transfusion-related 
infection (e.g., urticaria, new bronchospasm) 
3. Any cardiac arrest or death that occurs within 24 hours from the start of study product will be 
reported as a pre-specified, infusion-associated significant event. Any cardiac arrest or death 
that occurs during the study period will be a reportable event that will be reviewed in detail. 
 
A serious adverse event is any event that is fatal or immediately life threatening, is permanently 
disabling, or severely incapacitating, or requires or prolongs inpatient hospitalization. Important 
medical events that may not result in death, be life threatening, or require hospitalization may be 
considered serious adverse events when, based upon appropriate medical judgment, they may 
jeopardize the patient or subject and may require medical or surgical intervention to prevent one 
of the outcomes listed above. 
1. ‘Life-threatening’ means that the patient was, in the view of the investigator, at immediate 
risk of death from the reaction as it occurred. This definition does not include a reaction 
that, had it occurred in a more serious form, might have caused death. Assessment of the 
cause of the event has no bearing on the assessment of the event’s severity. 
2. Adverse events will be considered to be study-related if the event follows a reasonable 
temporal sequence from a study procedure and could readily have been produced by the 
study procedure. 
All adverse events that do not meet any of the criteria for serious should be regarded as non-
serious adverse events.  
 
An unanticipated problem (UP) is any incident, experience, or outcome that meets all of the 
following criteria (129): 
 
Unexpected, in terms of nature, severity, or frequency, given the research procedures that 
are described in the protocol-related documents, such as the IRB-approved research 
protocol and informed consent document, as well as the characteristics of the subject 
population being studied;  
 
Related or possibly related to participation in the research. In this guidance document, 
possibly related means there is a reasonable possibility that the incident, experience, or 
outcome may have been caused by the procedures involved in the research;  

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 
Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
Adverse Event Reporting Period 
Reportable adverse events that occur during the 28 days following study product administration 
must be reported to the Investigator-Sponsor. Patients who are discharged home or outside 
facilities prior to study day 28 will be contacted after day 28 to determine vital status and for the 
occurrence of adverse events.  
 
Prolonged Hospitalization or Surgery 
All study subjects will be hospitalized at the time of study enrollment, by virtue of the disease 
being studied. Any adverse event that results in prolonged hospitalization should be documented 
and reported as a serious adverse event unless specifically instructed otherwise in this protocol.  
12.2 Recording of Adverse Events 
Assuring patient safety is an essential component of this protocol. Each participating investigator 
has primary responsibility for the safety of the individual participants under his or her care. The 
Principal Investigator at each study site will evaluate all clinically important adverse events. The 
Study Coordinator must view patient records for possible clinically important adverse events 
throughout the study period.  
 
Expected events for ARDS are untoward clinical occurrences that are perceived by the investigator 
to occur with reasonable frequency in the day to day care of patients with ARDS treated in an ICU 
with mechanical ventilation. Examples of adverse events that are expected in the course of ARDS 
include transient hypoxemia, agitation, delirium, nosocomial infections, skin breakdown, and 
gastrointestinal bleeding. Such events, which are often the focus of prevention efforts as part of 
usual ICU care, will not be considered reportable adverse events unless the event is considered by 
the investigator to be associated with the study cell product or procedures, or is unexpectedly 
severe or frequent for an individual patient with ARDS. Examples of unexpectedly frequent 
adverse events would be repeated episodes of unexplained hypoxemia. This would be in contrast 
to an isolated episode of transient hypoxemia (e.g., Sp02 ~85%), related to positioning or 
suctioning. This latter event would not be considered unexpected by nature, severity or frequency.  
 
Organ failures related to ARDS or the patient’s underlying condition that are systematically 
captured by the protocol should not be reported as adverse events unless they are considered to be 
study related.  
 
All adverse events occurring during the study period must be reported in the patient’s case report 
form. The clinical course of each event should be followed until resolution, stabilization, or until 
it has been determined that the study treatment or participation is not the cause. Serious adverse 
events that are still ongoing at the end of the study period must be followed to determine the final 
outcome. Any serious adverse event that occurs after the study period and is considered to be 

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possibly related to the study treatment or study participation should be recorded and reported 
immediately to the study sponsor (see Section 12.3). 
12.3 Reporting of Serious Adverse Events and Unanticipated Problems 
12.3.1 Investigators’ Reporting Requirements to the Sponsor 
Investigators will report all serious AND unexpected, AND study-related adverse events to the 
study sponsor (who will run the Clinical Coordinating Center for this study) within 24 hours by 
fax, phone or email. Investigators must also report Unanticipated Problems, regardless of severity, 
associated with the study drug or study procedures within 24 hours. The investigator will then 
submit a detailed written report to the Clinical Coordinating Center located at University of 
California San Francisco. 
 
In this trial, Vanderbilt University IRB is the central IRB to support all participating sites. The 
Vanderbilt IRB must also be notified in a timely manner by the Clinical Coordinating Center, as 
per the IRB’s requirement. The Principal Investigator will then submit a detailed written report to 
the study sponsor no later than 5 calendar days after the investigator discovers the event. The 
investigator will also submit a detailed written report to the local IRB (if this is required by local 
IRB).  
 
The minimum necessary information to be provided at the time of the initial written report 
includes: 
 Study identifier 
 Study Center 
 Subject number 
 A description of the event 
 Date of onset 
 Current status 
 Whether study treatment was discontinued 
 The reason why the event is classified as 
serious 
 Investigator assessment of the association 
between the event and study treatment 
12.3.2 Sponsor Reporting: Notifying the FDA 
The study sponsor is required to report certain study events in an expedited fashion to the FDA. 
These written notifications of adverse events are referred to as IND safety reports. The following 
describes the safety reporting requirements by timeline for reporting and associated type of event: 
 Within 7 calendar days 
Any study event that is: 
– associated with the use of the study drug, and 
– unexpected, and 
– fatal or life-threatening  
 
 Within 15 calendar days 
Any study event that is: 
– associated with the use of the study drug, and 
– unexpected, and 

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– serious, but not fatal or life-threatening 
-or- 
– a previous adverse event that was not initially deemed reportable but is later found to fit 
the criteria for reporting (reporting within 15 calendar days from when event was 
deemed reportable) 
Any finding from tests in laboratory animals that:  
– suggest a significant risk for human subjects including reports of mutagenicity, 
teratogenicity, or carcinogenicity. 
 
Additional IND Reporting Requirements: 
Sponsors are also required to identify in IND safety reports all previous reports concerning similar 
adverse events and to analyze the significance of the current event in light of the previous reports. 
12.3.3 Sponsor Reporting:  Notifying the DSMB 
All pre-specified clinically important events and unexpected serious adverse events, including 
death, will be reported to the DSMB on an ongoing basis. The study sponsor will report all serious, 
unexpected, and study-related adverse events to the DSMB by email or telephone within 7 calendar 
days of the study sponsor being notified of the event. A written report will be sent to the DSMB 
within 15 calendar days, and these reports will be sent to investigators for submission to their 
respective IRBs, as required. The DSMB will also review all adverse events during scheduled 
interim analyses.  
 
It is the responsibility of the study sponsor to notify all participating investigators, in a written IND 
safety report, of any adverse event associated with the use of the drug that is both serious and 
unexpected. Additionally, sponsors are also required to identify in IND safety reports all previous 
reports concerning similar adverse events and to analyze the significance of the current event in 
light of the previous reports. IND safety reports will be sent to the participating investigators 
immediately after submission to the IND. 
 
The study sponsor will distribute the written summary of the DSMB’s periodic review of adverse 
events to investigators and submit to the central IRB at Vanderbilt University. 
12.4 Unblinding Procedures 
The DSMB will make decisions about the need for unblinding. If unblinding the study therapy is 
necessary to ensure a subject’s safety, this will be done by the DSMB after review of the clinical 
events. If this is done in conjunction with the site Principal Investigator, the study sponsor must 
be informed within 24 hours by phone, fax or email of the unblinding event, followed by a detailed 
written narrative within 48 hours of the event by the Principal Investigator at the study site.  
12.5 Stopping Rules  
The DSMB will review post-infusion safety data after 60 subjects have been enrolled and received 
study product; however, enrollment will not be suspended pending DSMB review. The study will 
be stopped for a safety evaluation by the DSMB if they have any concerns or if three subjects have 

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pre-specified clinically important events or unexpected serious adverse events EXCEPT death 
since death will be common in this critically ill population due the nature of the underlying illness 
(e.g., ARDS).  
 
The study will end when 120 patients have been recruited and received the study product and have 
all completed 60-day follow-up, after which data analysis will commence. This Phase 2b study 
will stop prior to completion if mandated by the Department of Defense-appointed DSMB or the 
FDA due to safety concerns.  
12.6 Medical Monitoring 
It is the responsibility of the Principal Site Investigator at each of the 7 hospital sites to oversee 
the safety of the study at his/her site. This safety monitoring will include careful assessment and 
appropriate reporting of adverse events as noted above, as well as the construction and 
implementation of a site data and safety-monitoring plan. Medical monitoring will include a 
regular assessment of the number and type of serious adverse events. The study will have an 
independent DSMB to oversee serious adverse events.  
12.6.1 Independent Data and Safety Monitoring Board 
This Phase 2b study will be monitored by an independent DSMB. The DSMB will contain 3 
members. There will be 2 intensivists familiar with the care of critically ill patients and ARDS,  at 
least one of whom will be familiar with the care of critically ill patients who have suffered trauma. 
There will also be a biostatistician. A DSMB Charter will define the DSMB’s responsibilities as 
described below. 
 
The DSMB will meet by teleconference at the planned interim safety analysis (60 patients) for this 
Phase 2b trial. At this meeting, the DSMB will review all safety data in aggregate; individual 
adverse event narratives will also be available to the DSMB for review. During the trial, the DSMB 
will review the safety data in an unblinded fashion. The DSMB will also receive reports of serious, 
unexpected, and study-related adverse events and unanticipated problems on an ongoing basis. 
 
The actual analyses will be conducted by the Clinical Coordinating Center Biostatistician who will 
be blinded to the randomization scheme.  
 The DSMB chair will be responsible for recording the summary of its various meetings and 
for reporting findings and/or recommendations to the study sponsor and to the funding 
agency, the Department of Defense (DoD). 
 
13 Data Handling and Record Keeping 
13.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Those 
regulations require a signed subject authorization informing the subject of the following:  
 What protected health information (PHI) will be collected from subjects in this study 

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 Who will have access to that information and why 
 Who will use or disclose that information 
 The rights of a research subject to revoke their authorization for use of their PHI  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization. For subjects that have revoked authorization to collect or use PHI, attempts should 
be made to obtain permission to collect at least vital status (i.e., that the subject is alive) at the end 
of their scheduled study period. 
13.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities 
in a clinical trial necessary for the reconstruction and evaluation of the trial. Source data are 
contained in source documents. Examples of these original documents and data records include: 
hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, 
copies or transcriptions certified after verification as being accurate and complete, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the 
pharmacy, at the laboratories, and at medico-technical departments involved in the clinical trial. 
13.3 Case Report Forms 
The study case report forms (CRFs) are the primary data collection instruments for the study. All 
data requested on the CRFs must be recorded. All missing data must be explained. If a space on 
the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”. If the item is not applicable to the individual case, write “N/A”. All entries should be 
printed legibly in black ink. If any entry error has been made, to correct such an error draw a single 
straight line through the incorrect entry and enter the correct data above it. All such changes must 
be initialed and dated. DO NOT ERASE OR WHITE OUT ERRORS. For clarification of illegible 
or uncertain entries, print the clarification above the item, then initial and date it. 
13.4 Records Retention 
It is the investigator’s responsibility to retain study essential documents for at least 2 years after 
the completion and publication of the clinical trial. These documents should be retained for a 
longer period if required by an agreement with the sponsor. In such an instance, it is the 
responsibility of the sponsor to inform the investigator/institution as to when these documents no 
longer need to be retained.  
 
14 Study Monitoring, Auditing, and Inspecting 
14.1 Study Monitoring Plan 
The data safety and monitoring plan for this Phase 2b trial will include a formal DSMB that will 
be approved by the central IRB at Vanderbilt University and the Department of Defense. Our data 

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safety monitoring board will include two critical care physician and a biostatistician. None of the 
DSMB members will be affiliated with this study or have a conflict of interest. The DSMB will 
meet before the clinical trial begins and subsequently at least once every six months to review the 
design, comment, and monitoring of the trial with special reference to safety issues. The DSMB 
will be available to review adverse events, which will also be reviewed by the Principal 
Investigators. Adverse events will be promptly report to the DSMB, the Vanderbilt IRB, and the 
FDA.  
 
Taylor Thompson, MD, will be appointed as the Research Monitor and the Chair of the DSMB for 
this Phase 2b trial. The independent Research Monitor has the authority to stop the research 
protocol in progress, remove individual human subjects from a research protocol, and take 
whatever steps necessary to protect the safety and well-being of human subjects until the IRB 
assesses the independent Research Monitor's report. 
 
A separate monitoring plan will be written to specify how the participating clinical sites will be 
monitored by the sponsor. 
14.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the central IRB 
at Vanderbilt University, the sponsor, government regulatory bodies, and University compliance 
and quality assurance groups of all study related documents (e.g., source documents, regulatory 
documents, data collection instruments, study data, etc.). The investigator will ensure the 
capability for inspections of applicable study-related facilities (e.g., bone-marrow or cell therapy 
laboratory, pharmacy, diagnostic laboratory). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
15 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice 
(FDA Title 21 part 312 and International Conference on Harmonization guidelines), applicable 
government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to the central IRB (cIRB) at Vanderbilt 
University for formal approval of the study. The decision of the cIRB concerning the conduct of 
the study will be made in writing to the investigator, and a copy of this decision will be provided 
to the sponsor before commencement of this study. The reliance on the cIRB have been approved 
by the local IRBs of all participating sites. All study approvals and related documents will be 
forwarded to local institional  IRBs, as requested.  
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 

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study. The consent form will be submitted with the protocol for review and approval by the central 
IRB for the study. The formal consent of a subject, using the central IRB-approved consent form, 
must be obtained before that subject undergoes any study procedure. The consent form must be 
signed by the subject or legally acceptable surrogate, and the investigator-designated research 
professional obtaining the consent.  
 
16 Study Finances 
16.1 Funding Source 
This study is financed through a grant from the Department of Defense (DoD), and California 
Institute for Regenerative Medicine for funding University of California Davis as an additional 
enrollment site. Both the DoD and NHLBI provided support for the production of MSCs at the 
University of Minnesota.  
16.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, 
financial gain greater than the minimum allowable by their institution, etc.) must have the conflict 
reviewed by a properly constituted Conflict of Interest Committee with a Committee-sanctioned 
conflict management plan that has been reviewed and approved by the study sponsor prior to 
participation in this study. Site investigators will follow their institutions conflict of interest policy. 
 
17 Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor 
any of the information provided by the sponsor for the purposes of performing the study, will be 
published or passed on to any third party without the consent of the study sponsor. Any investigator 
involved with this study is obligated to provide the sponsor with complete test results and all data 
derived from the study. 
 
 
 

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2007;175(10):1014-26. 

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Confidential  
 
 
 
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al. Mitochondrial Transfer via Tunneling Nanotubes is an Important Mechanism by Which 
Mesenchymal Stem Cells Enhance Macrophage Phagocytosis in the In Vitro and In Vivo Models 
of ARDS. Stem Cells. 2016;34(8):2210-23. 
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Confidential  
 
 
 
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Intensive Care Units in 50 Countries. JAMA. 2016;315(8):788-800. 
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with allogeneic mesenchymal stromal cells for moderate to severe acute respiratory distress 
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Hare JM, Traverse JH, Henry TD, Dib N, Strumpf RK, Schulman SP, et al. A 
randomized, double-blind, placebo-controlled, dose-escalation study of intravenous adult human 

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Confidential  
 
 
 
mesenchymal stem cells (prochymal) after acute myocardial infarction. J Am Coll Cardiol. 
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transplantation. Cytotherapy. 2009;11(5):503-15. 
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mortality in acute lung injury during the era of lung protective ventilation. Thorax. 
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Warren MA, Zhao Z, Koyama T, Bastarache JA, Shaver CM, Semler MW, et al. Severity 
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of Health and Human Services;  [updated January 15, 2007. Available from: 
http://www.hhs.gov/ohrp/policy/AdvEvntGuid.htm

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Date: April 19, 2022  
 
 
Confidential  
 
 
 
19 Appendices  
A. Time-Events Schedule 
B. Lung Injury Score 
C. De-identified Data Elements for Screened, Non-enrolled Subjects  
D. Ventilator Management 
E. Study Product Preparation Protocol 
F. Guidelines for Symptom Management During Investigational Product Infusion 
G. Mini-Bronchoalveolar Lavage Procedure 
H. Phase 2b Investigational Product Infusion Protocol 
I. Barotrauma  
J. Childs-Pugh Score for Liver Dysfunction 
K. WHO Ordinal Scale for Clinical Improvement (OSCI) 
L. Radiographic Assessment of Lung Edema (RALE) Score 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Michael A Matthay, MD 
 
           
 
 
         Page 80 
University of California, San Francisco  
                                                    Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
                                                                       Appendix A:  Time-Events Schedule 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix A: Time-Events Schedule 
Measurement/Event 
Day 0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
28 
60 
6m 
Prior to 
randomiza
tion 
Prior to 
MSC 
infusion& 
During 
and after  
MSC 
infusion 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics, History & Physical, Height, Weight 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Etiology of ARDS 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HCG (in females of childbearing age < 50 years old) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline stability assessment (Vital signs and ventilator parameters)$B 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanism of injury and trauma registry index (if applicable) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
APACHE III ScoreC 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECHOD 
A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 test 
A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 vaccination status 
A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Co-enrollment with other clinical trials and COVID-19 related therapiesM 
X 
 
 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
 
Vital Signs (HR, SBP, DBP, MAP, Temp oC, SpO2) ~$ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Central Venous Pressure ~$ 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
 
 
 
Record vasopressors or inotropes * (Y/N)$ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Fluids in/out, crystalloids, PRBC, FFP, platelets, cryoprecipitate, urine output 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
Modified Brussels Score and Brussels Organ Dysfunction Failure~E 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Sequential Organ Failure Score 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
Ventilator Parameters (including FiO2) # 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
Arterial Blood Gases (PaO2, PaCO2, pH, SpO2, base deficit)& 
X 
X 
X 
X 
X 
X 
A 
A 
A 
X 
 
 
 
 
 
 
 
 
 
 
Chest X-ray (# quadrants for lung injury score, RALE score)  
A 
 
 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
 
 
 
 
 
 
 
Pulmonary dead spaceF 
X 
 
 
X 
X 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Creatinine%G,H 
X 
 
 
A 
A 
X 
A 
A 
A 
X 
A 
A 
A 
A 
A 
A 
A 
A 
 
 
Total bilirubin, ALT, platelets%H 
X 
 
 
A 
A 
X 
A 
A 
A 
X 
A 
A 
A 
A 
A 
A 
A 
 
 
 
D-dimer, lymphocyte count, neutrophil counts, fibrinogen, ferritin and serum C-reactive protein  (if applicable) 
A 
A 
 
A 
A 
A 
A 
A 
A 
A 
 
 
 
 
 
 
 
 
 
 
Glasgow coma scoreJ 
X 
X 
 
X 
X 
X 
 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
Outpatient medication and on-study medication and study procedureK 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
DVT Prophylaxis medication¶ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Positive blood culture¶ 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Thromboembolic complications¶ 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Wound site infection and VAP assessment€ 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Blood for cytokines, mediators and markers of inflammationN  
 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood for DNA/RNA 
 
X 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine for biomarker measurementsO  
 
X 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mini-BAL 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ventilator history and ICU history@ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
Need for, timing and duration of dialysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
Vital Status § 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Ordinal Scale for Clinical Improvement (OSCI) 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
X 
 
 
Incidence of barotrauma 
X 
 
 
X 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
X=Required;   A=When available;  ~=Data gathered on days 0-14 or until d/c from study hospital; $=Data recorded every 15 minutes for at least two hours during “stable baseline” period and until the initiation of study product infusion,  every 15 minutes for the duration of 
the infusion and every hour  until 6 hours, then 12, 24 and 48 hour from the initiation of study product infusion; #=Data recorded every 15 minutes for at least two hours during “stable baseline” period and until the initiation of study product infusion,  every 15 minutes for the 
duration of the infusion and every hour  until 6 hours, then 12, 18, 24 and 36 hour from the initiation of study drug infusion, then day 2, 3, 4, 5, 6, and 7; &=ABG mandatory at the following timepoints: within 6 hours of randomization, prior to the start of the infusion (within 
90 minutes of starting the baseline stability period); within 15 minutes of the end of MSC infusion (~1 hour); after the initiation of the study product infusion, ABGs will also be REQUIRED at 6, 12, 18, 24, 30, 36 hours (+/- 1 hour for all timepoints), day 2 (48 hours +/- 4 
hours), 3  and 7 (anytime) if patient still has arterial line after study product infusion; €=Record only one episode during the 14 day period after study product infusion, no need for further assessment once first diagnosis is confirmed; %=Labs not available in the 24 hours 
before randomization must be obtained; ¶=Data gathered for first 14 days during current hospital admission; @=Measure at day 28. The 28-day follow up will be a telephone interview with structured survey if patient discharged prior to day 28; §=Measure at day 28, day 60, 
hospital discharge alive, and 6 months; the 6 month follow up will be a telephone interview with structured survey. B=Patient must achieve a stable baseline for ≥ 2 hours and the administration of study product must be initiated within 14 days of initial ICU admission; 
C=Record available clinical data within 24 hours prior to study randomization; D=Record ECHO if available, If more than one ECHO data available, select the data closest to randomization; E=Record clinically available worst SBP, PaO2/FiO2, SpO2/FiO2, creatinine, platelets, 
bilirubin, and vasopressor use; F=Measured on day 0, 1, 2, 3, 7 when patient is on assistant breathing;  G=Record clinically available creatinine in the 96 hours prior to  randomization, the worst creatinine of the day from day 1-14, the date and value of the highest creatinine 
between days 15-28 and the lowest value during the entire hospitalization obtained off dialysis; H=Data required prior to  randomization,  day 3 (+/-1 day) and day 7 (+/-1 day);  J=Mandatory at the following timepoints: pre-randomization, pre-infusion, day 1, 2, 3, 7, 14 and 
the date of hospital discharge; K=Record outpatient medication (anticoagulants/antiplatelets/antifibrinolytic) within 7 days prior to current hospital admission; record the following medication and procedures (glucocorticoids, NMBD, inhaled vasodilators, prone positioning, 
recruitment maneuvers, ECMO) prior to randomization and on day 1-7; and inpatient trauma specific medications for first 14 days during current hospital admission; M= Record any co-enrollment of clinical trials and COVID-19 related therapies within 7 days prior to current 
hospitalization until hospital discharge;  N=Blood specimens are required before the study product infusion, at 6, 12, 24 hours (+/-1 hour), and 2 (48 hours +/- 4 hours), 3 days (anytime) after the initiation of the study product infusion. O=Urine specimens are required before 
the study product infusion, at 24 hours and 2 days (48 hours +/- 4 hours) after the initiation of the study product infusion. 

Michael A Matthay, MD 
 
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University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix B: Lung Injury Score 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix B: Lung Injury Score 
 
The Lung Injury Score (116) is a validated 4-point score based on chest radiograph findings, 
PaO2/FiO2 ratio, PEEP and compliance. Scoring is performed for each individual component, and 
the score is the average of the 4 components. 
 
Lung Injury Scoring 
Value 
Score 
CXR (# of quadrants with 
infiltrates) 
 
 
 
 
 
PaO2/FiO2 
 
 
 
 
 
PEEP 
 
 
 
 
 
Compliance 
 
 
 
 
 
Total score 
 
 
Actual score (total points/4) 
 
 
 
 
Scoring: 
 
1 points 
2 points 
3 points 
4 points 
CXR (# of quadrants 
with infiltrates) 
 
2 quadrants 
3 quadrants 
4 quadrants 
PaO2/FiO2 
225-299 
175-224 
100- 174 
< 100 
PEEP 
6-8 
9-11 
12-14 
≥ 15 
Compliance 
60-79 
40-59 
20-39 
≤ 19 
 
Static compliance can be calculated as: Tidal volume/(Plateau pressure – PEEP) 
 
 
 

Michael A Matthay, MD 
 
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University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix C: De-identified Data Elements for Screened, Non-enrolled Subjects 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix C: De-identified Data Elements for Screened, Non-enrolled Subjects 
 
1. Was onset of ARDS acute? 
2. Did frontal CXR show bilateral infiltrates consistent with pulmonary edema? 
3. Number of quadrants with opacities? 
4. Is patient intubated? 
5. PaO2 
6. FiO2 
7. PEEP 
8. COVID-19 test result 
9. Was there evidence of left atrial hypertension or left ventricular dysfunction? 
10. Month of the year that patient met screening criteria 
11. Gender 
12. Ethnicity 
13. Age (if age >89, 89 will be entered for age) 
14. Reason(s) patient excluded from study 
15. If not excluded, not enrolled, why? 
16. Lung injury category (e.g. sepsis, pneumonia) 
17. Severe traumatic brain injury? 

Michael A Matthay, MD 
 
Page 83 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix D: Ventilator Management 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix D: Ventilator Management 
1.  Ventilator Management 
A modified, simplified version of the ARDS Network lung protective lower tidal volume strategy 
will be used in this trial.  This strategy, which was associated with low mortality rates in three 
previous ARDS Network trials (ARMA, ALVEOLI, and FACTT), will ensure that study subjects 
receive the beneficial effects of lung protection while participating in this trial (The Acute 
Respiratory Distress Syndrome Network and Brower et al., 2004). ARDS Network personnel have 
substantial experience in the application of this protocol from the three completed trials noted 
above. 
 
1. Any mode of ventilation capable of delivering the prescribed tidal volume (VT, 6ml/kg 
predicted body weight, +/- 2ml/kg) may be used, provided the VT target is monitored and 
adjusted appropriately. However, assist control ventilation is the preferred mode of 
ventilation.  
2. VT Goal:  6 ml/kg predicted body weight.  
3. Predicted body weight (PBW) is calculated from age, gender, and height (heel to crown) 
according to the following equations: 
a. Males: PBW (kg) = 50 + 2.3 [height (inches) – 60] 
b. Females:  PBW (kg) = 45.5 + 2.3 [height (inches) – 60] 
4. Measure and record inspiratory plateau pressure (Pplat) according to ICU routine (at least 
every four hours and after changes in VT and PEEP recommended). 
5. If Pplat > 30 cm H2O, reduce VT to 5 ml/kg and then to 4 ml/kg PBW if necessary to 
decrease Pplat to ≤ 30 cm H2O. 
6. If VT < 6 ml/kg PBW and Pplat < 25 cm H2O, raise VT by 1 ml/kg PBW to a maximum 
of 6 ml/kg. 
7. If “severe dyspnea" (more than 3 double breaths per minute or airway pressure remaining 
at or below PEEP level during inspiration), then raise VT to 7 or 8 ml/kg PBW if Pplat 
remains below 30 cm H2O.  If Pplat exceeds 30 cm H2O with VT of 7 or 8 ml/kg PBW, 
then revert to lower VT and consider more sedation. 
8. If pH < 7.15, VT may be raised and Pplat limit suspended (not required). 
9. Oxygenation target: 55 mm Hg < PaO2 < 80 mm Hg or 88% < SpO2 < 95%.  When both 
PaO2 and SpO2 are available simultaneously, the PaO2 criterion will take precedence.   
10. Minimum PEEP = 5 cm H2O. 
11. Adjust FIO2 or PEEP upward within 5 minutes if there are consistent measurements 
below the oxygenation target range. 

Michael A Matthay, MD 
 
Page 84 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix D: Ventilator Management 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
12. Adjust FIO2 or PEEP downward within 30 minutes if there are consistent measurements 
above the oxygenation target range.   
13. There are no requirements for maintaining a specific PEEP to FIO2 ratio.  The lower 
PEEP/higher FIO2 table represents a consensus approach developed by ARDS Network 
investigators in 1995.  The higher PEEP/lower FIO2 table (ALVEOLI) yielded equivalent 
results in a randomized trial (Brower et al., 2004)  and would be acceptable and perhaps 
preferable in patients who appear to respond with a substantial increase in arterial 
oxygenation in the transition from lower to higher PEEP. 
 
Lower PEEP/Higher FIO2 Treatment Group 
 
 
Higher PEEP/Lower FIO2 Study Group 
 
Note: Levels of PEEP in these FIO2/ PEEP tables represent levels set on the ventilator, not 
levels of total-PEEP, auto-PEEP, or intrinsic-PEEP. 
 
14. No specific rules for respiratory rate. It is recommended that the respiratory rate be 
increased in increments to a maximum set rate of 35 if pH < 7.30. 
15. No specific rules about I:E.  It is recommended that duration of Inspiration be ≤ duration 
of Expiration. 
16. Bicarbonate is allowed (neither encouraged nor discouraged) if pH < 7.30. 
17. Changes in more than one ventilator setting driven by measurements of PaO2, pH, and 
Pplat may be performed simultaneously, if necessary. 
 
     References: 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as 
compared with traditional tidal volumes for acute lung injury and the acute respiratory 
distress syndrome. The Acute Respiratory Distress Syndrome Network. 2000; 342:1301-
1308. 
 
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory 
pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 
351:327-336. 
 
FIO2 
.30 .40 .40 
.50 
.50 
.60 
.70 
.70 
.70 
.80  .90 
.90 
.90 
1.0 
PEEP 
5 
 5 
  8 
  8 
 10 
10 
10 
12 
14 
14 
14 
16 
18 
18-24 
FIO2 
.30 .30 .30 .30 .30 .40 .40 .50 
.50 
.50 – .80 .80 .90 
1.0 
1.0 
PEEP 
5 
8 
10 
12 
14 
14 
16 
16 
18 
20 
22 
22 
22 
24 

Michael A Matthay, MD 
 
Page 85 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix D: Ventilator Management 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
2.  Weaning 
Commencement of Weaning (applicable to patients ventilated invasively or non-invasively): 
Patients will be assessed for the following weaning readiness criteria each day between 0600 and 
1000. If a patient procedure, test, or other extenuating circumstance prevents assessment for these 
criteria between 0600 and 1000, then the assessment and initiation of subsequent weaning 
procedures may be delayed for up to six hours. 
 
1. At least 24 hours since enrollment in the trial 
2. FIO2  0.40 and PEEP  8 cm H2O or FIO2  0.50 and PEEP = 5 cm H2O 
3. Values of both PEEP and FIO2  values from previous day (comparing Reference 
Measurement values, section 6.3) 
4. Not receiving neuromuscular blocking agents and without neuromuscular blockade 
5. Patient exhibiting inspiratory efforts. If no efforts are evident at baseline, ventilator set 
rate will be decreased to 50% of baseline level for up to 5 minutes to detect inspiratory 
efforts 
6. Systolic arterial pressure  90 mm Hg without vasopressor support ( 5 mcg/kg/min 
dopamine or dobutamine will not be considered a vasopressor) 
 
Spontaneous Breathing Trial Procedure and Assessment for Unassisted Breathing: 
If criteria 1-6 above are met, then initiate a trial of up to 120 minutes of spontaneous breathing 
with FIO2 < 0.5 using any of the following approaches: 
1. Pressure support (PS) < 5 cm H2O, PEEP < 5 cm H2O  
2. CPAP < 5 cm H2O  
3. T-piece  
4. Tracheostomy mask  
 
The clinical team may decide to change mode during spontaneous breathing (PS = 5, CPAP, 
tracheostomy mask, or T-piece) at any time during the spontaneous breathing trial. 
 
Monitor for tolerance using the following: 
1. SpO2  90% and / or PaO2  60 mm Hg 
2. Mean spontaneous tidal volume  4 ml/kg PBW (if measured) 
3. Respiratory Rate  35 / min 
4. pH  7.30 (if measured) 
5. No respiratory distress (defined as 2 or more of the following): 
a. Heart rate ≥ 120% of the 0600 rate ( ≤ 5 min at > 120% may be tolerated) 
b. Marked use of accessory muscles 
c. Abdominal paradox 
d. Diaphoresis 
e. Marked subjective dyspnea 

Michael A Matthay, MD 
 
Page 86 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
   
Appendix D: Ventilator Management 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
 
If any of the goals a-e are not met, revert to previous ventilator settings or to PS greater than 
or equal to 10 cm H2O with Positive End-expiratory Pressure and FIO2 = previous settings and 
reassess for weaning the next morning.  The patient will be reassessed for weaning (Section 
E2) the following day. 
 
Decision to remove ventilatory support: 
If tolerance criteria for spontaneous breathing trial (a-e above) are met for at least 30 minutes, 
the clinical team may decide to discontinue mechanical ventilation. However, the spontaneous 
breathing trial can continue for up to120 minutes if tolerance remains in question.  
 
3.  Definition of Unassisted Breathing  
1. Spontaneously breathing with face mask, nasal prong oxygen, high flow nasal oxygen, or 
room air, OR 
2. T-tube breathing, OR 
3. Tracheostomy mask breathing, OR 
4. CPAP  5 without PS or IMV assistance, OR 
5. Use of CPAP or BIPAP solely for sleep apnea management.  
 
4.  Definition of Extubation 
1. Removal of an oral or nasotracheal tube. 
2. If a patient receives a tracheostomy, the time of extubation is defined as the time when 
the patient achieves unassisted breathing as defined in Section 3. 
 
5.  Completion of Ventilator Procedures 
Patients will be considered to have completed the study ventilator procedures if any of the 
following conditions occur: 
1. Death 
2. Hospital discharge 
3. Alive 28 days after enrollment 
 
If a patient requires positive pressure ventilation after a period of unassisted breathing, the 
study ventilator procedures will resume unless the patient was discharged from the hospital or 
> 28 days elapsed since enrollment. 
 
6.  Removal from the Ventilator Management Protocol 
Patients may be removed from the 6 ml/kg PBW tidal volume ventilation requirement if they 
develop neurologic conditions where hypercapnia would be contraindicated (e.g., intracranial 
bleeding, GCS < 8, cerebral edema, mass effect [midline shift on CT scan], papilledema, 
intracranial pressure monitoring, fixed pupils). 

Michael A Matthay, MD 
 
Page 87 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
Appendix E: Study Product Preparation Protocol 
 
Allogeneic Bone Marrow-derived Human Mesenchymal Stromal Cells 
(hMSCs) 
 
Document Date 
February 24, 2020 
 
To be used in support of 
Protocol Title: 
A Phase 2b, Randomized, Double-blind, Placebo-controlled, 
Multi-center Clinical Trial of Allogeneic Bone Marrow-
derived Human Mesenchymal Stromal Cells for the Treatment 
of Acute Respiratory Distress Syndrome 
Protocol 
Number: 
UCSF-hMSC-ARDS-P1P2-14 
Sponsor-
Investigator: 
Michael A. Matthay, MD 
University of California, San Francisco 
 
 
 

Michael A Matthay, MD 
 
Page 88 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
1.Background 
Allogeneic, bone marrow-derived human mesenchymal stromal cells (hMSCs) will be received 
frozen from: 
University of Minnesota Medical Center (UMMC)  
Clinical Cell Therapy Laboratory  
Molecular and Cellular Therapeutics (MCT)  
1900 Fitch Avenue 
Saint Paul, MN 55108 
The cellular product is cryopreserved for long-term storage. The cryopreserved hMSCs are 
formulated in CryoStor (90%) and DMSO (10%). 
Once received at the clinical site, the hMSCs will be stored under controlled conditions in liquid 
nitrogen tanks in the Clinical Bone Marrow Transplant Facility (or equivalent).  
Just prior to use, the cellular product will be thawed and  diluted with 1:1 mix of 5% human serum 
albumin and 10% Dextran 40 for intravenous administration in the Clinical Bone Marrow 
Transplant Facility (or equivalent) by trained facility technicians. 
→ The hMSCs administration must be completed within 4 hours of the start of the thaw 
procedure. The hMSCs will be administered over 60-80 minutes.   
→ Each Clinical Bone Marrow Transplant Facility (or equivalent) will develop their own site-
specific Standard Operating Procedure in support of this study protocol. The laboratory-specific 
standard operating procedure at each site will be reviewed by the Clinical Coordinating Center 
including the affiliated Clinical Bone Marrow Transplant Facility prior to initiating the clinical 
trial at that site. To assist with this process, the Clinical Coordinating Center will share the SOP 
developed by the UCSF Clinical Bone Marrow Transplant Facility (see below). 
 
 
 

Michael A Matthay, MD 
 
Page 89 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
 
Protocol Title: 
(Check 
Protocol) 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical Trial of 
Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the Treatment of Acute 
Respiratory Distress Syndrome 
Protocol 
Overview: 
Protocol: UCSF-hMSC-ARDS-P1P2-14 
PI:  Matthay, Michael Michael.Matthay@ucsf.edu 
MD: Liu, Kathleen Dori Kathleen.Liu@ucsf.edu 
CRC: Kimberly Yee 415-502-1596 | Email: kimberly.yee2@ucsf.edu 
Research Analyst: Hanjing Zhuo (415) 502-7434 Hanjing.Zhuo@ucsf.edu 
QC Testing: Jenny Fang Xiaohui.Fang@ucsf.edu 
 
Randomized, double-blind, placebo-controlled, multi-center.  
Subjects with ARDS after trauma or not traumatic cases of ARDS will receive a single infusion of hMSCs 
or placebo. A Phase 2b trial with this cell-based therapy will be used to test the safety and efficacy based 
on potential treatment of the major abnormalities that underlie ARDS after trauma, including oxygenation, 
carbon dioxide excretion, degree of pulmonary edema on the chest radiograph, systemic organ 
dysfunction, secondary infections, and altered lung endothelial and epithelial permeability and 
inflammation.  
Manufacturing 
Facility: 
List names, 
addresses, & 
responsibilities 
Minnesota Cell Therapy Clinical Laboratory - contract manufacturer, manufacture, QC testing, Storage, 
release, & distribution 
UCSF Medical Center- IND holder, study oversight, coordinating center, eligibility determination  
BMTL- Storage, randomization, distribution, thawing/pooling, QC testing and Release for Infusion 
M Health Fairview | Cell Therapy Clinical Laboratory 
MCT Facility | Dock B  
Contact Information: 
Molecular & Cellular Therapeutics 
1900 Fitch Avenue 
Saint Paul, MN 55108 
Contacts:  
Main lab - (612) 625-8204 
Darin Sumstad (sumst003@umn.edu) 
Diane Kadidlo (kadid003@umn.edu) 
David McKenna, MD (mcken020@umn.edu; pager 612-
899-7375) 
UCSF Medical Center 
BMT Laboratory 
505 Parnassus Avenue, M547 
San Francisco, CA 94143Contact: 
Lizette.caballero@ucsf.edu, ph. 415-353-
1351 
Melanie.Mcmillan@ucsf.edu ph. 415-353-
1789 
Materials 
Needed 
Water Bath                                                    Laminar Flow Hood 
Sterile Docking Device                                  Wafers 
Heat Sealer                                                   Scale 
Plasma-Lyte A                                              Trypan Blue 
Sterile Water                                                 Alcohol Pads                                         
Aerobic culture bottle                                    Anaerobic culture bottle 
Angel Wings Blood Transfer Set                   Needle free spike 
300ml Transfer Pack                                     Charter Medical 6 Lead Harness Set                                        
Sterile Zip-Lock Bag                                      Pipette tips 
Sterile syringes -   3ml, 5ml, 10ml, 60ml       Sterile towel 
Hemostat                                                       Plastic BagSyringe  
Tip Cap Red                                                  Transport cooler 
Frozen Gel Packs                                         Thermometer 
Infusion Filter                                                0.9% Sodium Chloride 
Amber Bag and IV Tubing Cover                  5% Human Serum Albumin 
Hemacytometer                                             Dextran 40 
Pipette                                                           400ml Transfer Pack 
Microscope      
CLINICAL STUDY- PROTOCOL SPECIFIC SOP (PSS) 
 
 

Michael A Matthay, MD 
 
Page 90 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
Section A: hMSC Product Receipt 
A.1 
 
When receiving hMSC products, follow Instruction located on the hMSC Receipt  Instructions 
document located in the Tree. HPCT Adult Lab >>Immuno>>hMSC ARDS Trauma >>Current 
Forms >>hMSC Receipt Instrutions  
 
Attention Lab Staff: Keep doctors, nurses, and research personnel blind at all times. 
Section B: Preparation and Randomization on the Day of Infusion 
B.1 
Assign a UCSF DIN.  
□ Call PIC to assign a DIN number on the Apheresis Collection Number Accountability Log  
□ Place the sticker on page one of this PSS. 
 
B.2 
Fax order received: ARDS MSC STUDY ORDERS: Preparation and Randomization for cell 
infusion. This order will include all the information needed in the Randomization Portal (A second 
order must be received before thawing cells) 
Note: There is a time window of about 45 minutes unitl the next order is faxed. 
 
B.3 
 Randomization Procedure: 
1. To access the electronic randomization system, go to www.studydata.net. 
2. Login and select “statrand” from the dropdown box. 
3. From the Main Menu dropdown select “New Randomization”. 
4. To randomize, enter all the data in the green section and press the Save button. 
5. Note the Randomization time below. 
6. Print a copy of the randomization page. 
7. After you have pressed Save, exit this page by returning to the Randomization List form the 
Main Menu 
                   
                  Randomized to:  INTERVENTION (CELLS)       CONTROL (PLACEBO) 
 
                  Randomization Date/Time: ________________________ 
 
If patient is randomized to cell dose proceed to step B.4.  
 
If patient is randomized to Placebo proceed to B.7 
 
B.4 
Prepare water bath and biosafety hood for thawing and reconstitution of product. Refer to: 
SOP-0906 Cellular Therapy Thawing Procedure 
SOP-0959 Laminar Flow Hood Operation and Maintenance Procedure     
 
 
 
 N/A 
PLACEBO 
B.5 
Determine the number of cells to thaw.  
 Use the Dose Table located in the Study Binder. 
 Use the Height/Gender provided on the order (see B.1). 
 
Minimum number of cells to thaw based on Dose Table:_________________ x106 
 
 
 
 
 N/A 
PLACEBO 
 
 
 
 
 

Michael A Matthay, MD 
 
Page 91 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech 
Initials 
/Date  
B.6 
Select bags from current inventory to reach minimum number of cells to thaw in B.5.  
□ Look for hMSC products by using the hMSC/ARDS Investigational Drug Accountability 
Log FORMS-0585  
□ Waste as few cells as possible. 
□ Select hMSC products from a single donor by using bags with the same UMMC DIN 
TABLE 1 
 
Product Code 
UMMC DIN 
Include flag character 
 
Viable Cell 
Dose (X106) 
Bag 
Volume 
(ml) 
EU Dose 
 
(from CoA)1 
Tank Location 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TOTAL 
(A) 
                
(B) 
(2) 
 
1Endotoxin Dose (EU) documented on the COA based on viable cell dose frozen                    
 
2Total EU_________ ÷ PBW _____________(kg) = __________EU/kg 
  
3Acceptable limit = <5EU/kg (If the result is >5.0 EU/Kg then select another combination of MSC 
 
Calculated 
by/Date: 
 
__________ 
 
 
 
Verified 
by/Date: 
 
__________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
 
B.7 
Prepare a 1-10°C credo cooler for product transport. Refer to section that describes how to set up 
credo in SOP-0929 “Transport and Shipping of Cellular Therapy Products”. This PSS will describe 
the documents necessary for transport in this clinical trial. 
 
B.8 
Prepare an Infusion Bag 
□ Label an empty 400mL TP with a partial label: Patient name, MRN, DIN 
□ Label as “Infusion Bag” 
□ Log all reagents and supplies on a Reagents and Supplies Sheet (FORMS-0080) 
 
B.9 
Prepare the Reconstitution Media Bag: 
□ 
Label a 400mL transfer pack (TP) “Reconstitution Media”. 
□ 
Seal and remove excess tubing. 
□ 
Add 160 mL of Dextran 40. 
□ 
Add 160 mL of 5% Human serum albumin (HSA).  
□ 
Aseptically spike one port with a needle free spike. 
□ 
Keep refrigerated.  
Note: If 5% Human Serum Albumin is not available: mix 200 ml 0.9% Saline + 50 ml 25% 
Human Serum Albumin in a 300mL transfer pack labeled “5% Human Serum Albumin” + Date. 
Seal and remove excess tubing. 
 
 
 

Michael A Matthay, MD 
 
Page 92 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
B.10 
If more than one product bags is needed prepare a Pooling 6 lead harness set: 
  Close all tubing clamps from spikes in the pooling harness. 
  
□ 
Spike the “Infusion Bag” from step B.8 into the pooling harness. 
□ 
Heat seal and remove any excess tubing lines from the harness.  
o 
For example. If three hMSC bags will be thawed and pooled, heat seal and 
remove 3 tubing lines. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N/A 
 
 N/A 
 PLACEBO 

Michael A Matthay, MD 
 
Page 93 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
Section C: Confirmation of Subject Stability  on the Day of Infusion 
C.1 
Patient has met the clinical stability criteria, confirmation to thaw cells received VIA fax: ARDS 
MSC STUDY ORDERS: Confirmation of subject stability (Start thaw of cells within 15 minutes of 
receipt of this order). 
 
             Time notification received:______________________ 
 
Section D: Thaw and Reconstitution of Product 
D.1 
 
If PLACEBO proceed to Step D.7 
 
THAW PROCEDURE: 
Remove the hMSCs from inventory and thaw up to 2 bags at a time if needed. Refer to SOP-0906 
“Cellular Therapy Thawing Procedure” 
 Inspect the bags using FORMS-0120 “Frozen Bag Inspection Prior to Release” 
 Remove bag(s) from cassette and place into zip lock bag.  
 If the product bag has leaks or cracks, do not use it and replace with new bag. 
 Immerse the sealed zip bag containing the frozen hMSCs in the water bath, gently rocking the 
bag to mix the suspension during the thawing.  
 
 
 
 
 N/A 
PLACEBO 
D.2 
DOCUMENT: 
 
Water Bath Temp:________________ (370C +/- 30C) 
 
Thaw Start Time (first bag):_____________ (Start timer for 30min. Perform viability between 30 
min to 1 hours post start of thaw) 
 
Thaw Finish Time (last bag):________________ 
 
Thaw Product Expiration Date/Time:_________________ (4 hours post thaw start time first bag) 
 
 
Documented 
by/Date: 
____________ 
 
Checked 
by/Date: 
____________ 
 
 
 
 N/A 
PLACEBO 
 
 

Michael A Matthay, MD 
 
Page 94 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
D.3 
*If multiple hMSC bags were thawed, mark this section as N/A and proceed to Step D.4 
 
RECONSTITUTION PROCEDURE FOR 1 BAG OF hMSC: 
1) Aseptically transfer the thawed bag into the hood.  
□ 
Remove the bag from the zip bag. 
□ 
Spray bag with 70% Isopropanol 
2) Aseptically spike the thawed hMSC bag with a needle free spike. 
3) Aseptically spike the empty “Infusion Bag” bag with a needle free spike. 
4) Using a sterile syringe, draw the hMSC product out of the thawed bag, note the volume, and 
add the product to the “Infusion Bag”. 
5) Using a sterile syringe add reconstitution media equal to the amount of hMSC in the “Infusion 
Bag”. Refer to volume (B) from step B.6. 
_____________mL + ________________________mL =   ___________mL 
Product Volume(B)         Reconstitution Media to add      Final Volume (C) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
D.4 
*If one hMSC bag was thawed, mark this section as N/A and proceed to Step D.3 
 
RECONSTITUTION PROCEDURE FOR >1 BAGS OF hMSC: 
 
1) Aseptically transfer the thawed bags into the hood.  
□ 
Remove the bags from the zip bag. 
□ 
Spray bags with 70% Isopropanol 
 
2) Connect thawed hMSC bags to the pooling harness. 
□ 
Ensure the clamps on the pooling harness are closed. 
□ 
Spike the hMSC bags with the spikes on the harness. 
 
3) Insert a needle free spike into the other port on all of the thawed hMSC bags. 
 
4) Open the clamps and transfer the hMSC product into the empty 400mL “Infusion Bag”. Close 
the all clamps. 
 
5) Using a sterile syringe add reconstitution media equal to the amount of hMSC in the empty 
hMSC bags. Each bag may have different volumes. Refer to volume (B) from step B.6. 
 
6) Gently swirl the hMSC bags with the reconstitution media. Open the clamps and allow the 
reconstitution media to transfer into the “Infusion Bag” with the hMSC product. Use air to facilitate 
the transfer if necessary. Close the clamps. 
 
7) Heat seal and disconnect pooling harness from bag. Leave about 4inches of tubing on the bag. 
 
____________mL + ____________________ mL =   ___________ mL   
Product Volume (B)         Reconstitution Media added               Final Volume (C) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
 
 

Michael A Matthay, MD 
 
Page 95 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
D.5 
Mix gently and allow the cells to equilibrate for 5 minutes. 
Time End of Equilibration: _________________ 
 
 
 N/A 
PLACEBO 
D.6 
 
While cells are in equilibration weigh the product bag to determine the final product volume.  
________________g    -     _________________g    =     _______________mL 
Weight of product bag (g)                       Weight of transfer pack (g)                         Final Product volume* (Q) 
*Note: g = mL 
 
Calculate the volume of reconstitution media needed to  achieve a final volume of 300mL. 
 
300mL         -      ________________________ mL  = ________________________mL 
                           Final Product volume (Q)                 Reconstitution Media to add (D) 
 N/A 
PLACEBO 
D.7 
 
Cell product - After equilibration, bring volume up to 300mL.  
□ 
Add reconstitution media volume (D) to the “Infusion Bag” via needle free spike. Mix gently. 
□ 
Mix gently. 
□ 
This is the Final Invesgtigational Product Bag. 
 
Placebo:  
□ 
300mL of reconstitution media is the Final Investigational Product Bag 
□ 
Remove 20mL of reconstitution media for QC testing 
o 
Use a sterile syringe and syringe tip cap 
o 
Label with Study ID and “QC sample” 
□ 
Re-label transfer pack as “Infusion Bag” 
□ 
Go to step E.1 
 
 
 
 
 

Michael A Matthay, MD 
 
Page 96 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
D.8 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Remove QC sample and bring final infusion volume to 300mL: 
1. Mix bag well with gentle swirls.  
2. Using an appropriate size syringe, remove the QC sample volume (N).  
3. Cover syringe with a syringe tip cap. 
4. Re-suspend the Final Investigational Product to 300mL by adding reconstitution media. 
Refer to volume (O). 
TABLE 2 
Calculate the Volume of cells to infuse and for QC 
% Cells to infuse = 
 
__________________________  ÷   _________________________   * 100 
Assigned dose to infuse x106 (Z)         Total cell dose thawed x106  (A)  
(F) 
Volume of cells to infuse =  
 
300 mL *  ____________ 
                % to infuse (F) 
   
(G) 
Volume for QC =  
 
300 mL –  _____________________ 
                 Volume (mL) to infuse (G)                   Note: Minimum of 8mL needed             
   
(N) 
Reconstitution media volume needed to re-suspend final product =   
 
300 mL -  _____________________  
                Volume (mL) to infuse (G)  
(O) 
 
 
Calculated 
by/Date: 
 
____________ 
 
 
 
Verified 
by/Date: 
 
____________ 
 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
 
 
Section E: Labeling Product  
E.1 
Prepare Final Label. Refer to SOP-0887 “Labeling Procedure used in the BMT Laboratory.” Print 
two labels with the same information. One to be affixed directly to the cell product/placebo bag 
and the second to be affix outside the amber bag cover: 
 
Use the Product Code S2511. Standard Label. 
 Scan final product DIN (assigned by UCSF) 
 Blood Type: Unknown 
 Donation Type: For use by intended recipient(s) only 
 Donor Type: Leave blank 
 Donor info: Leave blank 
 Recipient info: Name. MRN, DOB 
 Collection center: Leave blank  
 Processing Facility: BMT Lab 
 Collection date/time: handwrite N/A  
 Expiration date/time: 4 hours post start of thaw or For Placebo: see E.2 
 Volume: 300 ml 
 
 
 

Michael A Matthay, MD 
 
Page 97 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
E.2 
Placebo: Generate a “fake” expiration Date/Time for Placebo to keep the study blinded. 
 Assign an expiration using the receipt time of the “Confirmation of Subject Stability Order”. 
 Add 10-30 minutes (choose at random) to the receipt time and then add 4 hours to 
calculate the expiration time. 
 
Calculation: __________ + __________+ 4 hours = _____________ 
Receipt time     (10-30min)                       Expiration time 
 N/A CELLS 
E.3 
 Obtain a check of the two labels by a second trained staff. 
 Apply the Product Label to the Final Investigational Product Bag. 
 
Labeled 
by/Date: 
 
____________ 
 
Verified 
by/Date: 
 
Section F: Preparing Infusion Filter and Amber Plastic Covering 
F.1 
Cover Y-type Infusion Set with amber plastic tubing.  
□ 
Leave access to the 2 spikes. 
□ 
Tape the end that will be inserted to the infusion line to the amber cover. This will 
prevent the amber cover from falling off. Ensure the infusion line cap can be easily 
removed. 
□ 
See Figure 1 below. 
FIGURE 1 
 
 
 
 
 

Michael A Matthay, MD 
 
Page 98 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
/Date  
F.2 
 
Attach Y-type Infusion Set to the saline bag using aseptic technique. 
□ 
Close all of the clamps 
□ 
Spike the saline bag with one of the infusion filter spikes 
 
 Prime the Y-type Infusion Set:   
 Close all clamps.  
 Insert one spike of the Y-type infusion set into the 250 mL saline bag. Open the clamp. 
 Squeeze and release to allow solution to fill filter chamber half way. Leave room so nurse 
can count drips. 
  Open the regulating clamp to prime remainder of the tubing. Purge remaining air in the 
tubing. There should not be any air bubbles left in the tubing.   
  Close the clamp close to the saline bag.  
 
Attach the Y-type Infusion Set to the Final Investigational Product Bag 
 Close all clamps. 
 Insert the other spike of the Y-type infusion set into the Final Investigational Product Bag. 
 Ensure all clamps are closed. 
 
 
F.3 
Cover the product bag using the amber plastic cover. 
 Tape the bottom of the amber plastic cover to the amber tubing cover. 
 Make sure the bag content is not visible. Refer to FIGURE 2. 
 Ensure access to the roller clamp on the saline line is available. 
 Clamp the loop at the top of the transfer pack with a hemostat to give the nurse easy access 
 Affix duplicate of the cell dose product/placebo label outside of the amber plastic cover. 
FIGURE 2 
 
 
 

Michael A Matthay, MD 
 
Page 99 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
Section G: Packing final product for transport at 1-10°C and Release for Infusion 
G.1 
Prepare final product for transport: 
 Place the final product/placebo bag into a biohazard bag. Then place into the prepared Credo 
cooler.Refer to  SOP-0929 Transport and Shipping of Cellular Therapy Products. 
 Place a thermometer in the cooler. Ensure the thermometer probe is in the pocket with the 
product. 
 Place a Circular of Information for the use of 3rd party mesenchymal stromal cells inside a plastic 
bag and place inside cooler. Copies are in the study binder.  
 
 
G.2 
Fill out Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells Infusion 
Form with the following information: 
 
 Recipient Name, MR#, DOB and Study ID 
 Patient’s Weight = Predicted Body Weight 
 Product Identification = DIN 
 Randomization Date/Time 
 Product Expiration Date/Time 
 Signatures: Reviewed by and Verified by 
 Signatures: Removed from lab by and Verified by  
 Insert this form and circular of information inside a plastic bag and place inside cooler. 
 
 
G.3 
                                             FINAL RELEASE 
Manufacturer Final Certificate of Analysis for Bone Marrow-Derived Mesenchymal Stromal Cells 
filed? 
  Yes     No  
 
 
 
Product receipt and storage without incident?        
  Yes          No 
 
Released by:_____________________________  
Date:__________________________                    Time Released: ___________________ 
NOTE: Release product if the answer to all of the questions is YES and PASS. If product 
does not meet release criteria, approval as urgent medical need from Medical Director 
is required. 
TABLE 3 
Cell Dose 
Product 
assessment 
Specification 
Results 
Pass/Fail 
Endotoxin 
< 5.0 EU/kg 
EU/kg3 
 Pass     Fail 
Single Donor 
Used 
Single Donor 
Used 
 Yes     No 
 Pass     Fail 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
G.4 
SF General (ZSFGH) Patients ONLY: 
 
Call AM-TRAN 1-877-243-8733 and schedule STAT pick-up going to San Francisco General. 
 
 N/A 
 
 

Michael A Matthay, MD 
 
Page 100 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
G.5 
UCSF Parnassus Heights Patients ONLY: 
 
Deliver cells to bedside nurse or doctor. 
 N/A 
G.6 
Document product issue using FORMS-0124 “Issue Log”.  
 
Time Released to Courier:_______________  □N/A if transported by BMT Lab 
 
DO NOT TAKE THIS PSS TO ICU 
 Section H: Quality Control (QC) Testing  
H.1 
Use QC sample (from step D.7 or D.8) to inoculate sterility cultures.  
 Use technique described in SOP-0912 “Sterility Testing for Cellular Therapy Products and 
management of Positive Cultures”.  
 Label bottles with: DIN, Date, hMSC Clinical Trial and Tech’s initials. 
 
Aerobic & Anaerobic sterility testing Sent on:___________________ by:______________ 
 
 
 
H.2 
Sterility Results: 
 
 Positive    Notified to:______________ Date/Time:________________ 
 
 Negative 
Sterility Result 
review 
by/date:  
 
H.3 
Using QC sample (from step D.8) perform:  
  WBC count via hemocytometer 
  Trypan Blue Viability Testing: Refer to SOP-0935 “Trypan Blue Viability Procedure” 
  Time Viability was Done: _______________________ 
  Calculations using memacytomer: 
 
 
 
Viable Cell Count 
Total Cell Count 
(Viable + Non-Viable) 
Side 1 
 
 
 
Side 2 
 
 
 
TOTAL COUNT 
 
(H) 
                                                  (I) 
 
                            ___________ ÷ __________ X 100 = _________________% 
                                    (H)                     (I)                         % Cell Viability (J) 
 
If % Cell Viability is <70 notify bmtlab@ucsf.edu  and Kathleen.Liu@ucsf.edu within 24 
hours. 
 
 
 
 
 
Calculated 
by/Date: 
 
____________ 
 
 
 
Verified 
by/Date: 
 
____________ 
 
 
 
 
 
 
 N/A 
PLACEBO 
 
 

Michael A Matthay, MD 
 
Page 101 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
H.4 
Calculate TNC count and recovery %: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If % Viable Cells Recovery  is <70 notify bmtlab@ucsf.edu  and Kathleen.Liu@ucsf.edu  
within 24 hours. 
 
TABLE 4 
QC SAMPLE: Total Cell Count Thawed/Recovered 
Patient Name: 
 
 
Study ID: 
DIN: 
Product 
Code(s) 
 
Total Cell Count (Viable + Non-Viable)  
(I) 
Total Cells/mL= (106)=(I) ÷ (# of large squares counted) * 2 
(TB Dilution factor) * (any other dilution) * 1 X104 
  
(K) 
Total Cells thawed/recovered=(x108)=  (K) * 300mL              
  
(L) 
Total Viable Cells = (108)=(L) * (J) 
  
(M) 
Viable Cells Recovery (%) = (M) / (A) x 100 
 
 
 
 
 
 
 
Calculated 
by/Date: 
 
____________
_ 
 
 
 
Verified by/Da
 
____________
_ 
 
 
 
 
 
 N/A PLACEB
 
 
 
Calculated 
by/Date: 
 
____________ 
 
 
 
Verified 
by/Date: 
 
____________ 
 
 
 
 
 
 
 
 N/A 
PLACEBO 
 Section I: Clerical Documentation 
I.1 
 
The remaining volume from the QC sample will be given to the clinical research team for testing. 
Contact Jenny Fang by text (415) 316-9895 and email Xiaohui.Fang@ucsf.edu to schedule a 
pickup. 
 
 Place a syringe tip cap on the syringe and store at 2-8°C. 
 Make a copy of TABLE 4 and send with QC sample. 
 
 
I.2 
Order IECTW to the ZZ account using Sunquest: 
 
Accession # _________________________ 
 
I.3 
Infuse cells in the BMT Inventory Database 
□ 
Using the Tank Summary screen, select a bag that was thawed by its location in the 
database. 
□ 
Then select Discard/Transfuse Collection from the drop down 
□ 
Select “discard” 
□ 
In the Disposition box, enter the patients Name and MRN 
□ 
Select the check boxes that correlate with the bags that were infused to the patient 
□ 
Submit Edits 
□ 
Print the screen and file in the patients records 
 N/A 
PLACEBO 
 
 

Michael A Matthay, MD 
 
Page 102 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
 
 Appendix E: Study Product Preparation Protocol 
Date: April 19, 2022  
 
Confidential  
 
PSS-0022 (02-24-2020) 
 
 
SOP/ 
Step 
# 
STAT: A Phase 2b, Randomized, Double-blind, Placebo-controlled, Multi-center Clinical 
Trial of Allogeneic Bone Marrow-Derived Human Mesenchymal Stromal Cells for the 
Treatment of Acute Respiratory Distress Syndrome 
Tech Initials 
I.4 
 
Update the hMSC/ARDS Investigation Drug Accoutabilty Log FORMS-0585 
□ 
Complete the Patient Information section that correlates to the bags that were infused. 
 
 N/A 
PLACEBO 
Approval/Review of Protocol Summary 
All processes required by the protocol that differ from BMT Lab SOPs are listed above. The descriptions of the protocol 
and processes have been reviewed and approved by the BMT Lab Senior Supervisor and Director. They are considered 
acceptable protocol specific processes and do NOT require documentation or handling as a Deviation. 
PSS 
Summary 
Reviewed/ 
Approved By: 
 
_____________________________________                      ________________ 
   BMT Lab Supervisor/Designee Signature                                         Date 
 
_____________________________________                      ________________ 
               Andrew Leavitt, MD                                                               Date 
           BMT Lab Medical Director 

Michael A Matthay, MD 
 
Page 103 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                       Appendix F: Symptom Management During Infusion Guidelines 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix F: Guidelines for Symptom Management During Study Product 
Infusion 
 
Adverse Reactions 
Signs and Symptoms 
Management 
Hypersensitivity 
 
Hypersensitivity to 
allogeneic plasma proteins. 
 Dyspnea 
 Hypotension 
 Fever 
 Urticaria 
 Tachycardia 
 Hypoxemia 
 Pause MSC infusion 
 Check vital signs and O2 saturation 
 Hydrocortisone 1mg/kg IV 
 If still symptomatic after 
hydrocortisone, then 
diphenhydramine 25-50 mg IV 
 Increase supplemental O2 if O2 
saturation is <93% and/or dyspnea 
 Resume MSC infusion after 
reasonable resolution of signs and 
symptoms. 
Leukoagglutination 
 
Because some leukocytes 
may be present in the MSC 
preparation (although MSC 
purity will typically be 
>95%), leukoagglutination 
symptoms may occur. 
 Cough 
 “Tickle in throat” 
 Dyspnea 
 Hypoxemia 
 Chest pressure 
 Pause MSC infusion. 
 Check vital signs and O2 saturation 
 Increase supplemental O2 if O2 
saturation is <93% and/or dyspnea. 
 Resume MSC infusion after 
reasonable resolution of signs and 
symptoms. 
Volume Overload 
 
The volume of the MSC 
will be set at 300 ml total. 
Pulmonary edema may 
occur in this population. 
This can occur with or 
without concurrent cardiac 
dysfunction. 
 Dyspnea 
 Hypoxemia 
 Frothy, clear or pink 
sputum 
 Tachycardia 
 Lack of fever 
 Distended neck veins 
 Pause MSC infusion. 
 Check vital signs and O2 saturation. 
 Increase supplemental O2 if O2 
saturation is <93% and/or patient is 
dyspneic. 
 Furosemide (≥ 10 mg IV) 
 Resume MSC infusion after 
reasonable reduction of signs and 
symptoms. 
Transfusion 
Incompatibility 
 
The infusion of allogeneic 
MSC can be incompatible 
based on the presence of 
allo-antibodies in the donor 
and/or recipient serum. 
Transfusion incompatibility 
 Fever 
 Hypotension 
 Dyspnea 
 Low back pain 
 Dark urine 
 Drop in blood 
hemoglobin 
 Stop MSC infusion. 
 Check vital signs and O2 saturation. 
 IV fluid resuscitation immediately if 
hypotensive. 
 Forced diuresis and urinary 
alkalinization with IV D5W + 2 
amps/l sodium bicarbonate. 

Michael A Matthay, MD 
 
Page 104 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                       Appendix F: Symptom Management During Infusion Guidelines 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Adverse Reactions 
Signs and Symptoms 
Management 
reactions are usually 
symptomatic and 
occasionally life-
threatening. 
 
 Disseminated-
intravascular 
coagulation 
 Send recipient blood for a 
“transfusion reaction analysis” to the 
blood bank. 
 Consider mannitol 25 gm IV if 
suspicion of a transfusion ABO 
incompatibility reaction is high. 
 Consider blood cultures (and culture 
of the MSC product) followed by 
broad spectrum anti-bacterial 
antibiotics. 
 The attending BMT physician will 
be informed of the episode and will 
decide whether to restart the MSC 
infusion or abort the MSC infusion. 
 If the MSC infusion is aborted, the 
balance of the MSC product will be 
quarantined in the BMT laboratory 
refrigerator for possible additional 
analysis. 
Reactions to 
Cryopreservatives (e.g. 
DMSO) 
 
DMSO is added to all MSC 
products being 
cryopreserved to protect 
the MSC from hypothermal 
damage.   
 Metallic/garlic taste 
 Nausea/emesis 
 Flushing of face 
 Intestinal cramps 
 Acute hypertension 
 Bradycardia (first, 
second, or third degree 
atrioventricular block 
on electrocardiogram) 
 Pause MSC infusion. 
 Check vital signs and O2 saturation. 
 Administer additional anti-emetics if 
appropriate. 
 If bradycardia, perform an 
electrocardiogram. If patient is 
asymptomatic with first or second 
degree atrio-ventricular block on 
EKG, resume MSC infusion.  If 
symptomatic, stop infusion and 
administer atropine 0.5 -1mg.  
 If bradycardia is present and 
electrocardiogram shows third 
degree atrio-ventricular block, 
consider placement of a temporary 
pacemaker.  Consult Cardiology. 
 Infuse remainder of previously non-
thawed MSC after reasonable 
resolution of the signs and 
symptoms of an acute DMSO 
reaction and acquisition of 
hemodynamic stability. 
Infection/Endotoxemia 
 Hypotension 
 Stop the MSC infusion 

Michael A Matthay, MD 
 
Page 105 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                       Appendix F: Symptom Management During Infusion Guidelines 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Adverse Reactions 
Signs and Symptoms 
Management 
 
The infusion of infected 
MSC products is usually 
fatal.  A rapid response to 
the acute adverse 
signs/symptoms of the 
infusion of the infected 
MSC may be life-saving. 
 Fever 
 Oliguria/anuria 
 Tachycardia 
 Dyspnea/ hypoxemia 
 Disseminated 
intravascular 
coagulation 
 Signs/symptoms 
within “minutes” of 
MSC infusion 
 Culture the recipient’s blood and the 
MSC product. 
 Immediately start broad spectrum 
antibiotics. The usual default should 
be vancomycin, meropenem or 
imipenim, and tobramycin. 
 Use hemodynamic support as 
appropriate (IV fluids +/- 
vasopressors). 
 Notify the BMT laboratory clinical 
scientists of the suspicion of an 
infected MSC product. 

Michael A Matthay, MD 
 
Page 106 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                                       Appendix G: Mini-Bronchoalveolar Lavage Procedure 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix G.  Mini-Bronchoalveolar Lavage Procedure 
 
The mini-BAL procedure involves blind specimen sampling from distal airspaces of patients with 
endotracheal or tracheal intubation. Specimens are obtained with the CombicathTM (Plastimed) 
catheter that is commonly used for the diagnosis of ventilator-associated pneumonia. The catheter 
is introduced from its protective sheath into the endotracheal or tracheal tube through a standard 
bronchoscopy adapter, and then gently advanced into the lungs until it becomes wedged in a distal 
airway. The catheter then is withdrawn approximately 3 cm to allow room for the inner catheter to 
be advanced into the distal airway. This is accomplished by removing the white protective spacer 
and gently advancing the inner catheter to its full length and securing it to the outside catheter by 
slightly twisting it into the outside catheter. Then, two 30-mL syringes containing 20 mL normal 
saline and a 5mL air bolus are injected rapidly into the lungs. Once the air bolus clears the second 
syringe, gentle aspiration is applied to the syringe for approximately 10 seconds to retrieve as 
much of the instilled fluid as possible (usually 5-10 ml). When completed, the catheter is removed 
from the endotracheal tube. The recovered aspirated samples are then emptied into a standard 
screw-top specimen container used for BAL samples. If the clinical condition warrants it, 1 ml can 
be deposited into a sterile container to be sent to the microbiology laboratory for culture. 
 
Note: The mini- BAL procedure can be done with either one or two clinicians but it is easier to do 
(and typically more effective) when two clinicians are involved: one to advance, wedge, and 
manipulate the Combicath and the other to instill and aspirate the lavage. The patient should be 
pre-oxygenated on an FiO2 of 1.0 for 10 minutes prior to the procedure and routine endotracheal 
suctioning should be done first to remove sputum from the airways.  
 
After the mini- BAL, routine suction should be repeated to remove any excess BAL fluid that may 
be present in the airways. Assess patient’s oxygenation and ventilatory status and return patient to 
their baseline FiO2 when clinically indicated, usually within 5-10 minutes. The ventilator circuit 
should be returned to its original configuration by replacing the bronchoscopy swivel adapter with 
a clean adapter that was originally present in the circuit. 
 
The mini-BAL should NOT be performed under the following circumstances: 
1. FiO2 greater than 0.70 AND PEEP greater than 14 cm H2O 
2. Hemodynamic instability (despite fluid resuscitation/pressor support) 
3. Open external ventricular device or intracranial pressure greater than 15mmHg or unstable 
4. Most recent INR greater than 2.0 or PTT > 40 
5. Most recent Platelets less than 50x103/mm3 (within 36 hours of BAL) 
 
Since this is a study procedure, any associated adverse event should be reported as a study related 
event. Transient hypoxemia is considered an expected event for ARDS, but prolonged or severe 
hypoxemia following mini-BAL should be reported as an adverse event.

Michael A Matthay, MD 
 
Page 107 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                      Appendix H: Phase 2b Investigational Product Infusion Protocol 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix H. Phase 2b Investigational Product Infusion Protocol 
 
BACKGROUND:  Human mesenchymal stromal cells (hMSCs) are being tested in a placebo-
controlled trial as a novel therapy for the acute respiratory distress syndrome. Several factors are 
essential to the safe administration of hMSCs. They include accurate identification of the donor, 
the recipient; the product; and the cell dose. Therapies that can damage hMSCs include 
hemodialysis. In addition, recognition and management of the potential side effects associated with 
hMSC infusion are also important.  
  
Each study site will develop its own site-specific Standard Operating Procedure in support of this 
protocol. The site-specific standard operating procedure will be reviewed by the Coordinating 
Center prior to initiating the clinical trial at that site. 
 
1. 
 OBJECTIVES 
1.1 To ensure the safe and effective infusion of either clinical grade allogeneic bone marrow-
derived human mesenchymal stromal cells (hMSCs) or the placebo. 
1.2 To ensure the administration of the full hMSC dose (10 million cells/kg predicted body 
weight based on cell viability at the time of initial cell preparation at UMMC).  
1.3 To blind investigators to the product being infused (hMSCs or placebo). 
 
2. 
MATERIALS/EQUIPMENT  
2.1 250mL Normal Saline bag (delivered by BMT lab) 
2.2 Standard blood filter tubing Y set (170-260 micron filter): At UCSF Medical Center, this is 
ICU Medical B9211 (delivered by BMT lab) 
2.3 Opaque bag to blind investigational product bag (delivered by BMT lab) 
2.4 Semi-opaque tubing sleeve to cover tubing (delivered by BMT lab) 
2.5 Gloves (in ICU) 
2.6 One 3-way luer stopcock (in ICU) 
2.7 10mL luer-lock syringe (in ICU) 
2.8 Pressure bag (in ICU) – can be used for COVID-19 patients who have their IV poles outside 
the room 
 
3. 
POLICIES 
3.1 A study physician from the study must initiate and be present for the entire duration of the 
investigational product infusion. 
3.2 A study physician must write an order to administer the investigational product. 
3.3 For subjects randomized to receive hMSCs, the investigational product infusion must be 
completed within 4 hours of the start of the cell thaw protocol. To keep study investigators 
blinded, the investigational product expiration time will be documented on the 
investigational product bag by the bone marrow transplant (BMT) laboratory staff. This time 
will be 4 hours to the minute after the start of the cell thaw protocol. Placebo products will 
be assigned a product expiration time by the BMT lab to maintain blinding. Infusion supplies 

Michael A Matthay, MD 
 
Page 108 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                      Appendix H: Phase 2b Investigational Product Infusion Protocol 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
will be picked up from the laboratory by a study personnel or transported to the ICU by BMT 
laboratory staff. Product expiration time will be documented by the BMT lab on the STAT 
Infusion Record and will be reviewed with study personnel. The start and end of the infusion 
will be documented on the STAT Infusion Record.   
3.4 Never discard investigational product. In the event of an adverse reaction terminating the 
infusion, return any un-transfused product to the BMT laboratory immediately. 
- 
Note: For COVID-19 suspected or confirmed positive patients, investigational product 
bags and tubing do not need to be returned to the BMT Lab 
3.5 No prophylactic pre-medications (e.g. acetaminophen or diphenhydramine) will be 
administered prior to the investigational product infusion.  If such medications are ordered 
by the clinical team and given prior to or during the infusion, however, their use does not 
preclude proceeding with the infusion. 
3.6 The following medications should be immediately available at the patient’s bedside during 
the infusion and the post-infusion monitoring period: epinephrine 1 mg for intravenous 
administration, hydrocortisone 100 mg for intravenous administration, and diphenhydramine 
50 mg for intravenous administration. 
3.7 The investigational product can be infused via peripheral or central venous access.  If 
peripheral, the IV should preferably be 18 gauge, but no smaller than 20 gauge. 
3.8 Ideally a separate port or line should be used for the investigational product infusion. The 
infusion should not be “piggy backed” into a medication line. If absolutely necessary, a 
stopcock can be used at the lumen connection to create a separate, dedicated line for the 
investigational product infusion. Avoid administration with dextrose containing solutions; 
Normal saline, Plasmalyte, and Lactated Ringers are acceptable. 
3.9 Dialysis Patients:  Patients receiving intermittent dialysis may be dialyzed prior to the 
investigational product infusion, but should not be dialyzed until 24 hours or more after 
receiving the infusion if possible. Continuous renal replacement therapy will be allowed to 
continue during the hMSC or placebo infusion. 
3.10 Positioning: Patients must remain in the supine or prone position for the duration of the 
infusion and the post-infusion observation period. 
3.11 Apply standard precautions and aseptic technique at all times. 
3.12 Verify patient’s identity per National Patient Safety Goals (two identifiers). (At UCSF 
Medical Center, the Department of Nursing Blood and Blood Components Administration 
Procedure should be followed). 
3.13 Monitor the patient for reaction to the investigational product infusion during administration 
(see Appendix F for potential side effects and symptom management guidelines). 
 
4. PROCEDURE 
4.1 Study Physician to write order for investigational product infusion. This order also confirms 
the date, and time of the investigational product infusion. No investigational product will be 
thawed, processed, or released from the BMT laboratory without this order. (At UCSF 
Medical Center: Fax infusion order to BMT Lab, fax #353-1227.  Confirm infusion time with 
BMT laboratory at 353-1789). 
4.2 Personnel from the BMT lab will set up IV tubing as follows: 250mL normal saline bag 
spiked on to one limb of “Y-set” standard blood filter tubing (170 - 260 micron filter tubing, 

Michael A Matthay, MD 
 
Page 109 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                      Appendix H: Phase 2b Investigational Product Infusion Protocol 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
for example ICU Medical B9211). The BMT lab will saline prime the blood filter tubing 
setup. The IV tubing will be covered with the blinding sleeve. 
4.3 The investigational product will be administered as 300 mL in a 300 mL transfer bag; this 
bag will be covered with an opaque bag to blind investigators to the content. The BMT 
laboratory will label both the transfer bag and the blinding bag with the patient identifiers, 
then spike the investigational product bag onto the saline-primed IV tubing. 
4.4 The Study Physician will: 
 
Confirm that the patient has met criteria to receive the investigational product infusion: 
in addition to meeting inclusion criteria and having no exclusion criteria, the 2 hour 
stable baseline period must have been achieved, and the PaO2/FiO2 ratio on a blood gas 
obtained within 90 minutes of starting the baseline stability period cannot equal or 
exceed 250. If the PaO2/FiO2 ratio is equal or greater than 250, the patient is no longer 
eligible to receive the investigational product. 
 
Follow National Patient Safety Goals to identify the patient (two identifiers).  (At UCSF 
Medical Center: Verify patient identification per Department of Nursing Blood and 
Blood Components Administration Procedure). 
 
Verify that the signed consent is in the patient’s medical record. 
 
Review the infusion order. 
 
BMT lab personnel or a study physician will review the information on the 
investigational product bag with the bedside RN or study physician for the following:   
 
Recipient name/medical record number (MRN) 
 
Recipient date of birth  
 
Product expiration date/time 
 
Product identification number 
 
Product volume 
One person should read the information on the product and a second person should compare it 
with the information on the paperwork and patient identification band. One of these two 
individuals should be a study investigator.  
 
Prior to infusion, the study physician should ensure that the following medications are 
available at the patient’s bedside: 
 
Epinephrine: 1 mg 
 
Hydrocortisone: 100 mg 
 
Benadryl: 50 mg 
4.5 The study physician will be present for the entire infusion procedure: 
 
The investigational product bag will arrive from the BMT lab already spiked and attached to 
the saline-primed tubing, and covered with the semi-opaque sleeve. 
o 
The investigational product can be infused immediately after the product arrives at the 
bedside from the BMT laboratory and all patient checks have been completed. There is 
no need to wait for the bag to come to room temperature. 
 
For COVID-19 patients with the IV pole outside of the patient’s room, the study personnel 
can wrap the investigational product with a pressure bag. 
 
The study physician will attach the primed filter tubing to a three-way stopcock and the 
intravenous line through which the investigational product is to be infused. 

Michael A Matthay, MD 
 
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University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                      Appendix H: Phase 2b Investigational Product Infusion Protocol 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
o 
Do NOT use bifuse tubing. DO NOT INFUSE THROUGH A NEEDLELESS CAP. 
 
The study physician will confirm that all IV connections are secure and that the infusion lines 
from the investigational product bag to the patient are visible but covered with the semi-
opaque sleeve. 
 
Document the start date and time of the investigational product infusion on the STAT 
Infusion Record. 
 
If there is accidental unblinding, contact CCC and the investigator on-call to discuss how to 
proceed. 
4.6 Start the infusion: 
 
At each center, the priming volume of the filter set must be measured and infusion drip rates 
should be calculated  prior to enrollment of the first study patient:  
o 
For example, for ICU Medical B9211, the priming volume is 16.9 mL. The # drops/mL 
for this filter set per the manufacturer is approximately 10. 
o 
The drip chamber should not be primed to “full” since the infusion rate will be set based 
on the number of drops/minute that are used 
o 
The clamps CAN be opened and closed through the blinding tubing. If you are having 
difficulty opening and closing the clamps, however, you can cut a small vertical hole in 
the sleeve to allow direct access to the clamp. 
 
Run the entire volume of investigational product (300 mL) at the same rate over 60 minutes, 
checking the drop rate at the start of the infusion, approximately 5 minutes later, and 
periodically throughout the infusion. These can be visualized through the semi-opaque tubing 
sleeve. The drop rate should be checked by counting the number of drops over 30 seconds 
and calculating the number of drops/minute. 
o 
If using a pressure bag, pump the bag until the target drop rate is reached. 
 
For the ICU Medical B9211filter set: 
o 
The target infusion drop rate is 40 drops/30 seconds for the entire infusion 
o 
Continue checking the drop rate periodically throughout the infusion. If the infusion 
drop rate falls to 20-25 drops/30 seconds, increase the drop rate back to 40 drops/30 
seconds. 
4.7 Do not run normal saline concurrently with the investigational product. 
4.8 When the investigational product bag is empty, proceed to the RINSE AND FLUSH 
PROCEDURES (4.12) to rinse the bag and flush the line.  
4.9 If the investigational product does not infuse easily by gravity or using a pressure bag, you 
may attempt to attach the luer-lock syringe to the three-way stopcock and push the 
investigational product through line slowly (2-5 mL/min) via a syringe. 
4.10 We do not anticipate that clumping should be an issue. However, save original filter set for 
the bone marrow transplant laboratory; they should visually examine the filter set for 
clumping prior to disposal. If clumping is significant and leads to unblinding of the bedside 
investigator or is noted by the BMT laboratory, contact the CCC and the investigator on call 
immediately. 
Note: For COVID-19 suspected or confirmed positive patients, investigational product bags 
and tubing do not need to be returned to the BMT Lab 
4.11 Monitoring:  

Michael A Matthay, MD 
 
Page 111 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                      Appendix H: Phase 2b Investigational Product Infusion Protocol 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
 
Blood pressure, heart rate and oxygen saturation will be continuously monitored for the 
duration of the infusion and documented every 15 minutes during the infusion. 
 
An arterial blood gas will be obtained within 90 minutes prior to beginning the baseline 
stability period and within 15 minutes of the end of the infusion. If the PaO2/FiO2 ratio on 
the blood gas obtained during the baseline stability period is greater than 250, the patient 
should NOT receive the investigational product. 
 
See Appendix F for potential side effects of the infusion. Monitor periodically during the 
infusion for these side effects.  If the patient experiences significant side effects, consider 
pausing or stopping infusion. 
4.12 RINSE AND FLUSH PROCEDURE: Approximately 100 mL of saline total should be 
used to rinse the investigational product bag and flush the line, ensuring that the 
investigational product has been rinsed from the bag and infused through the priming setup.   
 
At the end of the infusion, rinse the investigational product bag with normal saline using this 
protocol. To do this: (1) Clamp the investigational product line to the patient (2) Unclamp 
the saline line and lower the investigational product bag to allow for saline to enter the 
investigational product bag; (3) After a small amount of saline (approximately 20 mL) has 
entered the investigational product bag, reclamp the saline line; (4) Swirl the saline in the 
investigational product bag; (5) Re-hang the investigational product bag, then open the line 
and infuse the saline rinse from the investigational product bag into the patient until the bag 
is empty; (6) Finally, allow 80 mL of saline to run through the filter to flush the remaining 
rinse volume into the patient.  The rinse will include 100 mL used to flush the bag and 
will  be infused over 12-15 minutes: 
 
100 mL * 10 drops/mL = 1000 drops/(80 drops/minute) = 12.5 minutes 
 
The target infusion rate for the rinse and flush is 40 drops/30 seconds (same as the start 
of the infusion) and the infusion should be complete in  12-15 minutes 
o Note: If using a pressure bag, after the initial 20 mL of saline has been infused, the 
next 80 mL of saline needs to be manually pushed with a syringe. 
4.13 Investigational product bags and tubing should be returned to the BMT laboratory 
o Note: For COVID-19 suspected or confirmed positive patients, investigational product 
bags and tubing do not need to be returned to the BMT Lab. 
4.14 Obtain and document vital signs at completion of infusion. 
 
5. 
Documentation: 
5.1 Complete the Infusion Record. The Study Physician must perform patient assessment for any 
adverse events.  A copy of this infusion record should be placed in the patient’s paper medical 
record or scanned into the electronic medical record; a hard copy must also be sent to the 
local BMT lab. 
5.2 The study investigator will confirm with the bedside RN the total volume (investigational 
product and saline wash) used during the infusion procedure so this can be documented in 
the patient’s medical record.  
5.3 Study MD writes an event note documenting the procedure in the electronic medical record, 
including confirmation of the appropriate product and any complications or adverse 
reactions. 

Michael A Matthay, MD 
 
Page 112 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                                                                                     Appendix I: Barotrauma 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix I. Barotrauma 
 
Evidence of barotrauma includes the following: 
 Pneumothorax 
 Bronchopleural fistula 
 Tracheobronchial fistula 
 Pneumomediastinum 
 Subcutaneous emphysema 
 Pneumoatocoele 

Michael A Matthay, MD 
 
Page 113 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                                        Appendix J: Childs-Pugh Score for Liver Dysfunction 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix J. Childs-Pugh Score for Liver Dysfunction 
 
 
Measure 
1 point 
2 points 
3 points 
Units 
Bilirubin (total) <34 (<2) 34-50 (2-3) 
>50 (>3) 
μmol/l 
(mg/dl) 
Serum Albumin >3.5 
28-35 
<28 
g/l 
INR  
<1.7 
1.71-2.20 
> 2.20 
no unit 
Ascites 
None 
Suppressed with 
medication 
Refractory no unit 
Hepatic 
Encephalopathy  None 
Grade I-II (or 
suppressed with 
medication) 
Grade III-
IV (or 
refractory) 
no unit 

Michael A Matthay, MD 
 
Page 114 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                                        Appendix K: Ordinal Scale for Clinical Improvement 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix K. Ordinal Scale for Clinical Improvement (OSCI) 
 
Patient State 
Descriptor 
Score 
Uninfected 
No clinical or virological evidence of infection 
0 
Ambulatory 
No limitation of activities 
1 
Limitation of activities 
2 
Hospitalized Mild Disease 
Hospitalized, no oxygen therapy 
3 
Oxygen by mask or nasal prongs 
4 
Hospitalized Severe Disease 
Non-invasive ventilation or high-flow oxygen 
5 
Intubation and mechanical ventilation 
6 
Ventilation + additional organ support – pressors, 
RRT, ECMO 
7 
Dead 
Death 
8 
 

Michael A Matthay, MD 
 
Page 115 
University of California, San Francisco  
 
 
Clinical Study Protocol UCSF-hMSC-ARDS-P1P2-14 
                                         Appendix L: Radiographic Assessment of Lung Edema (RALE) Score 
 
Date: April 19, 2022  
 
 
Confidential  
 
 
 
Appendix L. Radiographic Assessment of Lung Edema (RALE) Score 
 
 
 
 
.