Efficacy of Coenzyme Q10 Supplementation on Multi-Organ Dysfunction in Severely Burned Patients
Phase: PHASE3
Conditions: Multiple Organ Failure
Sponsor: American Burn Association

 
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Efficacy of Coenzyme Q10 Supplementation on Multi-Organ  
Dysfunction in Severely Burned Patients 
 
NCT03968640 
 
PROTOCOL 
 
Updated 04-26-2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Table of Contents: 
 
I. Principal Investigator................................................... 
3 
 
II. Co-Investigators and key study personnel…………. 
3 
III. Background .............................................................. 
5 
 
IV. Preliminary studies.................................................... 
8 
V. Study objectives and hypotheses…………………… 
10 
VI. Research design……………………………………. 
10 
 
Brief study overview…………………………... 
10 
Study investigators, personnel, and centers…… 
11 
 
Description of the recruitment process………… 
11 
 
Description of the informed consent process….. 
11 
 
Randomization procedures……………………. 
12 
 
Study population………………………………. 
12 
 
 
Inclusion criteria………………………. 
12 
 
 
Exclusion criteria……………………… 
13 
 
Rationale for the dosing regimen……………… 
13 
 
Measurement of biomarkers…………………… 
14 
VII. Statistical endpoints and approach to data analysis.. 
15 
Primary endpoint……………………………….. 
15 
Secondary endpoints…………………………… 
17 
Data analysis…………………………………… 
19 
Sample size calculation………………………… 
19 
VIII. Data management and data safety monitoring plan.. 
20 
 
Data management……………………………….. 
20 
 
Data safety monitoring plan & interim analysis… 
21 
 
Risk management and emergency response…….. 
21 
IX. Risks of study participation…………………………. 
21 
X.  IND Exemption…………………………………………22 
X. Project milestones……………………………………. 
22 
XI. References…………………………………………… 23 
 
 
 
 
 

 
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I. 
PRINCIPAL INVESTIGATOR: 
 
Herb A. Phelan, MD, MSCS 
Department of Surgery 
Division of Burns/Trauma/Critical Care 
UT-Southwestern Medical Center/Parkland Memorial Hospital 
5323 Harry Hines Blvd., E5.508A 
Dallas, TX 75390-9158 
214-648-6841 
herb.phelan@utsouthwestern.edu 
 
II. 
CO-INVESTIGATORS AND KEY STUDY PERSONNEL: 
 
James H. Holmes IV, MD 
Wake Forest University School of Medicine 
jholmes@wakehealth.edu 
 
Steve E. Wolf, MD 
University of Texas Medical Branch- Galveston 
swolf@utmb.edu 
 
Amalia Cochran, MD 
The Ohio State University Wexner Medical Center 
Amalia.Cochran@osumc.edu 
 
James Hwang, MD 
University of Alabama-Birmingham Medical Center  
jameshwang@uabmc.edu 
 
Dhaval Bhavsar, MD 
University of Kansas Medical Center 
dbhavsar@kumc.edu 
 
Gary Alec Vercruysse, MD 
University of Michigan 
vercruys@med.umich.edu 
 

 
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Anjay Khandelwal, MD 
Case Western Reserve University School of Medicine 
akhandelwal@metrohealth.org 
 
Jeremy Goverman, MD 
Massachusetts General Hospital 
JGOVERMAN@mgh.harvard.edu 
 
Tony Baldea, MD 
Loyola University Medical Center 
abaldea@lumc.edu 
 
Janelle Wagner, MD 
Temple University 
Janelle.Wagner@tuhs.temple.edu 
 
Nicholas Meyer, MD 
Columbia St.Mary’s-Wisconsin 
Nicholas.meyer@ascension.org 
 
Tina Palmieri, MD 
University of California- Davis 
Tina.Palmieri@ucdmc.ucdavis.edu 
 
Rachel Karlnoski, PhD 
University of South Florida 
rkarlnos@health.usf.edu 
 
David Smith Jr., MD 
University of South Florida 
dsmith3@health.usf.edu 
 
Fred Endorf, MD 
Hennepin County Medical Center 
frederick.endorf@hcmed.org 
 
Lori Palfalvi, CRA 
American Burn Association 
palfalvi@ameriburn.org 
 
Mary Beth Lawless, RN, MSN 
UC Davis, American Burn Association 
mblawless@ucdavis.edu 
 
 
 
 

 
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III. 
BACKGROUND 
 
Based on estimates reported in 2010, burn injuries account for 603,000 visits to US 
emergency departments and 50,000 hospital admissions1 with inpatient hospital costs 
totaling $1 billion1. Multiple organ dysfunction syndrome (MODS) is a major factor in the 
morbidity and mortality of severely burned patients. The elements of MODS after burn 
injury include acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), liver 
and cardiovascular dysfunction, and coagulopathy. Although the molecular mechanisms 
underlying MODS in burns are not fully understood, inflammation and mitochondrial 
dysfunction play important roles in the development of multi-organ dysfunction2-5. 
The inflammatory cascade behind MODS complicates attempts to treat another 
leading cause of mortality in burn patients, that of sepsis6. Effective pharmacologic 
strategies to prevent and/or treat MODS and sepsis in burns or major trauma remain elusive 
due in part to the belief that any anti-inflammatory strategies used to treat MODS patients 
will of their nature suppress immune function, thereby increasing susceptibility to infection 
and sepsis. Hence, new strategies with the dual capability of inhibiting 
inflammation/dysfunction in organs (e.g., lung, heart, kidney, liver), while preserving or 
enhancing the bactericidal capability of immune cells, are eagerly awaited. 
Mitochondrial dysfunction and multi-organ dysfunction in burns: An increasing 
body of evidence implicates the role of the mitochondria in clinical outcome after burn 
injury as mitochondrial dysfunction has been implicated in the pathogenesis of MODS 
after critical illness and severe burn injury7-10 . Additionally, mitochondrial dysfunction 
appears to play a part in the metabolic changes that accompany thermal injury such as 
hyperglycemia, insulin resistance11, hypermetabolism12, hyperlactatemia, increased 
glutamine consumption13, and muscle wasting. Although the underlying molecular 
pathogenesis is incompletely understood, mitochondrial dysfunction appears to be a major 
commonality of these burn- induced metabolic aberrations. In light of this, improving 
mitochondrial function would appear to be a reasonable approach to ameliorating burn-
induced MODS. Finding a suitable strategy to accomplish this goal, however, has been a 
major challenge and the safety and efficacy of therapies that target the mitochondria have 
not yet been evaluated in a clinical trial in burns. 
Coenzyme Q10 (CoQ10) deficiency and mitochondrial dysfunction: Coenzyme Q 
(CoQ) is an essential co- factor in the mitochondrial electron transport chain (ETC). 
CoQ10 is the major species of CoQ found in humans and contains 10 isoprenyl side chains 
(Fig. 1). It exists in oxidized (ubiquinone) and reduced (ubiquinol) forms. In its reduced 
form, it acts as a lipophilic anti-oxidant14 and while both forms are used as dietary 
supplements, ubiquinol has greater bioavailability compared to ubiquinone15. Primary 
(congenital) and acquired CoQ10 deficiencies cause mitochondrial dysfunction, which, in 
turn, leads to metabolic aberration and dysfunction of multiple organs and systems, 
including heart, skeletal muscle, vasculature (endothelium), immune, and central nervous 
system16. Conversely, mitochondrial dysfunction and damage can lead to CoQ10 

 
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deficiency17-20, since CoQ10 is biosynthesized in the mitochondria. Thus, mitochondrial 
damage and CoQ10 deficiency form a vicious cycle. 
Dr. Masao Kaneki showed that plasma CoQ10 concentrations are lower in surgical 
intensive care unit (ICU) patients21 and septic patients22 than in healthy controls. Further, 
his preliminary data show that plasma CoQ10 levels are significantly lower in burn patients 
compared to healthy controls. In addition, CoQ10 content in peripheral blood mononuclear 
cells (PBMCs) tends to decline after burn injury and therefore is lower in burn patients 
compared to healthy controls. These results suggest that burn-induced CoQ10 deficiency 
may contribute to mitochondrial dysfunction, leading to metabolic alterations and multiple  
organ dysfunction. While CoQ10 supplementation may reverse or lessen the severity of 
these complications in burn patients, this therapy has not yet been fully explored. 
Decreased complex I activity in burn patients: Complex I (NADH:ubiquinone 
oxidoreductase) is an essential component of the mitochondrial electron transport chain 
(ETC), participating not only in 
cell respiration, but also in 
cellular/organismal reactive 
oxygen species (ROS) 
homeostasis, apoptosis initiation 
or modulation, and O2 sensing23. 
CoQ10 receives electrons from 
nicotinamide adenine 
dinucleotide hydrate (NADH) 
dehydrogenase at complex I or 
from succinate dehydrogenase at 
complex II and transfers electrons 
to cytochrome C at complex III in 
the mitochondrial ETC (Fig. 2). 
Complex I is made up of at least 
46 subunits and is the largest 
complex in mitochondrial ETC. A previous study has shown that a decrease in complex I, 
but not complex II, activity in skeletal muscle predicts the prognosis of critically ill 
patients24, 25. Moreover, decreased complex I activity in peripheral blood mononuclear 
cells (PBMCs) is 
associated with 
immune 
dysregulation24. 
These findings 
indicate the clinical 
importance of 
decreased complex I 
in burns and critical 
illness. In fact, Dr. 
Kaneki’s 
preliminary 
experiments showed 
that complex I 
activity in PBMCs 
was significantly 
Figure 1. CoQ10 exists in exists in oxidized (ubiquinone) 
and reduced (ubiquinol) forms 
Figure 2. CoQ10 receives electrons from NADH dehydrogenase at complex 
I or from succinate dehydrogenase at complex II and transfers electrons to 
cytochrome C at complex III in the mitochondrial ETC 

 
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lower in burn patients than healthy controls. 
Disruption of mitochondrial integrity and inflammatory response: Mitochondria 
are not just the power plants of cells. They lie at the crossroads of energy metabolism, 
apoptosis and inflammatory response, and in fact, regulate their function. When 
mitochondrial integrity is disrupted, mitochondrial DNA (mtDNA) is released into the 
cytosol where it activates DNA sensors (e.g., toll-like receptor-9 [TLR9], AIM2), leading 
to an inflammatory response26, particularly activation of NLRP3 (nucleotide-binding 
domain, leucine-rich-containing family, pyrin domain-containing-3) inflammasome27. 
Once NLRP3 inflammasome is activated, it causes activation and cleavage of caspase-1, 
which, in turn, cleaves pro-interleukin (IL)-1β, converting it into mature, active IL-1β. This 
is reminiscent of the induction of apoptosis by cytochrome C release from the 
mitochondria. Of note, CoQ10 content in PBMCs is lower in fibromyalgia patients than 
healthy controls, which parallels inflammation in PBMCs. CoQ10 supplementation 
reduced inflammation in PBMCs of fibromyalgia patients28. The latter study indicates that 
CoQ10 deficiency can cause inflammation, which is reversed or ameliorated by CoQ10 
supplementation. Similarly, CoQ10 supplementation prevented burn-induced NLRP3 
activation, as indicated by cleavage of pro-caspase-1 and pro-IL-1β, in mouse skeletal 
muscle. 
Circulating mitochondrial damage-associated molecular patterns (DAMPs): 
mtDNA and mitochondrial proteins (e.g., heat shock protein 60, formyl peptides) are 
increased in the circulation after major trauma, including burn injury, owing in a 
significant part to mitochondrial disintegrity and apoptotic cell death29-31. These 
mitochondrial damage-associated molecular patterns (DAMPs, aka alarmins) play a crucial 
role in sterile systemic inflammatory response in major trauma. Dr. Kaneki’s preliminary 
data showed that plasma mtDNA concentrations were significantly greater in burn patients 
than healthy controls, consistent with previous studies in non-burn major trauma patients29-
33. In his preclinical study in mice, CoQ10 administration prevented burn-induced increases 
in circulating mtDNA and high-mobility group protein B1 (HMGB1) concentrations. 
Together, these findings suggest that CoQ10 supplementation may reduce elevated 
DAMPs and control systemic inflammatory response in burn patients. Of note, in his pilot 
study in burn patients, CoQ10 supplementation tended to inhibit increased plasma mtDNA 
levels compared with placebo. These findings suggest that CoQ10 supplementation may 
ameliorate the disruption of mitochondrial intergrity and thereby inhibit an elevation in 
mitochondrial DAMPs in the circulation in burn patients. 
CoQ10 as a protector of mitochondria from oxidative stress: Burn injury induces 
oxidative stress34, 35, which, in turn contributes to organ damage and dysfunction. 
Oxidative stress causes damage and disintegrity of the mitochondria. Conversely, the 
mitochondria serve as the major site of reactive oxygen species (ROS) generation in cells, 
and the mitochondria generate increased amounts of ROS when they are damaged. Hence, 
inherent defense mechanisms that protect against oxidative stress are necessary to the 
mitochondria. The reduced form of CoQ10 (ubiquinol) is a membrane-localized 
antioxidant that resides in the mitochondria and is an integral component of the 
mitochondrial anti-oxidative stress defense mechanism36. Reduced form CoQ10 
(ubiquinol) supplementation mitigates oxidative stress in many human diseases37-39 and 
increases resistance to oxidative stress in mice40. CoQ10 deficiency, therefore, increases 
susceptibility to oxidative stress, leading to aggravated oxidative damage and 
mitochondrial dysfunction, and CoQ10 administration prevented burn-induced oxidative 
stress in the mitochondria of mouse skeletal muscle in Dr. Kaneki’s work. These 

 
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several lines of evidence support our expectation that CoQ10 supplementation will 
exert protective effects against oxidative stress in burns. 
Protective effects of CoQ10 in burned mice: Recently, Dr. Kaneki’s preliminary data 
showed that supplementation with reduced form CoQ10 (ubiquinol) (40 mg/kg, SC, b.i.d.) 
prevents burn-induced mitochondrial dysfunction/disintegrity, insulin resistance, 
hyperlactatemia, oxidative stress in the mitochondria, and NLRP3 inflammasome activation 
in mice. Full thickness third degree burn injury (30% TBSA) induced the following effects: 
(1) decreased activity in mitochondrial ETC (e.g., complex I) and decreased mtDNA-to-
nDNA ratio in muscle; (2) morphological abnormalities in the mitochondria (i.e., elongation 
of mitochondria, loss of cristae structure); (3) insulin resistance in skeletal muscle; (4) 
hyperlactatemia; (5) mtDNA translocation to the cytosolic fraction; (6) NLRP3 
inflammasome activation; and (7) increased circulating levels of mtDNA and HMGB1. 
These changes were reversed or lessened by CoQ10 supplementation. These findings 
indicate that CoQ10 supplementation reduces the severity of burn-induced mitochondrial 
dysfunction/disintegrity and metabolic derangements, thereby mitigating multi-organ 
dysfunction. Moreover, his preliminary study showed that CoQ10 supplementation 
improved survival, bacterial clearance, and systemic inflammatory response in septic mice. 
Safety of CoQ10 supplementation: CoQ10 is an essential nutrient and has an 
excellent safety profile41. CoQ10 is commercially available to the general public in doses 
up to 600 mg/day. Previous clinical studies have reported the safety of high-dose, long-term 
CoQ10 supplementation in patients with amyotrophic lateral sclerosis (3,000 mg/day)42 and 
Huntington’s disease (3,600 mg/day)43. CoQ10 is a nutrient, but since it is biosynthesized 
in the mitochondria of every cell type of our body, it is not considered a vitamin. To date, 
CoQ10 status has not been studied in burns or major trauma. Although the majority of 
CoQ10 in the human body is produced endogenously in healthy adults, it has been 
estimated that approximately 20% to 25% of circulating CoQ10 is derived from dietary 
sources44. Nonetheless, current standard enteral and parenteral nutritional support 
preparations do not include CoQ10. 
 
IV. 
PRELIMINARY STUDIES 
 
Pilot clinical study: Dr. Kaneki conducted a pilot double-blind randomized, placebo-
controlled clinical study of CoQ10 (ubiquinol) supplementation (1,800 mg/day) after burn 
injury at the Massachusetts General Hospital (MGH) (Clinical Trials.gov. Identifier: 
NCT02251626; PI: Masao Kaneki). The objectives of this study were to evaluate the safety 
and bioavailability of CoQ10 supplementation in burn patients. Eligible adult patients with 
≥5% TBSA burn were enrolled within 72 hours after burn injury. The intervention consisted of 
enteral CoQ10 supplementation or placebo for 4 weeks or until hospital discharge, whichever 
came first. Prior to CoQ10/placebo supplementation, blood samples were collected (designated 
as Day 0). The effects of CoQ10 supplementation on CoQ10 levels in plasma and peripheral 
blood mononuclear cells (PBMCs) were studied. Thirty patients were enrolled and studied 
(each arm: n=15). Block randomization was used and enrollment was not stratified by burn 
size in the pilot study. An investigational new drug (IND) exemption was obtained from the 
U.S. Food and Drug Administration (FDA) for CoQ10 (ubiquinol) (1,800 mg/day) in adult 
burn patients. 
Overall demographics: There was no difference in age, gender, burn size (%TBSA) or 
Revised Baux score between the CoQ10 and the placebo groups. The characteristics of the 
cohort can be seen in Table 1. No adverse events or protocol deviations were noted in the 

 
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conduct of the overall study.  
CoQ10 deficiency in burn patients in comparison with healthy controls. The pilot 
study showed that plasma total and reduced CoQ10 concentrations, reduced-to-total CoQ10 
ratio and CoQ10 content in PBMCs were significantly lower in burn patients on Day 0 
(baseline) prior to the CoQ10 or placebo supplementation (n=30) compared with healthy 
controls (n=12) (age [y.o.]: 40 ± 4 [mean ± SEM]). In the placebo group, CoQ10 levels in 
plasma and PBMCs remained significantly lower on Day 3 and Day 6 as well as Day 0 
compared with healthy controls. 
Table 1. Pilot study 
population 
Age 
(year) 
Female, 
n (%) 
%TBSA 
LOS 
(days) 
Revised Baux 
Score 
CoQ10 Grp (n=15) 
48.9 ± 3.9 
3 (20.0) 
19.4 ± 4.9 
22.0 ± 3.4 
69.5 ± 6.3 
Placebo Grp (n=15) 
48.2 ± 4.7 
5 (33.3) 
13.9 ± 2.8 
21.9 ± 5.3 
65.0 ± 7.0 
P value 
0.90 
- 
0.33 
0.99 
0.63 
CoQ10 supplementation effectively increased CoQ10 levels in burn patients. 
CoQ10 supplementation significantly increased plasma total and reduced CoQ10 
concentrations, % reduced CoQ10, and CoQ10 content in PBMCs in burn patients 
compared with the placebo group and with the baseline levels prior to the supplementation 
(Day 0). These data indicate that burn injury decreases CoQ10 levels, which are reversed 
by CoQ10 supplementation. 
CoQ10 supplementation tended to inhibit increased circulating mtDNA levels in 
burn patients. The pilot data showed that plasma mtDNA levels were significantly greater 
in burn patients than healthy controls. These results are consistent with previous studies in 
non-burn major trauma patients29-33. In the placebo group, plasma mtDNA levels tended to 
increase on Day 3 relative to Day 0 although there was no statistical significance (p<0.10). 
On the other hand, in the CoQ10 group there was a trend toward decreased plasma mtDNA 
levels on Day 3 relative to Day 0 (p<0.10). The Day 3-to-Day 0 ratio of plasma mtDNA 
levels tended to be lower in the CoQ10 group than the placebo group (p=0.0765), but there 
was no statistical significance possibly owing to the small sample size. Our data suggest 
that CoQ10 supplementation may protect against burn-induced mitochondrial disintegrity 
and thereby inhibit an increase in circulating mtDNA levels. 
Taken together with previous studies and Dr. Kaneki’s preliminary data in mice, these 
findings provide sufficient scientific evidence to test the hypothesis that CoQ10 
supplementation prevents MODS by ameliorating mitochondrial dysfunction/disintegrity in 
burn patients. Collectively, our data warrant a large-scale clinical trial to evaluate the safety 
and efficacy of CoQ10 supplementation in severely burned patients. 
 
 

 
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Fig. 3. Schematic presentation of the overall 
hypothesis. Based on previous studies and Dr. 
Kaneki’s preclinical and clinical pilot results, 
we posit that burn injury causes mitochondrial 
dysfunction/ disintegrity in parallel with 
CoQ10 deficiency, which in turn induces 
and/or exacerbates multi-organ dysfunction, 
leading to worse prognosis. Importantly, pilot 
clinical data showed that burn injury causes 
CoQ10 deficiency, which was reversed by 
CoQ10 supplementation. Moreover, this 
preliminary data showed that CoQ10 supplementation prevents burn-induced 
mitochondrial dysfunction/disintegrity, metabolic aberration, oxidative stress and 
inflammation. These results warrant a clinical trial of CoQ10 supplementation in burn 
patients. 
 
STUDY OBJECTIVES AND HYPOTHESES 
 
Primary objective: To evaluate the efficacy of reduced form CoQ10 (ubiquinol) 
supplementation in severely burned adult patients in the mitigation of MODS between 72 
hours after burn injury and 12 weeks, death, or discharge (whichever comes first). 
 
Primary objective hypothesis: Reduced form CoQ10 supplementation will result in a 
statistically significant reduction in the incidence of MODS between 72 hours after burn 
injury and 12 weeks, death, or discharge (whichever comes first) as compared to placebo.  
 
Secondary objectives: To evaluate the effect of reduced form CoQ10 (ubiquinol) 
supplementation in severely burned adult patients on the following clinical outcome events 
and biochemical measurements in plasma and urine between 72 hours after burn injury and 
12 weeks, death, or discharge (whichever occurs first): 
1. 
The six individual organ systems comprising the MODS score and their times of 
occurrences,  
2. 
The weighted composite score of the six constituents 
3. 
The maximum total Sequential Organ Failure Assessment (SOFA) score 
4. 
The maximum SOFA score for each organ 
5. 
AUC of total SOFA score (score x days) 
6. 
AUC of SOFA score for each organ (score x days) 
7. 
Delirium (CAM-ICU) (number of days) 
8. 
Length of hospital stay (number of days) 
9. 
Sepsis (Sepsis-3) (number of incidence) 
10. Septic Shock (Sepsis-3) (number of incidence) 
11. Plasma mitochondrial DNA (4 blood collections) 
12. 3-Methylhistidine (3-MH) and creatinine in urine (a biomarker of muscle wasting) 

 
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Secondary objective hypothesis: Reduced form CoQ10 supplementation will result in a 
statistically significant reduction in each of the secondary endpoints between 72 hours after 
burn injury and 12 weeks, death, or discharge (whichever comes first) as compared to placebo.  
 
RESEARCH DESIGN 
 
Brief study overview: We will conduct a two-arm, prospective, double-blind, randomized, 
placebo-controlled clinical trial to evaluate the efficacy and safety of reduced form CoQ10 
(ubiquinol) supplementation in severely burned adult patients (total n=290) at 15 mature burn 
centers across North America. Stratified block randomization will take place by site and 
Revised Baux score. The formula for the Revised Baux score is: Age + Percent Burn 
(%TBSA) + 17 x (Inhalation Injury, 1 = yes, 0 = no). This formula has been widely adopted 
for mortality prediction in burn patients45,46. In previous studies, a trend has been shown for a 
sharp increase in mortality when the Revised Baux score exceeds approximately 11045,47,48. 
Therefore, patients enrolled in this study will be stratified for randomization into two groups 
based on the Revised Baux score: (1) less than 110; and (2) equal to or greater than 110. The 
intervention will consist of a loading dose of reduced form CoQ10 of 1,800 mg/day tid for 4 
weeks to be followed by a maintenance dose of 600 mg/day once daily from weeks 5 to 12. 
The intervention or allocation-controlled placebo will be administered by 72 hours after injury 
and will continue until 12 weeks after injury or until death or discharge, whichever comes first. 
Oral tablets (600 mg/tablet) will be administered to CoQ10 subjects who can swallow while a 
liquid form (100 mg/mL) will be administered to CoQ10 subjects requiring an enteral tube for 
nutrition. There will be no post-discharge study procedures. 
 
Study investigators, personnel, and centers: 
Herb A. Phelan MD, MSCS; UT Southwestern Medical Center/Parkland Memorial Hospital 
James H. Holmes IV, MD; Wake Forest University School of Medicine 
Steve E. Wolf, MD; University of Texas Medical Branch- Galveston 
Amalia Cochran, MD; The Ohio State University Wexner Medical Center 
James Hwang, MD; University of Alabama-Birmingham Medical Center  
Dhaval Bhavsar, MD; University of Kansas Medical Center 
Gary Alec Vercruysse, MD; University of Michigan 
Anjay Khandelwal, MD; Case Western Reserve University School of Medicine 
Jeremy Goverman, MD; Massachusetts General Hospital 
Tony Baldea, MD; Loyola University Medical Center 
Janelle Wagner, MD; Temple University 
Nicholas Meyer, MD; Columbia St. Mary’s-Wisconsin 
Tina Palmieri, MD; University of California- Davis 
Rachel Karlnoski, PhD; University of South Florida 
David Smith Jr., MD; University of South Florida 
Fred Endorf, MD; Hennepin County Medical center 

 
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Lori Palfalvi, CRA; American Burn Association 
Mary Beth Lawless, RN, MSN; UC Davis, American Burn Association 
 
Description of the Recruitment Process: Study coordinators will screen the medical records 
of newly admitted patients using the inclusion/exclusion criteria. Only English and/or 
Spanish-speaking adult subjects or surrogates (≥18 years) will be approached to consider 
study participation since this represents the overwhelming majority of patients who receive 
care in the study sites. No remuneration will be provided. 
 
Description of the Informed Consent Process: The physician, who is known to the potential 
subject and has firsthand knowledge of the patient's medical history, will approach the 
patient/family at the bedside to briefly introduce the study and emphasize that the 
patient/family is free to participate or not, and ask if the patient/family would like to hear 
more information about the study from a physician-associate. If answered in the affirmative, 
a co- investigator or their designated research coordinator will be notified. This study 
collaborator will subsequently come to the bedside and provide more detail about what the 
study would involve for the patient and again emphasize the voluntary nature of 
participation. If the patient/family expresses reluctance, then the topic of participation would 
end at that point. If the patient/family expresses an interest in participation, the MD co-
investigator or study coordinator would discuss the study in more detail, answer questions, 
and obtain informed consent in a private room. Human subjects’ questions will be addressed 
by physician investigators listed on the IRB protocol during the consent process and 
throughout the trial. 
In compliance with the guidelines, the following categories of surrogates (listed in 
preferred order) may provide consent in writing on behalf of potential subjects incapable of 
providing informed consent: i) court appointed guardian with specific authority to consent 
to participation in research or authority to make health care decisions for a class of 
diagnostic and therapeutic decisions inclusive of the proposed research; ii) health care 
proxy/person with durable power of attorney with specific authority for making health care 
decisions inclusive of the proposed research; or iii) spouse, adult child, or other close family 
member who knows the subject well and has been involved in their care. Assent of subjects 
will be a requirement for participation in the research unless the subject is incapable of 
giving assent due to his/her medical condition. A licensed physician colleague or a well-
trained study investigator will obtain informed consent. Participants will be given as much 
time as necessary to consider participation or to discuss the study with anyone before 
making a decision. Routine care will be provided to the patient regardless of enrollment to 
the study. This fact will be explained to the patients and/or legal guardian.  
 
Randomization procedure: Permuted-block randomization stratified by study site and 
Revised Baux score will be performed. This study procedure will utilize the RS2 system 
that was developed by the ABA’s Data Coordinating Center (DCC) based out of UC-Davis 
and which has been used in previous burn trials successfully. 
 
Study population: 
 
Table 2. 
 

 
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Inclusion Criteria 
 
Rationale 
Age 18 years and older 
Military age subjects. There are no 
limitations on gender, race, or ethnicity. 
Burn patients with 20% or greater of total body 
surface area (TBSA) burn and equal to or less 
than 70% TBSA burn 
Burns greater than 20% are considered to 
be severe and potentially life threatening. 
Burns larger than 70% carry an excessive 
mortality and confound the primary 
endpoint of MODS 
Capable of receiving routine oral, enteral 
nutrition, or a combination of routine oral and 
enteral nutrition 
CoQ10 is not available in injectable form 
for humans. The enrolled patients will 
receive tablets (softgels) or liquid form of 
CoQ10 or placebo. 
Enrolled within 72 hours after burn injury 
This timepoint is early enough that a 
preventative effect of CoQ10 replacement 
can manifest 
Patient or legally authorized representative 
(LAR) who is capable of giving full informed 
consent 
Principle of autonomy 
Anticipated hospital stay: 2 weeks or more 
This duration is the common timeframe 
for MODS development should it occur. 
 
 
 
Exclusion Criteria 
 
 
Rationale 
Patients with liver disease (bilirubin greater 
than 3 or diagnosis of liver cirrhosis) at the 
time of admission, hyperthyroidism that 
currently requires treatment, diagnosis of 
chronic heart failure, chronic renal failure 
requiring hemodialysis, malignancy currently 
undergoing treatment, or history of cancer or 
hematological malignancy treatment within 5 
years 
The primary endpoint of MODS scoring 
is intended for acute organ dysfunction. 
Subjects with chronic, pre-existing organ 
dysfunction are confounders  
History of HIV or AIDS 
MODS is driven by the immune system 
so pre-existing immune dysfunction is a 
confounder 
Presence of concurrent injuries apart from burn 
injury that may produce long-term disabilities 
(e.g., spinal cord injury, anoxic brain injury) 
Nonthermal injury is a MODS risk by 
itself and therefore methodologically 
problematic 

 
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Participation in another research study that 
may confound the results of this study in the 
opinion of the site principal investigator 
Concurrent enrollments in prospective 
studies with non-competing endpoints are 
common events in academic burn centers 
Pregnant women 
Vulnerable population 
Prisoners 
Vulnerable population 
 
Rationale for the dosing regimen: The dosing regimen for CoQ10 supplementation consists 
of a loading dose of 600 mg po tid (ie, 1800 mg/day total)for 4 weeks followed by a 
maintenance dose of 600 mg/day (once daily) for an additional 8 weeks (12 weeks total) or 
until death or hospital discharge, whichever comes first. This regimen is based on Dr. 
Kaneki’s pilot study in adult burn patients. This dose effectively increased CoQ10 levels 
both in plasma and in PBMCs in the randomized burn patients including those with 20% - 
70% TBSA burn injury. In contrast, in the placebo group, CoQ10 levels declined after burn 
injury. A relatively high dose (i.e., 1,800 mg/day) is necessary to effectively increase 
intracellular CoQ10 levels in the initial period of CoQ10 supplementation. As shown in 
previous studies and pilot data, plasma CoQ10 concentration increased within an hour after 
oral intake of CoQ10. However, intracellular CoQ10 is delayed with oral CoQ10 intake. 
Presumably, this occurs because cells lack the specific molecular machinery required to 
uptake extracellular CoQ10, since CoQ10 is endogenously synthesized in every cell type. 
On the other hand, a relatively low-dose of CoQ10 (200-300 mg/day) supplementation 
achieves the plateau level of intracellular CoQ10 within 4 weeks in healthy individuals49. 
Once the CoQ10 has reached the desired plateau within 4 weeks, a lower dose (600 mg/day) 
is sufficient to maintain the plateau. 
Because of the lipophilic nature of CoQ10, bile acids secreted in the intestine at 
the time of meals or enteral feeding facilitate absorption of CoQ10 as well as other lipids 
by the intestine. We propose, therefore, to give CoQ10 supplementation within 30 minutes 
after meals or enteral feeding. CoQ10 tablets (softgels) and liquid form (100 mg/mL) and 
respective placebo will be provided by Kaneka Nutrient Corp. (Pasadena, TX).   
  
Measurement of Biomarkers 
Plasma samples for mitchondrial DNA (mtDNA) assays: Plasma samples will be collected 
on the first 100 subjects enrolled across all centers. These four plasma samples will be 
collected at four separate time points: 1) at the time of enrollment (and therefore within 72 
hours of injury), 2) on post-burn day 7, 3) on post-burn day 14, and 4) on post-burn day 
21). Each specimen will be handled in an identical fashion. To remove residual cells, 
platelets, microparticles, and debris, EDTA-plasma samples will be obtained from whole 
blood (10 mL) and then the plasma samples will be spun twice at 5,000g50. mtDNA will be 
extracted using the mtDNA extraction kit (Wako Chemicals), and mtDNA levels will be 
evaluated by real-time PCR using specific primers for mtDNA (forward: 5’- 
CACTTTCCACACAGACATCA-3’; reverse: 5’-TGGTTAGGCTGGTGTTAGGG-3’)51. 
Plasma samples will be stored at -80ºC freezer until the measurement. As a standard for the 
measurement of mtDNA levels, we will use the plasmid vector, in which we subcloned the 
PCR product from the human PBMC-derived DNA using these primers. 
 
Urine samples for 3-methylhistidine and creatinine assays: 24-hour urine samples will be 
collected on the first 100 subjects enrolled across all centers. 24-h urine samples will be 

 
15
collected for three consecutive days at four time points, namely on Days 1-3 (first), 7-9 
(second), 14-16 (third), and 21-23 (fourth). Each specimen will be handled in an identical 
fashion. First, 20 mL of 6N HCl will be added to each container prior to each 24 hour urine 
collection. 24 hours later, the total 24 hour urine volume will be recorded and that given 24-
hour urine specimen will be placed on ice. Once all three 24 hour urine specimens for a 
given time point are completed, a 20 mL urine sample from each individual 24-hour urine 
specimen will be collected (2 tubes of 10 mL each) and frozen at -80 degrees C until the 
measurements. This process will be repeated on each of the three days’ collection at the 4 
time points. Therefore, each of the first 100 subjects enrolled will generate twelve urine 
specimens over the four time points.  
3-Methylhistidine concentrations will be quantified by negative chemical ionization gas 
chromatography mass spectrometry as described in our previous studies52,53. Urinary 
creatinine concentrations will be measured by a commercial kit. The average of three 
measurements on the three consecutive days at each time point will be used for statistical 
analysis to minimize possible day-to-day variations. 
 
STATISTICAL ENDPOINTS AND APPROACH TO DATA ANALYSIS 
 
This two-arm balanced double blind parallel Randomized Clinical Trial (RCT) study will be 
performed using an intention to treat (ITT) analysis population that includes all randomized 
patients. 
 
Primary endpoint: The primary endpoint will be the count of the following events. This 
count will be used to create a composite score ranging from 0 to 6 by assigning 1 to each 
event regardless of stage, scores and severity that individual subjects encounter from 72 
hours after burn injury through 12 weeks or until death or discharge, whichever occurs first: 
1. 
Acute Kidney Injury (AKI) (KDIGO Stages 1 – 3) 
2. 
ARDS (The Berlin ARDS Definition: Mild, Moderate, Severe) 
3. 
Cardiovascular Dysfunction (SOFA Scores 1 – 4) 
4. 
Coagulopathy (SOFA Scores 1 – 4) 
5. 
Liver dysfunction (SOFA Scores 1 – 4) 
6. 
Death (all causes) 
We will calculate mean values of the composite sum scores among the study patients in the 
CoQ10 and placebo arms, and then test their difference by using an independent samples t-
test if the observed data are evident to follow a normal distribution by Shapiro-Wilk’s test. 
Otherwise, Mann-Whitney U test will be applied and the group specific medians and 
quartiles will be used as the summary statistics. 
 
AKI: AKI represents the acute loss of kidney function and is associated with a profound and 
severe increase in morbidity and mortality in burn patients54. Early AKI, which occurs less 
than 3 days post-burn, is usually related to inadequate fluid replacement during the initial 
resuscitation. AKI can occur later in the hospitalization and late AKI is multifactorial in 
origin and often associated with sepsis development55. For the purposes of this study, we 
will follow the definitions and classification guidelines set forth in "AKI of Kidney Disease: 
Improving Global Outcomes (KDIGO)”56,57 (Table 3). Published in 2012, this guideline has 
been used in critically ill patients and in combat-injured populations58. 

 
16
Stage 
Table 3. AKI (KDIGO) 
1 
Increase in serum creatinine (SCr) by ≧ 0.3mg/dL within 48 hours or increase in 
SCr 1.5 to 1.9 times baseline which is known or presumed to have occurred within 
the prior 7 days 
2 
Increase in SCr to 2.0 to 2.9 times baseline 
3 
Increase in SCr to 3.0 times baseline or increase in SCr to ≧ 4.0 mg/dL or 
initiation of renal replacement therapy 
 
ARDS: ARDS is a common complication in critically ill burn patients leading to increased 
mortality. The American European Consensus Conference (AECC) ARDS definition was 
revised by the Berlin definition in 2012 (Table 4). Since then, the ARDS Berlin definition has 
been used in critically ill patients59, including wartime military burns60. We will use the ARDS 
Berlin definition in this study. 
 
Table 4. The ARDS Berlin Definition 
Oxygenation 
Mild 
200mmHg < PaO2/FiO2 ≦ 300mmHg 
Moderate 
100mmHg < PaO2/FiO2 ≦ 200mmHg 
Severe 
PaO2/FiO2 ≦ 100mmHg 
Cardiovascular dysfunction: To assess cardiovascular dysfunction, we will use the 
sequential organ failure assessment (SOFA) scores (Table 5). The SOFA score is a simple 
and objective score that allows for calculation of both the number and the severity of organ 
dysfunction in six organ systems (e.g., respiratory, coagulation, liver, cardiovascular, renal), 
and the score can measure individual or aggregate organ dysfunction61 and has been used in 
many previous studies in critically ill patients, including burn victims. Cardiovascular 
dysfunction is a common complication of severe burn injury. CoQ10 deficiency causes 
and/or exacerbates heart failure and clinical trials have shown the protective effects of 
CoQ10 supplementation in chronic heart failure. 
Coagulopathy: Severe burn injury is associated with systemic coagulopathy, which is 
characterized by procoagulant changes, as well as impaired fibrinolytic and endogenous 
anticoagulation systems62-65. The exact pathophysiology of burn-induced coagulopathy is 
incompletely understood, but recent studies indicate that circulating mtDNA and 
mitochondrial damage can induce hypercoagulopathy and thrombocytopenia66-68. It is 
conceivable, therefore, that CoQ10 supplementation may ameliorate coagulopathy by 
mitigating mitochondrial dysfunction/disintegrity in burn patients. 
Liver dysfunction: Hepatic function plays pivotal roles in immune function, acute-phase 
response, systemic inflammatory response, detoxication, and metabolism. Burn causes 
dysfunction and morphological changes (e.g., hepatomegaly) of the liver69. Although 
liver failure is not a frequent complication of burn injury, increased serum bilirubin level 
is associated with the mortality of severely burned patients70. 
 
         Cardiovascular System 
Coagulation 
Liver 
SOFA Score Hypotension 
Platelets (103/µl) Bilirubin (mg/dl) 
1 
MAP＜70 mm Hg 
＜150 
1.2 - 1.9 
2 
dop≦5 or dob (any dose) 
＜100 
2.0 - 5.9 
3 
dop＞5 OR epi=≦0.1 OR nor≦0.1 
＜50 
6.0 - 11.9 

 
17
4 
dop＞15 OR epi＞0.1 OR nor＞0.1 
＜20 
＞12.0 
 Table 5. Cardiovascular, coagulation and liver SOFA score. MAP: mean arterial 
pressure; dop: dopamine; dod: dobutamine; epi: epinephrine; nor: norepinephrine. 
Adrenergic agents administered for at least 1 hour (doses given are in µg/kg/min). 
 
 Note that "coma" is not included within the primary endpoint calculations, even though 
mitochondrial dysfunction impairs the central nervous system. The rationale for this 
exclusion is that precise evaluation of coma and consciousness (e.g., Glasgow coma scale) is 
sometimes difficult to carry out due to intubation and sedation in severely burned patients. 
However, delirium will be evaluated by the Confusion Assessment Method for Intensive 
Care Unit (CAM-ICU) as one of our secondary endpoints. 
 
Scientific rationale for the primary endpoint: To evaluate the efficacy of CoQ10 
supplementation in severely burned patients, we have chosen dysfunction of multiple 
organs and systems as the primary endpoint based on the following scientific rationale. 
First, multi-organ dysfunction is a major determinant of the mortality and long-term 
clinical and functional outcomes of severely burned patients. Second, mitochondrial 
dysfunction/ dysintegrity is involved in dysfunction of multiple organs and various cell 
types, including heart, kidney, lung, liver, and platelets. Third, CoQ10 is biosynthesized in 
the mitochondria and required for function and integrity of the mitochondria in every cell 
type and CoQ10 deficiency causes mitochondrial dysfunction in various cell types and a 
broad range of organs and systems. Fourth, previous clinical trials have shown that CoQ10 
supplementation improves heart, kidney, and liver function in various human diseases, 
although the effects of CoQ10 have not been studied in patients with burn injury or major 
trauma. Fifth, in burn patients CoQ10 supplementation tended to lessen the burn-induced 
increase of circulating mtDNA levels in our pilot study. Increased circulating mtDNA is 
both an indicator of systemic mitochondrial disintegrity and an inducer or enhanced 
systemic inflammation. In burned mice, CoQ10 supplementation prevented burn-induced 
mitochondrial dysfunction/disintegrity and metabolic aberration, while simultaneously 
inhibiting increased circulating mtDNA levels. Collectively, these data support the 
hypothesis that CoQ10 supplementation mitigates dysfunction of multiple organs and 
systems by ameliorating burn-induced mitochondrial dysfunction and disintegrity. 
 
Scientific rationale for the observation period: Studies in trauma patients have suggested the 
organ dysfunction that develops soon after trauma (i.e., during the first 48 -72 h) rapidly 
resolves in a high proportion of patients and may reflect the reversible derangement of organ 
function induced by the inciting event or incomplete resuscitation. Thus, it has been 
proposed that later assessment of organ function (i.e., 3 days after injury) will yield a more 
accurate definition of multiple organ failure in trauma patients, which is needed to evaluate 
the relationship between trauma-induced organ dysfunction and prognosis71,72. In the acute 
phase, particularly the first 72 hours after severe burn injury, organ dysfunction frequently 
occurs, causing AKI (e.g., oliguria), cardiovascular dysfunction (e.g., hypotension), and 
coagulopathy (e.g., thrombocytopenia)73. In some cases, the organ dysfunction is transient 
and the patient may recover during the late-acute or sub-acute phase. In such cases, the 
recovery from organ dysfunction is associated with relatively good prognosis. In contrast, if 
the organ dysfunction continues beyond the acute phase or if it occurs or recurs at a later 
time, the clinical outcome is typically worse. Therefore, we will evaluate the effects of 

 
18
CoQ10 supplementation on the aforementioned multi-organ dysfunction that patients 
encounter beginning 72 hours post-burn injury and thereafter. 
 
Secondary endpoints: Secondary endpoints will be the following outcome events 
observed from 72 hours after burn injury through 12 weeks or until death or discharge 
(whichever occurs first) and the biochemical measurements in plasma and urine. 
1. 
The six individual binary outcome MODS events and their times of occurrences, 
(i.e., the constituents of the primary composite score) 
2. 
Weighted composite score of the six constituents 
3. 
Maximum total SOFA score 
4. 
Maximum SOFA score for each organ 
5. 
AUC of total SOFA score (score x days) 
6. 
AUC of SOFA score for each organ (score x days) 
7. 
Delirium (CAM-ICU) (number of days) 
8. 
Length of hospital stay (number of days) 
9. 
Sepsis (Sepsis-3) (number of incidence) 
10. 
Septic Shock (Sepsis-3) (number of incidence) 
11. 
Plasma mitochondrial DNA (4 blood collections) 
12. 
3-Methylhistidine (3-MH) and creatinine in urine (a biomarker of muscle wasting) 
 
Scientific rationale for the clinical secondary endpoints: To comprehensively evaluate the 
effects of CoQ10 supplementation on dysfunction of organs and systems, we will examine 
total and individual scores of multiple organs/systems. Severity of multiple organ 
dysfunction is associated with the morbidity and mortality of burn victims. We will, 
therefore, evaluate weighted composite score of the six events that constitute the primary 
endpoint, where stages 1, 2 and 3 of AKI, and mild, moderate and severe ARDS are counted 
as score 1, 2 and 3, respectively. Regarding cardiovascular dysfunction, coagulopathy and 
liver dysfunction, we will use the SOFA scores (Table 5) for the weighted composite score. 
Moreover, over and above the maximum severity of organ dysfunction, its duration also 
affects the clinical trajectory of severely burned patients. Therefore, to take both severity 
and duration of organ dysfunction into account, we will analyze the area under the curve 
(AUC) for the SOFA score as previously described74. 
Our preclinical and pilot clinical studies suggest that CoQ10 supplementation may 
prevent the development and/or exacerbation of mitochondrial dysfunction/disintegrity and 
multi-organ dysfunction in burn victims. However, it is possible that CoQ10 
supplementation may exert beneficial effects in the recovery phase as well as acute and 
subacute phases. We will, therefore, investigate the time-dependent effects of CoQ10 
supplementation longitudinally. 
Delirium, a common complication and significant clinical issue in burn patients, is 
associated with long-term outcome75. Dr. Kaneki’s preliminary data showed in mice that 
mitochondrial dysfunction in the central nervous system plays a critical role in 
surgery/anesthesia-induced delirium76. However, the effect of CoQ10 on delirium has not 
yet been studied in any disease. CAM-ICU will be used to assess delirium77. 
Sepsis and septic shock are major causes of mortality in burn patients. Dr. Kaneki’s 
preliminary study showed in mice that CoQ10 supplementation improved bacterial clearance 
and survival of septic mice and prevented inflammation organ inflammation (e.g., heart, 
liver, kidney). For the diagnosis of sepsis and septic shock, we will use the Third 

 
19
International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) that was issued 
in 201678,79. 
 
Scientific rationale for the biochemical secondary endpoints: To evaluate the effect of 
CoQ10 supplementation on systemic mitochondrial disintegrity, we will measure mtDNA 
abundance in the circulation. Mitochondrial disintegrity and apoptotic cell death have been 
implicated in the rise of circulating mtDNA. Moreover, circulating mtDNA functions as a 
damage-associated molecular pattern (DAMP), which induces and/or exacerbates systemic 
inflammatory response in major trauma29, 33. In our pilot study, plasma mtDNA levels were 
significantly higher in burn patients compared with healthy controls. These results are 
consistent with previous studies in non- burn trauma patients. In our preclinical study in 
mice, burn caused an increase of mtDNA levels in plasma, which was mitigated by CoQ10 
administration. Similarly, there was a trend toward decreased circulating mtDNA levels in 
the CoQ10 group compared with the placebo group (P<0.10), although statistical 
significance was not achieved possibly due to the small sample size (n=15 per group). 
  
Muscle wasting is a major metabolic complication of burn injury and worsens the 
clinical outcome of burn patients. Muscle wasting interferes with the ability to wean off 
mechanical ventilation, recovery, and rehabilitation after burn injury. Moreover, muscle 
wasting is an essential component of burn cachexia and hypermetabolism, both of which 
are major contributors to worse prognosis after severe burn injury. Increased proteolysis is 
a major component of burn-induced muscle wasting. After burn injury, both breakdown 
and synthesis of proteins increase in skeletal muscle; however, the increase in protein 
breakdown exceeds that of protein synthesis, leading to muscle atrophy80,81. To evaluate 
muscle wasting, therefore, we will measure 3-methylhistdine in 24-h urine samples, an 
indicator of protein breakdown in muscle, and normalize it to creatinine concentrations. 
Because 3-methylhistdine is present only in actin and myosin and is not reutilized for 
protein synthesis after it is released during proteolysis82, increased 3-methylhistdine-to- 
creatinine ratio in urine indicates accelerated myofibrillar protein breakdown83. Burn injury 
increases 3- methylhistdine-to-creatinine ratio in human and rat urine52,53. 
 
Data Analysis: For between-arm comparisons of single valued (either measured at once or as 
an aggregated variable such as AUC over a period) outcomes, we will apply chi-square test if 
the outcome is binary, and t-test or Mann-Whitney U-test to continuous outcomes based on 
the best fit of Shapiro-Wilk’s test. The between-arm difference in the distributions of times to 
the first event and multiple events (of the six constituents) will be examined by using single 
event time Cox’s model and the times to correlated multiple events using Cox’s model 
allowing multivariate frailty, respectively. The incidence rates of each individual event, with- 
and without differentiating its severity, as a binary outcome will be compared between the 
two arms by means of longitudinal logistic modeling with generalized estimating equation 
(GEE)84 to allow more than one events per patient. For the repeated measures analysis of the 
longitudinal plasma mitochondrial DNA and urine 3- methylhistidine (3-MH), we will 
examine if the mean levels over time are different between the two arms by using 
longitudinal general linear mixed effects model85 which will provide the within group time 
dependency patterns as a linear effect or more complex form of non-linear patterns which 
would be able to characterize the time dependent treatment effects over time along with 
testing for time × group interaction(s) of those model parameter(s). Total and organ-specific 
SOFA scores over time will also be examined by this mixed effects models of which the 

 
20
particular interest is to test if the improvement in the longitudinal mean SOFA scores is 
greater during certain time window. All analyses will also be extended to adjust for the 
influencing effects of any baseline demographic and/or clinical indications. Missing data may 
be unavoidable. Because the informed consent from many study enrollees will be obtained 
through the family members (i.e., surrogates), a small portion (up to 2% attrition rate) of the 
enrolled patients may voluntarily withdraw from the study. Before final analysis, we will 
check the missing data pattern of the outcomes first. If there are systematic differences in 
missing data patterns between the study groups and/or patient characteristics (e.g., burn type), 
we will take into account such problems in the analysis. The longitudinal mixed effects 
modeling will provide unbiased and consistent estimates of the effects provided that the 
missing data mechanism is ‘missing at random’ (MAR). If necessary, multiple-imputation 
will be applied to all endpoints analyses. All statistical tests will be two-sided and will adopt 
a 5% significance level.  
Sample size calculation: The sample size of 290 study patients for this study is determined 
to achieve an adequate statistical power at a 5% Type-1 error rate for the primary endpoint 
analysis by the following statistical calculations. We first estimated the expected means and 
variances of the composite scores (assuming the six individual events are independent) for 
the Control and CoQ10 treatment arms under the assumption depicted in Table 6 via 1000 
repeated simulated data sets (n = 5000 each), instead of calculating them algebraically. 
Each simulation run calculated the means and variances of the two arms, and the 
resulting average means (and variances) over 1000 simulations were 2.43 (1.04) in the 
placebo arm and 1.94 (1.05) in CoQ10 arm respectively. Based on the assumption about the 
event incidence rates and the estimated means and variances of the composite scores from 
the simulated data sets, the calculated required sample size per treatment arm (using 
PASS110) to detect such a difference (i.e., 20% reduction in the overall events) with 80% 
power at a 5% Type-1 error rate using 2-sided independent samples t-test was 142 per arm. 
We have estimated the incidence rates of dysfunction of each organ or system and 
mortality under the null hypothesis (H0), which are listed below in Table 6 (Control Arm), 
based on previous studies6,46,48,59,60,64,74,86-95 and Dr. Kaneki’s pilot study. 
 
Table 6. Elements of the composite endpoint 
and their assumed incidence rates 
Control 
Incidence Rate 
CoQ10 
Incidence Rate 
Acute Kidney Injury (KDIGO) (Stage 1 -3) 
40% 
32% 
ARDS (Berlin Definition) (Mild – Severe) 
40% 
32% 
Cardiovascular Dysfunction (Score 1 - 4) 
70% 
56% 
Coagulopathy (Score 1 - 4) 
70% 
56% 
Liver dysfunction (Score 1 - 4) 
10% 
8% 
Death (All Causes) 
8% 
6.4% 
 
Quarterly Enrollment Target: 290 burn patients will be enrolled at the 15 sites and each 
site is anticipated to enroll 19 patients during the study period. The quarterly enrollment 
targets are shown below in Table 7. 
 
   Table 7 
Year 
1 
Year 
2 
Year 
3 
Year 
4 
Q1 Q2 Q3 
Q4 
Q1 
Q2 
Q3 
Q4 
Q1 
Q2 
Q3 
Q4 
Q1 Q2 
Q3 
Q4 

 
21
Quarterly 
- 
- 
24 
24 
25 
24 
24 
25 
24 
24 
25 
24 
24 
25 
- 
- 
Cumulative 
- 
- 
24 
48 
73 
97 
121 146 
170 
194 219 
241 
265 290 
290 
290 
 
 
DATA MANAGEMENT AND DATE SAFETY MONITORING PLAN 
 
Data management:  Data will be housed in a secure database at the University of California 
Davis Data Coordinating Center (UCD-DCC). The UCD-DCC will utilize the RedCap data 
management tool to manage this clinical study. Records containing PHI will be managed 
according to the requirements of the HIPAA Privacy Rule. All subject case study forms and 
records will be de-identified and assigned a unique study number to protect patient privacy 
and maintain confidentiality. PHI will be maintained at the participating sites for the 
purpose of data verification. Any hard copy source documents will be stored in a locked file 
at each site for a minimum of three years after study closure and completion of analysis. If 
any information from this study is presented at scientific meetings or published, subject 
names and PHI will not be used. 
Data safety monitoring plan and interim analysis: We will follow the guidelines of the 
DoD to form the Data Safety Monitoring Board (DSMB). The DSMB will monitor the 
overall status of the trial: number of patients enrolled overall and per each center, adherence 
to protocol overall and per center and results of the interim analysis.  
Risk management and emergency response: We do not anticipate any severe adverse event 
(SAE) related to the supplement or placebo. No adverse events (AEs) occurred in Dr. 
Kaneki’s pilot study of CoQ10 that enrolled 30 burn patients. We will, however, establish 
risk management and emergency response plans. Site PIs and site Co-investigators will 
monitor the safety environment of the participants. If an adverse event (AE) or unanticipated 
problem occurs during the study period, it will be reported to the overall PI, the site PI, the 
overall study IRB, and the UCD-DCC. In that case the overall PI will report the AE to other 
site PIs. The site PI and/or overall PI will submit an expedited SAE report to the American 
Burn Association and the USAMRMC within 24 hours of the event being reported to the PI. 
The expedited report will be followed by a detailed, written SAE report. The DSMB will 
convene and decide necessary responses to unpredictable risks or changes in the protocols 
such as dose reduction and inclusion/exclusion criteria.  
 
RISKS OF STUDY PARTICIPATION 
 
Possible complications of non-surgical procedures: The blood samples will be 
withdrawn from an existing central IV line or venipuncture if a central IV line is not 
available. No new indwelling catheters will be placed in order to obtain blood samples. 
Blood draw from central venous lines may be associated to a small risk of infection; 
however the procedure will be only performed by authorized and experienced healthcare 
personnel. The risk of venipuncture is minimal. Hematoma formation and phlebitis are 
possible complications; however the occurrence is very rare with rapid resolution and 
venipuncture will be performed only when the patient needs other labs drawn in her/his 
clinical care. 
Supplementation side effects and toxicities: Risks and discomfort associated with this 

 
22
study will be small. CoQ10 is a nutrient and not a drug. Dr. Kaneki obtained an IND 
exemption from the FDA for his pilot study of CoQ10 supplementation (1,800 mg/day) in 
burn patients. The safety of CoQ10 and placebo supplementation in both tablet and liquid 
formulas has been shown in previous clinical studies in healthy subjects and patients with 
other disease conditions. High doses of CoQ10 (e.g., 2400 - 3,600 mg/day) have been used 
in clinical studies in the United States and the long-term safety of high-dose CoQ10 (3,000 
mg/day or 3,600 mg/day) has been shown in patients with Huntington’s disease, 
amyotrophic lateral sclerosis (ALS) and Parkinson’s disease, and in healthy subjects. To 
date, no serious adverse side effect of CoQ10 has been reported regardless of the dosage. 
Side effects are typically mild and brief, stopping without any treatment needed. 
Reactions are rare but may include nausea, vomiting, stomach upset, heartburn, diarrhea, 
loss of appetite, skin itching, rash, insomnia, headache, dizziness, increased light 
sensitivity of the eyes, fatigue, or flu-like symptoms. There may be other risks that are 
currently unknown about supplementation of CoQ10 or placebo. 
Psychosocial (non-medical) risks: Other potential major risks involve privacy concerns. 
As such, all data will be coded and only available to the immediate research team and the 
UCD-DCC. Data will be stored in the HIPPA- compliant REDCap (Research Data Capture) 
system. Whole blood samples will be labeled according to an established code to be able to 
identify patients when/if needed. All samples will be stored in a secure -80°C freezer at 
UTMB. Subject identifying information and the informed consent will be maintained in a 
locked cabinet in a locked room in the Clinical Research Department of each study site. 
Results obtained from individual subjects will be analyzed, reported, and discussed in 
reference to Subject ID only. All investigators and study staff are required to receive 
training in the ethical use of humans in research. We will not obtain any genetic 
information, such as DNA sequence, single-nucleotide polymorphism, haplotype and gene 
expression, although we will measure total amounts of mitochondrial DNA in plasma. 
 
IND EXEMPTION 
 
Given that CoQ10 is classified as a nutrient, Dr. Kaneki received an IND exemption for the 
original pilot trial. As we will be using the same preparation in the same route of 
administration and in the same dosage ranges, we do not have plans to repeat obtaining an 
IND exemption for the present study. 
 
PROJECT MILESTONES 
 
(1) Regulatory documents and research protocols (1-6 months): It will take at least 2- 3 
months for regulatory review and approval of this clinical trial by the USAMRMC Human 
Research Protection Office (HRPO). In the meantime, the protocol will be reviewed and 
approved by the UT Southwestern (UTSW) Institutional Review Board (IRB). As an 
institution, UTSW participates in SmartIRB, a platform designed to facilitate multicenter 
clinical research among participating institutions through single IRB reliance. We anticipate 
that the overall PI will have the protocol approved by the UTSW IRB prior to the funding 
start date and will have secured IRB reliance from the other 14 participating centers. A Data 
Safety Monitoring Board (DSMB) will be formed.  

 
23
(2) Inception of patient enrollment: After the IRB protocols are approved and data and 
sample collection methods are confirmed by site visits of the overall PI and the data 
management staff of the UCD-DCC within the first 6 months of Year 1, we will start 
enrollment of eligible patients by month 6. Human subjects protection, compliance, quality 
of data collection, and pace of enrollment will be monitored by the DSMB, the UCD-DCC, 
and the overall and site PIs.  
 (3) Data analysis and reports: In the latter half of Year 4, we will perform all the 
statistical analyses of clinical data and biomarkers and write reports and a manuscript. 
 
 
 
 
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