Ultra High Dose Diuretic Strategy for Management of Acute Decompensated Heart Failure - A Randomized, Double-Blind Pilot Trial
Phase: PHASE2
Conditions: Heart Failure; With Decompensation
Sponsor: Mayo Clinic

 
 
Ultra High Dose Diuretic Strategy for 
Management of Acute Decompensated Heart 
Failure - A Randomized, Double-Blind Pilot Trial 
 
NCT06036914 
 
8February2024 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 1 of 28 
CONFIDENTIAL 
 
Ultra-High Dose Diuretic Strategy for Management of Acute 
Decompensated Heart Failure - A Randomized, Double-Blind Pilot 
Trial  
 
 
 
 
Regulatory Sponsor: 
Yogesh N. V. Reddy, M.B.B.S., MSc 
Naveen Pereira, MD 
Department of Cardiovascular Disease 
Mayo Clinic 
200 First Street  
Rochester, MN 55905 
 
Co-I 
Timothy Larson 
Division of Nephrology 
Mayo Clinic 
Rochester MN 55905 
 
Study Intervention Provided by: : Mayo Pharmacy 
Protocol Number: (IRBe) 
IRB 23-005262 
 
IND Number: 
NA 
 
 
 
 
 
Initial version: 1May2023 Version (1.0) 
Amended version: 31August2023 Version (2.0)  
Amended version: 12December2023 Version (3.0) 
Amended version: 08February2024 Version (4.0) 
 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 2 of 28 
CONFIDENTIAL 
The table of contents headings and page numbers can be AUTOMATICALLY updated after all 
the other changes have been made to the protocol template.  Right click on the Table of Contents 
field and use the “Update Field” function in MS-Word. 
 
This should be done at the very end before finalizing the document then confirm that the 
section identification and page numbers are correct. 
 
Table of Contents 
 
1. 
STUDY 
SUMMARY……………………………………………………………….………………….Error! Bookmark not 
defined. 
2. 
STUDY 
TEAM 
ROSTER……………………………………………………………….……………Error! Bookmark not defined. 
3. 
STUDY 
OBJECTIVES…………………………………………………………………….…………Error! Bookmark not 
defined. 
3.1 
Primary Objective……………………………………………………………………………8 
3.2 
Secondary Objectives …………………………………………………………..…………8 
4. 
BACKGROUND 
AND 
RATIONALE……………………………………………………..………Error! Bookmark not defined. 
5. 
STUDY 
DESIGN……………………………………………………………………………………..Error! Bookmark not 
defined. 
6. 
SELECTION 
AND 
ENROLLMENT 
OF 
PARTICIPANTS……………………….…………..Error! Bookmark not defined. 
6.1 
Inclusion 
Criteria……………………………………………………………………………Error! 
Bookmark 
not 
defined. 
6.2 
Exclusion Criteria……………………………………………………………………2 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 3 of 28 
CONFIDENTIAL 
6.3 
Study 
Enrollment 
Procedures………………………………………………………Error! Bookmark not defined. 
7. 
STUDY 
INTERVENTIONS…………………………………………………………………………Error! Bookmark not 
defined. 
7.1 
Interventions, Administration, and Duration…………………………….……………..11 
7.2 
Handling of Study Interventions………………………………………………….………12 
7.3 
Concomitant Interventions………………………………………………………………..12 
7.3.1 Allowed Interventions…………………………………………………………….12 
7.3.2 Required Interventions…………………………………………………………...12 
7.3.3 Prohibited Interventions………………………………………………………….13 
7.3.4 Adherence Assessment…………………………………………………….3 
8. 
STUDY PROCEDURES……………………………………………………….…………………….13 
8.1 
Description of Evaluations……………………………………………………………………14 
8.1.1 Screening Evaluation……………………………………………………………..….14 
8.1.2 Enrollment,Baseline,and/or Randomization……………………………………………14 
8.1.3 Follow-up Visits………………………………………………………………………………15 
8.1.4 Completion/Final 
Evaluation……………………………….………………………………Error! Bookmark not defined. 
8.2   SCHEDULE OF EVALUATIONS…………………………………………………………………  
…Error! Bookmark not defined. 
9.     SAFETY ASSESSMENTS……………………………………………………………………………..15 
9.1 
  Adverse Drug Reactions and safety aspects with Pravastatin………………………….7 
9.2 
  Adverse Drug Reactions and safety aspects with spironolactone…………………….18 
9.3 
Specification of Safety Parameters………………………………………………………………Error! 
Bookmark not defined. 
9.4 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters…..Error! 
Bookmark not defined. 
9.5 
Adverse 
Events 
and 
Serious 
Adverse 
Events………………………………………………….Error! Bookmark not defined. 
9.5.1 
Classification 
of 
AE 
Severity…………………………………………………………………Error! Bookmark not defined. 
9.5.2 AE Attribution Scale……………………………………………………………………………17 
9.6 
Reporting 
Procedure…………………………………………………………………………………Error! 
Bookmark 
not 
defined. 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 4 of 28 
CONFIDENTIAL 
9.7 
Follow-up 
for 
Adverse 
Events……………………………………………………………….Error! Bookmark not defined. 
9.8 
Safety 
Monitoring……………………………………………………………………………………..Error! Bookmark not 
defined. 
10. 
INTERVENTION 
DISCONTINUATION………………………………………………………….Error! Bookmark not defined. 
11. 
STATISTICAL 
CONSIDERATIONS……………………………………………………………...Error! Bookmark not defined. 
11.1 
General 
Design 
Issues………………………………………………………………………………Error! Bookmark not defined. 
11.2 
Sample 
Size 
and 
Randomization………………………………………………………………….Error! Bookmark not defined. 
11.2.1 Treatment 
Assignment 
Procedures……………………………………………………..Error! Bookmark not defined. 
11.3 
Interim 
analyses 
and 
Stopping 
Rules……………………………………………………….Error! Bookmark not defined. 
11.4 
Outcome 
measures……………………………………………………………………………Error! Bookmark not 
defined. 
11.4.1 Primary 
trial 
objective……………………………………………………………………….Error! 
Bookmark 
not 
defined. 
11.4.1.1 Primary Outcome Measures ………………………………………………24 
11.4.2 Secondary 
trial 
objective……………………………………………………………..Error! Bookmark not defined. 
11.4.2.1 Outcome Measures………………………………………………………...24 
11.4.3 Third 
trial 
objective……………………………………………………………………Error! Bookmark not 
defined. 
11.4.3.1 Outcome Measures…………………………………………………………24 
11.5 
Data 
Analyses………………………………………………………………………………….Error! Bookmark 
not defined. 
12. 
DATA 
COLLECTION 
AND 
QUALITY 
ASSURANCE…………………………………………Error! Bookmark not defined. 
12.1 
Data 
Collection 
Forms………………………………………………………………………………..Error! Bookmark not defined. 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 5 of 28 
CONFIDENTIAL 
12.2 
Data 
Management…………………………………………………………………………………….Error! 
Bookmark 
not defined. 
12.3 
Quality 
Assurance……………………………………………………………………………………..Error! Bookmark not 
defined. 
12.3.1 Training………………………………………………………………………………...23 
12.3.2 Quality Control Committee…………………………………………………………...23 
12.3.3 Metrics ………………………………………………………………………………………….23 
12.3.4 Protocol Deviations…………………………………………………………………...23 
12.3.5 Monitoring………………………………………………………………………………24 
13. 
PARTICIPANT 
RIGHTS 
AND 
CONFIDENTIALITY………………………………………..Error! Bookmark not defined. 
13.1 
Institutional 
Review 
Board 
(IRB) 
Review……………………………………………………Error! Bookmark not defined. 
13.2 
Informed 
Consent 
Forms…………………………………………………………………………….Error! Bookmark not defined. 
13.3 
Participant 
Confidentiality……………………………………………………………………………Error! 
Bookmark 
not 
defined. 
13.4 
Study 
Discontinuation………………………………………………………………………………...Error! 
Bookmark 
not defined. 
14. 
ETHICAL 
CONSIDERATIONS……………………………………………………………………..Error! Bookmark not 
defined. 
15.
 
COMMITTEES………………………………………………………………………………………….Err
or! Bookmark not defined. 
16. 
PUBLICATION 
OF 
RESEARCH 
FINDINGS……………………………………………………Error! Bookmark not defined. 
17.
 
REFERENCES…………………………………………………………………………………………Err
or! Bookmark not defined. 
SUPPLEMENTS/APPENDICES…………………………………………………………………………….Err
or! Bookmark not defined. 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 6 of 28 
CONFIDENTIAL 
Appendix 
A………………………………………………………………………………………………………Error! 
Bookmark not defined. 
Data 
and 
Safety 
Monitoring 
Plan………………………………………………………………………….Error! Bookmark not defined. 
Appendix B………………………………………………………………………………………………………34 
DSMP Sample Study Report Outline…………………………………………………………….……….34 
 
 
 
 
 
 
 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 7 of 28 
CONFIDENTIAL 
 
List of Abbreviations 
 
 
LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
AF 
Atrial Fibrillation 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
 
 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
PHI 
Protected Health Information 
PI 
Principal Investigator 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SOP 
Standard Operating Procedure 
VT 
Ventricular Tachycardia 
 
 
 
 
 
 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 8 of 28 
CONFIDENTIAL 
1. Study Summary 
Title 
Ultra-High Dose Diuretic Strategy for Management of Acute 
Decompensated Heart Failure-A Randomized, Double-Blind Pilot Trial 
Running Title 
Ultra-High Dose Diuretics for Heart Failure 
Protocol Number 
23-005262 
Phase 
Phase: 2 
Methodology 
Randomized, parallel-group clinical trial in acute decompensated heart 
failure patients with volume overload (requiring hospitalization) 
 
Group 1: Ultra high dose intervention with intravenous bumetanide 
12.5 mg bid over 24 hours Group 2: Standard dose intervention with 
intravenous furosemide as twice the home dose of oral diuretic in 
furosemide equivalents bid  over 24 hours  
Overall Study 
Duration 
12 months 
Subject Participation 
Duration 
Approximately 24 hours 
Single or Multi-Site  
Single Site-Mayo Clinic Rochester, MN 
Objectives 
To determine the safety and efficacy of ultrahigh dose diuretics 
compared to standard dose diuretics over 24 hours in patients with 
decompensated heart failure 
Number of Subjects 
20 patients total 
Diagnosis and Main 
Inclusion Criteria 
We will include patients with decompensated heart failure requiring 
hospitalization for intravenous diuresis regardless of ejection fraction. 
Study Product, Dose, 
Route, Regimen 
Patients will be randomized 1:1 to ultra-high dose (IV bumetanide 12.5 
mg bid) vs standard dose (IV furosemide as twice the home dose of 
oral daily diuretic in furosemide equivalents administered bid) for 24 
hours. Participants will undergo comprehensive physiological 
assessment at baseline and 24 hours with short Iohexol clearance for 
true glomerular filtration rate, apnea hypopnea index, 
electrocardiography, echocardiography, serum, and urine biomarkers. 
Patients will be monitored for side effects including muscle cramps, 
new onset atrial fibrillation (AF), sustained ventricular tachycardia 
(VT), symptomatic hypotension (MAP<60 or systolic blood pressure 
<80 mmHg), development of renal insufficiency and dialysis initiation. 
Duration of 
Administration 
Patients will be on therapy for 24 hours.  

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 9 of 28 
CONFIDENTIAL 
Statistical 
Methodology 
The primary efficacy endpoint is urine output over 24 hours which will 
be compared by T test between the two groups. Primary safety 
endpoint will be incident decline in creatinine estimated glomerular 
filtration rate by 50% over 24 hours. Key secondary endpoints include 
weight change, NT-proBNP change, urine output, urine sodium 
excretion, creatinine, and cystatin C estimated GFR changes, apnea-
hypopnea index, Iohexol glomerular filtration rate, serum and urine 
proteomic analyses, peripheral vein pressure and echocardiographic 
changes over 24 hours, estimated GFR at day 7 or discharge 
(whichever is sooner) will each be compared by T test between the two 
groups.  
 
2. STUDY TEAM ROSTER 
Role/Name 
Contact Information 
Principal Investigator 
 
Yogesh Reddy, M.D. 
Department of Cardiovascular Diseases 
Mayo Clinic Rochester 
200 First Street SW 
Rochester, MN 55905 
Phone: 507-284-2904 
E-mail: reddy.yogesh@mayo.edu 
Naveen Pereira, M.D. 
Department of Cardiovascular Diseases 
Mayo Clinic Rochester 
200 First Street SW 
Rochester, MN 55905 
Phone: 507-284-2904 
E-mail: pereira.naveen@mayo.edu 
Co-Investigators: 
 
 
Virend Somers, MD 
Department of Cardiovascular Diseases 
Mayo Clinic Rochester 
200 First Street SW 
Rochester, MN 55905 
 
Timothy Larson, MD 
Department of Nephrology 
Mayo Clinic Rochester 
200 First Street SW 
Rochester, MN 55905 
 
 
 
 
 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 10 of 28 
CONFIDENTIAL 
3. 
STUDY OBJECTIVES 
3.1 
Primary Objective 
The primary objective of this trial is to demonstrate the superiority of ultrahigh dose diuretics 
compared to conventional diuretic strategies in terms of urine output at 24 hours. 
 
3.2 
Secondary Objectives 
The secondary objectives of this study are  
a) To demonstrate safety of ultrahigh dose diuretics at 24 hours defined as development of 
renal insufficiency (creatinine estimated GFR decline of 50%), and hypotension 
(symptomatic MAP<60 or systolic blood pressure <80 mmHg).  
b) To determine mechanistic changes in cardiac function, sleep parameters and biomarker 
changes in response to ultrahigh dose diuretics compared to standard dose diuretics. 
c) To compare 24 hour change creatinine and cystatin C based changes in GFR with gold 
standard Iohexol clearance testing of GFR among the two diuretic strategies 
 
3.3. 
 Exploratory Objectives 
a) To compare length of hospital stay in the ultrahigh versus usual dose groups 
b) To compare total diuretic use in hospital between the ultrahigh versus usual dose groups 
c) To compare 90-day heart failure rehospitalizations between the ultrahigh versus usual 
dose groups  
d) To compare creatinine based GFR changes from baseline to day 7 or discharge 
(whichever is sooner) between ultrahigh versus usual dose groups 
e) To explore proteomic changes in blood and urine between the ultrahigh versus usual dose 
groups 
f) To examine changes in apnea-hypopnea index between ultrahigh and usual dose groups 
g) To determine daytime and nighttime blood pressure patterns between ultrahigh and usual 
dose groups 
h) To compare arterial stiffness alterations between ultrahigh and usual dose groups 
i) To explore changes in liver elastography in the ultrahigh versus usual dose groups 
 
4. BACKGROUND AND RATIONALE 
4.1 Rationale  
Acute decompensated heart failure with volume overload is one of the most common causes 
of hospitalization and is associated with prolonged lengths of stay and substantial expense. 
Longer lengths of stay are not only associated with greater expense, but also increase the 
risk of deconditioning and secondary complications. Furthermore, current diuretic strategies 
are often associated with little to no weight loss in many patients over their hospital stay likely 
due to inadequate decongestion.1 Therefore, there remains an important unmet need to 
achieve more effective and pragmatic approaches to in hospital diuresis to maximize 
decongestion in a safe and time-efficient manner.  
 
Randomized trials of in hospital diuretic strategies are limited but the DOSE trial randomized 
patients to a high versus low dose diuretic strategy and demonstrated a trend to improved 
decongestion (that did not reach statistical significance) with small transient rises in creatinine 
without long term risk of complications or renal failure.2 More recent data suggested that rises 
in creatinine during diuresis are actually paradoxically associated with the best outcomes 
(likely due to it being a marker of effective decongestion), and there was no long term 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 11 of 28 
CONFIDENTIAL 
sequelae of these transient creatinine changes or even more sophisticated markers of tubular 
injury during diuresis.3 Therefore, small changes in creatinine during more aggressive diuresis 
are likely not clinically important. Additionally, patients with heart failure generally improve 
renal function, cardiac output and blood pressure once effectively decongested due to 
alleviation of renal congestion, relative pericardial restraint, improvement in right heart 
afterload from reduction in pulmonary artery pressure, and improvement in mitral/tricuspid 
regurgitation. Moreover, our observational data suggest that very high dose diuretic strategies 
in decompensated heart failure appears safe. The central hypothesis for this study is that a 
more aggressive diuretic strategy will result in larger volume and more rapid diuresis without 
harm. This will have advantages for patient care by simplifying diuretic strategies for 
decompensated heart failure to potentially a high dose strategy as default diuretic approach, 
enhance probability of effectively decongesting patients and potentially result in shorter 
lengths of stay with benefits for patients and healthcare systems. The PI has utilized >50 mg 
of bumetanide IV equivalents daily as standard of care for practice for management of heart 
failure patients in the cardiac ICU for the last 2 years (bumetanide bolus followed by 24 hour 
infusion at 2 mg/hour =>50 mg bumetanide daily) with what appears to be efficacy and safety 
in observational analyses. The current dose of bumetanide is administered as bolus dosing 
x2 at less than half of the usual dose utilized in the Mayo CCU by the PI to enhance feasibility 
and blinding with bolus dosing and will allow formal study of the risks and benefits of this 
approach in this pilot RCT. 
 
 
In this pilot study we will therefore compare an ultra-high diuretic strategy with a conventional 
diuretic strategy in patients with decompensated heart failure with a primary efficacy end point 
of urine output at 24 hours. The primary safety endpoint will be a decline in serum creatinine 
estimated GFR by 50% of baseline value at 24 hours. This will be a double-blinded 
randomized pilot trial of ultra-high dose diuretics (IV bumetanide 12.5 mg bid for 24 hours vs 
IV furosemide at usual doses (twice the home dose of oral daily diuretic in furosemide 
equivalents administered bid). New initiation of adjunct diuretics (thiazide, SGLT2 inhibitors, 
acetazolamide, and spironolactone) will be discouraged during the 24-hour study period. Key 
secondary endpoints include weight change, NT-proBNP change, urine output, urine sodium 
excretion, creatinine, and cystatin C estimated GFR changes, apnea-hypopnea index, Iohexol 
glomerular filtration rate, serum and urine proteomic analyses, peripheral vein pressure and 
echocardiographic changes over 24 hours, estimated GFR at day 7 or discharge (whichever 
is sooner) will each be compared by T test between the two groups. 
 
4.2  Hypothesis: 
Ultrahigh dose diuretic infusion will be associated with greater diuretic response and will not 
be associated with clinically significant decline in eGFR over 24 hours (defined as decline in 
creatinine estimated GFR of 50% from baseline at 24 hours). 
 
4.3 Innovation:  
1. Ultra-high dose diuretic strategies have not been compared to conventional diuretic 
strategies in a randomized trial 
2. The use of a double-blind strategy will minimize bias in terms of diuretic adjustment and 
alternative therapies.  
3. The measurement of serum and urine biomarkers of renal injury, peripheral vein pressure 
and echocardiography changes at baseline and at 24 hours will provide novel insight into the 
hemodynamic, renal, and cardiac response to decongestion. 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 12 of 28 
CONFIDENTIAL 
4. The relationship between creatinine based GFR during non-steady state conditions such 
as active diuresis and extracellular volume reduction during diuresis, and true GFR measured 
by Iohexol clearance testing has never been studied.  
5. The effect of rapid diuresis on cardiac structure and function has not been well studied 
6. The short-term effect of rapid volume removal on measures of sleep is unknown 
7. Proteomic changes associated with high versus usual dose diuretics will be assessed to 
evaluate for differential expression of key pathways between the two strategies  
 
4.4 .Significance:  
1. The demonstration of safety and efficacy with ultra-high dose diuretic strategy compared 
to conventional diuretic infusion will be an important safety and preliminary efficacy finding to 
support a multicenter randomized phase III trial for superiority in relation to clinical outcomes. 
2. Delineating mechanisms of hemodynamic benefit to more aggressive decongestion and 
relationship to renal indices will advance our understanding of human cardiorenal syndrome 
 
4.5 Brief Synopsis of Methods:  
• 
Accrual of 20 patients with decompensated heart failure requiring hospitalization 
randomized to ultra-high vs conventional dose diuretic arms in a double-blind design over 24 
hours. Anticipate 25 patients will be enrolled to accrue 20 patients. 
• 
Baseline assessment of renal Iohexol clearance, echocardiography, blood sampling and 
urine sampling and nocturnal Watch Pat one assessment (apnea-hypopnea index), with all 
above assessments repeated after 24 hours.  
• 
Follow up phone assessment at 90 days to assess heart failure readmission rates. 
 
5. STUDY DESIGN 
This study is a double-blind randomized phase II pilot trial testing the safety and efficacy of 
ultra-high dose diuretics compared to standard dose diuretics over 24 hours in acute 
decompensated heart failure. Subjects will be screened after admission to the hospital with 
decompensated heart failure following stabilization and will be consented and offered 
participation in the trial. Once consent has been obtained, baseline serum and urine 
measures will be obtained along with administration of randomized treatment assignment for 
a total of 2 intravenous doses bid. An ambulatory blood pressure monitor (ABPM) will be 
worn for a 48 hour period starting from randomization. Additional mechanistic measures 
including short renal Iohexol clearance (2 hour), echocardiography, arterial tonometry, liver 
elastography, and nocturnal apnea-hypopnea index (Watch Pat) will be performed. Final 
endpoint assessment with repeat of all baseline measures including Iohexol clearance, 
echocardiography, arterial tonometry, liver elastography, and nocturnal apnea-hypopnea 
index (Watch Pat) will be performed on Day 2 after the 24-hour intervention. A final phone 
call visit at 90 days will assess for adverse events and heart failure hospitalization over the 
post discharge period. 
 
 
6. SELECTION AND ENROLLMENT OF PARTICIPANTS 
6.1  Inclusion Criteria 
1. Age ≥ 18 years 
2. Diagnosis of decompensated heart failure receiving intravenous diuretics  
3. Ability to provide informed consent 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 13 of 28 
CONFIDENTIAL 
6.2  Exclusion Criteria 
1. Patients on home inotrope medications 
2. Patients with Chronic Kidney disease stage V and end stage renal failure on dialysis 
3. Patients lacking the capacity to consent for themselves 
4. Known pregnancy or breastfeeding mothers 
5. Complex congenital heart disease 
6. Allergy to furosemide or bumetanide 
7. Respiratory failure requiring non-invasive ventilation (CPAP/BiPAP) or invasive 
mechanical ventilatory support at the time of randomization 
8. Hypotension with systolic blood pressure <80 mm Hg at the time of randomization 
9. Acute coronary syndrome 
10. Sustained Ventricular tachycardia requiring treatment in the last 48 hours 
11. Patients weighing ≤ 40 kg 
 
 
6.3 
Study Enrollment Procedures 
Eligible patients will be identified from screening of the hospitalized heart failure patients and 
approached in person for potential consent.  
 
7. STUDY INTERVENTIONS 
7.1 Interventions, Administration, and Duration  
The ultrahigh dose diuretic arm will receive IV bumetanide 12.5 mg bid for 2 doses total within 24 
hours. The standard dose diuretic arm will receive IV furosemide at usual doses (twice the home 
dose of oral daily diuretic in furosemide equivalents) administered as 2 doses total within 24 
hours. Furosemide equivalents will be considered as follows (40 mg of intravenous furosemide 
= 1 mg oral bumetanide or 40 mg of torsemide or 80 mg of oral furosemide consistent with 
prior literature). There is variability in the reported literature on the conversion from torsemide to 
furosemide ranging from 1 mg: 1-2 mg conversion for torsemide to intravenous furosemide (JAMA 
2023 Jan 17;329(3):214-223). We selected a 1:1 conversion from torsemide to IV furosemide for 
the standard of care arm to avoid excessively high furosemide doses for those on high doses of 
home oral torsemide such as 100 mg bid. The determination of diuretic dose for each of the two 
study drug administrations in the usual care group will be determined as twice the total home daily 
diuretic dose as IV furosemide split over 2 doses for bid administration. (See table for conversion 
of commonly used doses) If patients are diuretic naïve, they will be administered 40 mg IV bid if 
randomized to usual care. This will be the lowest administered diuretic dose in the standard of 
care arm. Therefore, if patients are on very low oral diuretic doses at home, they will be 
administered no lower a dose than 40 mg IV bid of furosemide for standard of care arm. The 
maximum allowable dose of IV furosemide in the standard of care arm will be 100 mg IV bid. 
Patients will be monitored for side effects including muscle cramps, new onset Atrial fibrillation 
(AF), sustained Ventricular tachycardia (VT), symptomatic hypotension (systolic BP<80), and 
dialysis initiation. Following the 2 study drug doses, patients will be subsequently treated by their 
physicians as per standard of care. 
Home dose of diuretic 
Study diuretic in standard of care arm 
<80 mg of oral furosemide equivalent daily 
40 mg furosemide IV bid 
80 mg of oral furosemide equivalent daily  
40 mg furosemide IV bid  

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 14 of 28 
CONFIDENTIAL 
(40 mg of oral furosemide bid or 
20 mg torsemide oral bid or 
80 mg or furosemide daily or 
40 mg of torsemide daily or 
1 mg of bumetanide daily) 
120 mg of oral furosemide equivalent daily 
(60 mg of oral furosemide bid or  
30 mg torsemide oral bid or 
120 mg of oral furosemide daily or  
60 mg torsemide oral daily or 
1.5 mg of bumetanide daily 
60 mg furosemide IV bid  
160 mg of oral furosemide equivalent daily  
(80 mg of oral furosemide bid or 
40 mg torsemide oral bid or 
160 mg of furosemide daily or 
80 mg of torsemide daily or 
2 mg of bumetanide daily) 
80 mg furosemide IV bid  
200 mg of oral furosemide equivalent daily  
(100 mg of oral furosemide bid or 
60 mg torsemide oral bid or 
200 mg of furosemide daily or 
120 mg of torsemide daily or 
2.5 mg of bumetanide daily) 
100 mg furosemide IV bid  
>200 mg of oral furosemide equivalent daily 100 mg furosemide IV bid 
 
Furosemide oral equivalent conversion 
80 mg of oral furosemide = 40 mg of oral torsemide = 1 mg or oral bumetanide = 40 mg of IV 
furosemide  
7.2 Handling of Study Interventions  
The study drug will be prepared and provided by the St Marys research pharmacy after 
randomization. 
7.3 Concomitant Interventions 
7.3.1 Allowed Interventions 
All interventions necessary for the optimal medical therapy of the patients are allowed.  
7.3.2 Required Interventions  
None 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 15 of 28 
CONFIDENTIAL 
7.3.3 Prohibited Interventions 
Patients should not be on drugs that can significantly increase the risk side effects with  
bumetanide and furosemide, i.e., inotropic medications. New initiation of additional diuretic 
agents for synergistic diuresis (thiazide, acetazolamide, SGLT2 inhibitors and 
spironolactone) will be discouraged during the 24 hour study period to avoid electrolyte 
imbalance with potential randomization to very high dose diuretic arm. Following the 24 
hour study period, addition of other diuretics and medications is as per the treating team 
per standard of care. 
7.3.4    Adherence Assessment  
The number of study drug administered and use of adjunct diuretics outside study protocol 
will be monitored and collected. 
8. STUDY PROCEDURES 
An overview of the scheduled evaluations is provided in the following table.  
 
Schedule of Events 
 
Day of 
Consent 
(Day 1)  
Day 2  
Day 74 
(-4 days) 
Day 90 
(Phone 
visit) (+/- 
30 days) 
Informed Consent 
X 
 
 
 
Physical Exam 
X 
X 
 
 
Randomization to Medical 
Therapy 
X 
 
 
 
Administration of Medical 
Therapy 
X1 
X1 
 
 
Iohexol GFR testing 
X2 
X2 
 
 
Blood testing (NT proBNP, 
cystatin C, creatinine, 
hematocrit,) 
X 
X 
X7 
 
Research blood 
X3 
X3 
 
 
Urine testing (urine sodium, 
urine creatinine, NGAL, KIM-1) 
X3 
X3 
 
 
Electrocardiogram 
X5 
 
X6 
 
Echocardiogram 
X 
X 
 
 
Peripheral vein pressure 
X 
X 
 
 
Nocturnal Watchpat /Nox 
device screen 
X 
X 
 
 
Arterial Tonometry 
X 
X 
 
 
Ambulatory Blood Pressure 
X 
X 
 
 
Liver Elastography 
X 
X 
 
 
Adverse event assessment 
 
X 
X 
X 
Assessment for re-
hospitalization 
 
 
 
X 
Concurrent medication 
assessment 
X 
X 
 
X 
1Administration of Medical Therapy to be a total of 2 intravenous doses bid, administered by 
inpatient staff nurses 
2Iohexol GFR testing (Renal Clearance) to be performed at bedside by CRTU staff 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 16 of 28 
CONFIDENTIAL 
3Blood and urine samples to be collected by CRTU staff. Samples will either be collected by 
CRTU or transported by study staff to CRTU in tubes on ice when necessary. 
4Day 7 or day of discharge, whichever is earlier 
5Baseline ECG clinically indicated. If > 48 hours prior to randomization, must be repeated. 
6ECG for research for comparison 
7Estimated GFR at day 7 or discharge (whichever is sooner) 
 
8.1 Description of Evaluations 
8.1.1 Screening Evaluation 
Patients will be evaluated during their hospitalization for eligibility at St Marys hospital, Rochester, 
MN 
 
8.1.2 Enrollment, Baseline, and/or Randomization 
After confirming eligibility, informed consent will be obtained. Following consent, patients will be 
randomized 1:1 to ultrahigh vs standard dose diuretic strategies. 
Day 1 (0-24 hours) 
After randomization, patients will undergo comprehensive baseline assessment including 
weight, echocardiogram, history, and physical examination. Initial randomized therapy will be 
administered at least 6 hours after last clinically administered dose of IV diuretic (or immediately 
if no IV diuretic has been administered in the last 6 hours). Participants will be urged to void 
their bladders and discard urine at baseline immediately prior to receiving study drug. All 
baseline testing will be performed when feasible once consent is obtained. Baseline testing will 
include blood sample testing for NT proBNP, creatinine, cystatin C and hematocrit. Urine 
collection for urine creatinine and sodium will be specifically collected timed 1-2 hours after the 
administration of study diuretic dose to allow estimation of urine sodium excretion. 32 ml of 
blood and 30 ml of urine will be stored for future analyses. Peripheral venous pressure will be 
recorded from existing IV lines through pressure transducer monitoring from study team.  
In addition to blood testing as above, Iohexol  based GFR calculation using subcutaneously 
injected Iohexol and timed samples of blood and urine to calculate GFR will be used for 
research with a procedure following typical inpatient practice Iohexol  based GFR measurement. 
We will use the short  Iohexol protocol with subcutaneous iothalmate injection (Time 0:T0), urine 
sampling at 1 hour after subcutaneous injection, with total urine volume collected over the 1-
hour period (T0 to 1 hour). Urine and serum samples will be collected again approximately 45 
minutes later from T60. Serum and urine samples for Iohexol will be collected at two time points 
after T0: i) T60 and ii) 45 minutes after T60. We will also continuously collect urine from 
subcutaneous injection until the end of the test, for quality control as per standard clinical 
practice. If Foley catheter is not present at baseline, participants will be asked to void voluntarily 
prior to renal study initiation with bladder scanning to confirm residual urine following bladder 
emptying. Ambulatory blood pressure monitoring (ABPM) will be recorded via an upper arm cuff 
on the non-dominant arm. Over a 48-hour period (Days 1 & 2), a blood pressure reading will be 
taken every 30 minutes during the day and every hour at night. Arterial stiffness will be 
assessed via carotid tonometry and placing a femoral and brachial blood pressure cuff on the 
upper thigh and upper arm. A liver ultrasound scan (Fibroscan) of the abdominal region will 
quantify liver elastography and potential liver disease. 
Nocturnal screening for apnea-hypopnea index as a measure of sleep apnea will be performed 
using Watch Pat or Nox device. The Watch Pat is a non-invasive wrist monitor and will be worn 
overnight to test for sleep apnea The Nox device is a portable polysomnography device to 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 17 of 28 
CONFIDENTIAL 
measure sleep quality and determine sleep apnea presence. If patients have known sleep 
apnea, they will continue their home CPAP/BiPAP during the overnight test. 
 
 
8.1.3  Follow-up Visits 
Day 2 (24-48 hours) 
All baseline testing including blood sampling and storage, urine sampling and storage, short 
Iohexol clearance, history/physical including weight, echocardiogram, arterial stiffness, liver 
scan, and nocturnal Watch Pat screen will be repeated 24 hours after initial assessment. ABPM 
will continue and terminate after 48 hours of blood pressure recording. Following this all study-
related procedures will be complete. Hospital length of stay and total diuretic use will be 
documented. Clinical creatinine measurements obtained at Day 7 or discharge will be recorded 
for exploratory analyses. All AE’s will only be collected for Days 1 through Day 7. 
 
Day 90  
Phone call to review hospitalizations, AEs, and concomitant medications. Re- Hospitalizations will 
be collected as AEs, not lab values.  Following this all study-related procedures will be complete.  
 
 
9. SAFETY ASSESSMENTS  
9.1 Adverse Drug Reactions and safety aspects with bumetanide  
Muscle aches and myalgias is a known side effect of bumetanide and will be assessed by a Likert 
questionnaire (scale 0-10). New onset atrial fibrillation, ventricular tachycardia will be assessed 
by review of telemetry monitoring. Blood pressure will be assessed before administration of each 
diuretic dose and if blood pressure is <80 mm Hg this will be reviewed by the PI and clinical team 
before administering subsequent diuretic dose. 
 
9.2 Adverse Drug Reactions and safety aspects with furosemide 
Adverse reactions will be recorded as above for bumetanide. 
9.3  Specification of Safety Parameters 
Renal function panel will be checked at least twice as is standard practice during intravenous 
diuresis and K and Mg replacement will be adjusted as per electrolyte panel checks with oral KCl 
and Mg repletion utilized as per clinical practice. Intravenous repletion will be used when oral 
therapy is not tolerated. In the presence of substantial hypokalemia (K<2.9 mEq/dl), the 
subsequent diuretic dose will be held until K repletion has been administered.  
Blood pressure monitoring prior to each dose will ensure hemodynamic stability prior to 
administration of subsequent diuretic dose. If the systolic BP is <80 mmHg this will be reviewed 
by the PI and clinical team before administering subsequent diuretic dose. 
During arterial stiffness measures, if aortic pulse pressure is greater than 50 mmHg (derived from 
brachial BP), we will forgo carotid tonometry and femoral blood pressure measures. 
9.4 Methods and Timing for Assessing, Recording and Analyzing Safety Parameters 
Hemodynamic safety will be recorded by blood pressure monitoring prior to each administered 
study dose. 
9.5 Adverse Events and Serious Adverse Events 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 18 of 28 
CONFIDENTIAL 
All patients will be evaluated for adverse events (AEs) and serious adverse events (SAEs) 
routinely at the time of follow-up evaluations. In addition, patients will be instructed to call in with 
concerns and/or present to their primary care providers. Should concerns for AEs and SAEs be 
raised, these will then be evaluated further. The time frame of evaluation for AEs and SAEs is 
confined to the duration of their participation in this study. All events are to be recorded within 1 
day of  the study team being notified regardless of their relationship to the study intervention and 
will be adjudicated and classified as outlined below. 
For this study, and in agreement with general definitions, an AE is defined as  
• 
Any unfavorable and unintended diagnosis, symptom, sign (including an abnormal 
laboratory finding), syndrome or disease which either occurs during the study, having been 
absent at baseline, or if present at baseline, appears to worsen.  
A SAE is any adverse event that results in one or more of the following outcomes: 
• Death 
• A life-threatening event 
• Inpatient hospitalization or prolongation of existing hospitalization 
• A persistent or significant disability/incapacity 
• A congenital anomaly or birth defect 
• An important medical event based upon appropriate medical judgment 
Date and Time of Onset 
The date and time of onset is the date and time when the first sign(s) or symptom(s) were first 
noted. If the adverse event is an abnormal clinically significant laboratory test or outcome of an 
examination, the onset date is the date the sample was taken, or the examination was performed. 
 
Classification of AE Severity 
The Investigator must grade each adverse event according to the National Cancer Institute (NCI) 
Common Terminology Criteria for Adverse Events (CTCAE) (version 5.0). According to this 
guidance document all adverse events are rated on a 5-point scale corresponding to mild, 
moderate, severe, life-threatening, or disabling and death. 
Each adverse event must be graded according to the specific criteria for grading as described in 
the CTCAE. For events not described in the CTCAE the following criteria will be used: 
• 
Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated. 
• 
Grade 2: Moderate; minimal, local, or noninvasive intervention indicated; limiting age-
appropriate instrumental ADL*. 
• 
Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care 
ADL**. 
• 
Grade 4: Life-threatening consequences; urgent intervention indicated. 
• 
Grade 5: Death related to AE. 
 
Activities of Daily Living (ADL) 
*Instrumental ADL refer to preparing meals, shopping for groceries or clothes, using the 
telephone, managing money, etc. 
**Self-care ADL refer to bathing, dressing and undressing, feeding self, using the toilet, taking 
medications, and not bedridden. 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 19 of 28 
CONFIDENTIAL 
AE Attribution Scale 
AEs will be categorized according to the likelihood that they are related to the study intervention 
as determined by a clinician. The causal relationship can be one of the following: 
 
0 = unrelated 
1 = Unlikely 
2 = Possibly related 
3 = Probably related 
4 = Definitely related 
 
9.6. Reporting Procedure 
The reporting system that will be used in this study is summarized in the following table. The study 
statistician, program manager, and PI will be involved in all data reviews. Any adverse event rate 
more than twice the expected will be reported to the Mayo Clinic IRB and the study sponsor.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SAE 
Reporting 
SAEs that are unanticipated, serious, and possibly related to the study intervention will be 
reported by the PI to the IRB, and sponsor in accordance with requirements. 
• 
Unexpected fatal or life-threatening AEs related to the intervention will be reported to the 
within 7 days. Other serious and unexpected AEs related to the intervention will be reported 
within 15 days. 
• 
Anticipated or unrelated SAEs will be handled in a less urgent manner but will be reported to 
the IRB, and sponsor and other oversight organizations in accordance with their 
requirements.  
9.7 Follow-up for Adverse Events 
 
The safety profiles of  the study intervention are very well characterized and defined (see above). 
The rates and outcomes are not expected to deviate from clinical practice and thus this study will 
adhere to practice standards with assessment of AEs at 24 hours and 90 days. 
9.8 Safety Monitoring 
 
The investigator will allocate adequate time for monitoring activities. The Investigator will also 
ensure that the compliance or quality assurance reviewer is given access to all the study-related 
documents and study related facilities (e.g., pharmacy, diagnostic laboratory, etc.), and has 
adequate space to conduct the monitoring visit. 
Data type 
Frequency of review Reviewer 
Subject accrual (including compliance 
with protocol enrollment criteria) 
Quarterly 
Study statistician, Program 
Manager, PI 
Status of all enrolled subjects, as of date 
of reporting 
Quarterly 
Study statistician, Program 
Manager, PI 
Adherence data regarding study visits and 
intervention 
Quarterly 
Study statistician, Program 
Manager, PI 
AEs and rates 
(including out-of-range lab values) 
Quarterly 
Study statistician, Program 
Manager, PI,  
SAEs 
Per occurrence 
Study statistician, Program 
Manager, PI, sponsor 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 20 of 28 
CONFIDENTIAL 
All SAEs will be reported to the IRB according to institutional policy. Screening and application of 
exclusion criteria will minimize potential risks. 
As a service to the investigator, this study may be monitored during the conduct of the trial by 
staff from the Mayo Clinic Office of Research Regulatory Support. Clinical trial monitoring may 
include review of the study documents and data generated throughout the duration of the study 
to help ensure the validity and integrity of the data along with the protection of human research 
subjects. This will assist investigators in complying with Food and Drug Administration 
regulations. 
 
10. INTERVENTION DISCONTINUATION 
 
Discontinuation of the study intervention is recommended for any incapacitating and/or life-
threatening side effect. Resuming the study medication will depend on an evaluation if the drug 
can be safely resumed. Patients may have to permanently discontinue study interventions and 
for this reason participation in this study if intolerable side effects persist.  
At any point in time and for any reason, patients may withdraw voluntarily from participation in the 
study.  
In the absence of any reason for premature termination as outlined above, participation will end 
for every patient after 6 months of trial participation. 
Blood pressure will be assessed before administration of the second dose of assigned IV diuretic. 
In the event of symptomatic hypotension (symptomatic MAP<60 or systolic blood pressure <80 
mmHg), the participant will be evaluated by the PI and study team and further dose of study 
medication will be suspended. The patient, PI and clinical team  will be unblinded to allow the 
clinical team to make a determination of optimal subsequent plans of care and diuretic dosing. 
 
Study stopping rules for safety  
We will also implement Bayesian monitoring with utilization of an independent study monitor Dr 
Kent Bailey who will have access to unblinded patient data as they accrue with continuous 
monitoring of safety. Among the high dose diuretic arm, assuming a probability of serious 
adverse events of 1/20 (5%) as prior information, we will monitor for 1) symptomatic 
hypotension (defined above) and 2) a decline in estimated GFR from 0-24 hours of >50%. 
Based on prior experience with this intervention, we formulated a Bayesian prior distribution for 
the adverse event rate p associated with this intervention, tantamount to observing 1 adverse 
event in 20 previous patients, or a 5% prior probability.   Based on this prior, the Bayesian prior 
probability that the true adverse event rate exceeds  20%  is only  6%.   We have developed a 
stopping boundary, based on the Bayesian analysis of the accumulating data and the criterion 
that we would stop the trial if the posterior probability that the true AE rate exceeds 20% gets to 
40% or more.  This leads to the monitoring boundary at which point, we will pause the study and 
consider protocol modification and/or cessation of the study as appropriate. This decision will 
discussed and made by the PIs from cardiology (Dr Pereira, Reddy) and nephrology (Dr Larson) 
and statistician (Dr Bailey) 
Posterior probability (%)  that p > 20% 
 
 
 
 
 
 
 
 
 
 
 
Number 
of AE 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
5 
4 
3 
2.8 
2.3 
 
 
 
 
 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 21 of 28 
CONFIDENTIAL 
1 
15.5 13.5 12.5 10 
8.5 
7 
6 
 
 
 
2 
 
30 
27 
24 
21 
18 
16 
14 
 
 
3 
 
 
46 
42 
39 
35 
32 
29 
26 
 
4 
 
 
 
62 
58 
54 
50 
47 
43 
 
5 
 
 
 
 
75 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Based on Mayo observational data, we do not anticipate safety concerns with the high dose 
diuretic arm. “The recommended use of higher than recommended diuretic dosing for 
bumetanide is consistent with heterogeneous clinical practice and forms the basis for this 
prospective study. In our retrospective analysis of 102 patients with severe heart failure 
admitted to the Cardiac intensive care unit, 28% of patients were receiving very high dose of 
diuretics (mean dose of 1386 furosemide equivalents administered as bumetanide infusion 
which would be equivalent to roughly  35 mg of bumetanide administered daily which exceeds 
the commonly recommended max daily dose of 10 mg of bumetanide which is not based on any 
data). Very high dose bumetanide compared to conventional therapy (1386 mean furosemide 
equivalents in 24 hours compared to 257 furosemide equivalents, p<0.0001) was not associated 
with differences in change in mean arterial pressure over the 72 hours of ultra high dose 
diuretics (mean BP change 2.2 +/- 12.1 vs 4.1 +-12.6, p=0.48) but there was greater loss in 
weight (-10.8 +- 8.7 vs -7.2 +-8.6 kg, p=0.05) and urine output (10.0 +-4.7 vs 8.1 +/-3.8, p=0.04) 
with no concerning worsening of renal function (creatinine change -0.03 +/- 0.91 vs -0.02 +/-
0.89, p=0.81). It is currently the PI’s current practice in the CCU in the last 2 years to use a 12.5 
mg bumetanide bolus followed by an infusion at 2 mg/hr (equivalent of 60.5 mg of bumetanide 
daily) in critically ill cardiac ICU heart failure patients, which has been extremely successful at 
decongestion with no apparent serious adverse events or untoward hypotension. However, this 
strategy of upfront high dose diuresis has not been tested with the rigor of a randomized trial 
forming the basis for this study. The chosen dose of 12.5 mg of bumetanide bid is < half of the 
currently used diuretic strategy in most CCU patients treated by the PI and many others at Mayo 
Clinic, Rochester, and a bolus of 12.5 mg of bumetanide has been reported in other studies of 
heart failure patients 
. There remains no 
randomized data that high dose diuretics are nephrotoxic and the transient changes in renal 
function observed in clinical randomized trials are reversible and not associated with need for 
dialysis and are paradoxically associated with better outcomes.3 
 
  
11.STATISTICAL CONSIDERATIONS 
 
11.1 General Design Issues and possible approaches to address them 
Muscle cramps is a possible side effect of high dose bumetanide infusions and may limit 
continuation of bumetanide therapy. In the event of severe muscle pain, the dose of subsequent 
blinded infusion can be decreased to half the infusion to minimize pain with analgesic use as 
needed. If side effect is severe requiring change in therapy despite electrolyte correction and 
decrease in diuretic dosing, patients will be unblinded with subsequent therapy provided as per 
clinical practice. Providers are variable in adjunct strategies with vasodilators, inotropes, and 
adjunct diuretics during management of acute decompensated heart failure. We will exclude 
patients with anticipated initiation or use of inotropes at baseline, and adjunct thiazide diuretics 
will be discouraged for the 24 hours during the study protocol. We will only recruit patients with 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 22 of 28 
CONFIDENTIAL 
stable respiratory status without use of non-invasive or invasive mechanical ventilation to  
minimize need for rescue therapies. 
 
11.2 Sample Size and Randomization  
This is a pilot study and sample size of 20 is selected based on feasibility to determine probably 
efficacy and safety to guide design of a pivotal trial. The dose separation between ultrahigh and 
standard dose diuretics is higher than has previously been tested and there is no data on 
diuretic differences at such high doses. 
 
 
 
 
11.2.1 Treatment Assignment Procedures 
Randomization will be performed 1:1 after consent without block randomization or stratification. 
 
11.3 Interim Analyses and Stopping Rules 
Given small sample size, no interim analyses are planned 
 
 
11.4 Outcome Measures 
11.4.1 Primary trial objective 
To determine the diuretic effect of ultrahigh compared to standard diuretic measures 
 
11.4.1.1 Primary outcome measures 
Urine output at 24 hours 
 
 
11.4.2 Secondary trial objective 
Determine renal, cardiac, and systemic effects of ultra-high dose compared to standard diuretic 
regiments 
 
11.4.2.1 Outcome measures 
Key secondary endpoints include weight change, NT-proBNP change, urine output, urine 
sodium excretion, apnea-hypopnea index,  Iohexol glomerular filtration rate, peripheral vein 
pressure and echocardiographic changes over 24 hours 
 
 
 
11.5 Data Analyses 
11.5.1 Statistical Considerations and Methodology 
1.1 Overview: This is a single-site, randomized, double-blind, parallel-group clinical trial in acute 
decompensated heart failure patients with volume overload requiring hospitalization.  Patients 
will be randomized in a 1:1 fashion to either ultra high dose intervention with intravenous 
bumetanide 12.5 mg bid over 24 hours (Group 1) or standard dose intervention with 
intravenous furosemide as twice the home dose of oral diuretic in furosemide equivalents 
administered bid over 24 hours (Group 2).   
1.2 Primary and Secondary Objectives 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 23 of 28 
CONFIDENTIAL 
1.2.1 
Primary objective: To determine the diuretic effect of ultra high compared to 
standard diuretic measures. 
1.2.2 
Secondary objective: To determine renal, cardiac, and systemic effects of ultra 
high dose compared to standard diuretic regiments. 
1.3 Primary and Secondary Outcomes 
1.3.1 
Primary outcome: urine output at 24 hours after initiation of intravenous diuretic. 
1.3.2 
Secondary outcomes: changes in the following measures over 24 hours after 
initiation of intravenous diuretic: 
1.3.2.1 Body weight 
1.3.2.2 NT-proBNP change 
1.3.2.3 Urine sodium excretion 
1.3.2.4 Apnea-hypopnea index 
1.3.2.5 Iohexol glomerular filtration rate 
1.3.2.6 Peripheral vein pressure 
1.3.2.7 Echocardiographic measures of cardiac output, estimated RV systolic 
pressure, RA pressure, LA strain, LV and RV global longitudinal strain, 
E/e’ 
1.4 Primary Analysis 
1.4.1 
The primary analysis will be to compare urine output at 24 hours after initiation of 
intravenous diuretic.  All patients meeting eligibility criteria who provide informed 
consent, are randomized, and receive any dose of intravenous diuretic will be 
included in the primary analysis based on intention-to-treat (ITT) principles.  The 
difference in 24-hour urine output between groups will be estimated using a linear 
regression model; 95% confidence intervals will be constructed using t-based 
methods. A p-value less than 0.050 will be considered statistically significant. 
1.5 Secondary Analysis 
1.5.1 
Linear regression models will be used to estimate the between group difference in 
24-hour change in each of the secondary outcomes; 95% confidence intervals will 
be constructed using t-based methods. 
1.6 Exploratory Analysis 
1.6.1 
We will quantify any differential treatment response by heart failure subtype 
(HFPEF, HFrEF) by including heart failure subtype as a covariate and as an 
interaction with the group effects in the models mentioned above. 
1.7 Sample Size Determination 
1.7.1 
Sample size was determined based on a combination of feasibility and also the 
variability of 24-h net urine output observed in the ATHENA-HF trial (Butler et al. 
2017).  Butler et al. observed a median (25th percentile, 75th percentile) net urine 
output of 1183 ml (510, 1955) in the usual care alone group and 1100 ml (483, 
2131) in the high dose spironolactone group. With a total sample size of 20 
patients (10 per group), we will have 80% power at the alpha=0.05 level of 
significance (two-sided) to detect a 1688 ml difference in 24-h urine output 
assuming a common standard deviation of 1200 ml and a dropout rate of 
10% or less.  With all other assumptions being the same, the following gives 
estimates of power for a range of differences.  Power was estimated using nQuery 
Advisor version 7.0 (two group t-test of equal means). 
Difference (mL) 
Power 
1500 
70% 
1600 
75% 
1700 
80% 
1800 
84% 
1900 
88% 
2000 
91% 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 24 of 28 
CONFIDENTIAL 
1.8 Randomization 
1.8.1 
Participants will be randomized in a 1:1 fashion while maintaining a level of 
unpredictability to future randomization assignment. The randomization 
sequences will be prepared by the study statistician (CTB) using random variable 
block sizes of two or four patients per block.  REDCap’s randomization module will 
be used to reveal the randomized assignment on a per-patient basis by pharmacy 
staff.    
1.9 Blinding 
1.9.1 
Patients and all study staff will be blind to the randomization assignment except 
for pharmacy staff and the study statistician. 
1.10 
Multiplicity Considerations 
1.10.1 We will report unadjusted p-values and describe the correlation of primary and 
secondary outcomes in publications to allow for additional researchers to evaluate 
the robustness of the findings. 
 
 
12.DATA COLLECTION AND QUALITY ASSURANCE 
12.1 Data Collection Forms 
The study case report form (CRF) is the primary data collection instrument for the study. All data 
requested on the CRF 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 use “white-out” for errors. For clarification of illegible or uncertain 
entries, print the clarification above the item, then initial and date it. If the reason for the correction 
is not clear or needs additional explanation, neatly include the details to justify the correction. 
The data collection tool for this study will be sponsor defined case report forms. The investigator 
will maintain complete and accurate study documentation in a separate file. Study documentation 
may include medical records, records detailing the progress of the study for each subject, signed 
informed consent forms, drug disposition records, correspondence with the study coordinator 
study monitor/sponsor, screening and consent information, severe adverse event reports, 
laboratory reports, subject diaries, data clarifications requested by the sponsor, and any other 
documentation deemed relevant and pertinent to the study and the study subjects.  Subject data 
necessary for analysis and reporting will be entered into a validated database or data system in 
accordance. Clinical data management will be performed in accordance with applicable data 
management vendor standards and data cleaning procedures. The investigator is responsible for 
the procurement of data and for the quality of data recorded on the CRFs. The handling of data, 
including data quality assurance, will comply with regulatory guidelines. 
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, records kept at the pharmacy, at the 
laboratories, and at medico-technical departments involved in the clinical trial. 
The investigator will maintain records and essential documents related to the conduct of the study.  
These will include subject case histories and regulatory documents. 
12.2 Data Management 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 25 of 28 
CONFIDENTIAL 
All study data will be collected at Mayo Clinic with the Department of Cardiovascular Diseases as 
the primary coordinating and data management center.  
REDCap will be used for clinical data management and randomization. These tools are 
institutionally supported and allow for rapid database development. The implementation of the 
software within a project includes training on the system’s use, robust error checking, security 
considerations, and full audit trail. Balance, which is integrated into REDCap, allows for a variety 
of randomization and minimization algorithms. 
Demographic and clinical data will be extracted from medical records including age and gender, 
vital signs, physical exam findings.  
For biospecimens, NT-pro-BNP, creatinine, hematocrit and cystatin C, urine sodium will be 
measured in real time, and the remainder will be stored for future analysis of cardiac biomarkers.  
The echocardiographic parameters that will be captured comprise: systolic, diastolic LV and RV 
function parameters including LVEF by M-Mode, 2 D, biplane Simpson, lateral and medial E/e’, 
left atrial volume index, right ventricular size and function, tissue velocities of the tricuspid 
annulus, TAPSE, lung ultrasound for B lines, IVC diameter/collapse, internal jugular 
dimension/size relative to carotid.  
All individually identifiable patient records and data will be stored in a database under coded 
accession numbers. A password is required to gain access to this protected and privileged 
information. Only the approved and trained study staff will have access to the database. For 
individuals providing data, e.g., core laboratory personnel, access will be limited to entering data 
only. All data are monitored regularly for entry and access, and a formal policy regarding 
protection of personal privacy is in place throughout Mayo Foundation. The key to identification 
of subjects will be maintained in a secure office environment under the direction of the 
investigators. The institutional commitment at Mayo Clinic to protect patients’ (and study 
participants’) privacy is a high priority. 
12.3 Quality Assurance 
12.3.1 Training 
The study will be performed only by adequately trained personnel. This applies to the 
entire study team roster. Only approved and trained study staff, experienced in trials such 
as these, will interact with the patients and manage the data forms and database. The 
echocardiography and laboratory teams are likewise experienced in these types of trials 
as is the section of biostatistics at Mayo.  
12.3.2  Quality Control Committee  
This study will not assemble a quality control committee. 
12.3.3  Metrics 
The primary outcome measure is urine volume. We will compare change in urine volume 
to body weight change as a metric of accurate urine output collection. Source document 
verification will be performed to ensure data fidelity as well. To ensure compliance with 
applicable regulatory requirements, the sponsor or designee may conduct a quality 
assurance audit. Regulatory agencies may also conduct a regulatory inspection of this 
study. Such audits/inspections can occur at any time during or after completion of the 
study. If an audit or inspection occurs, the investigator and institution agree to allow the 
auditor/inspector direct access to all relevant documents and to allocate his/her time and 
the time of his/her staff to the auditor/inspector to discuss findings and any relevant issues. 
12.3.4  Protocol Deviations 
Protocol deviations in diuretic administration and/or adjunct diuretic use will be recorded 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 26 of 28 
CONFIDENTIAL 
12.3.5 Monitoring 
 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, 
the sponsor 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., pharmacy, diagnostic 
laboratory, etc.). 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable compliance offices. 
13. PARTICIPANT RIGHTS AND CONFIDENTIALITY 
The study will employ standard methods for protecting the confidentiality of research materials 
through the use of coded identification numbers that are specific to the study on all materials 
except those that are necessary for participant contact, follow-up, and ongoing linkage with data 
such as those from medical records, using password-protected computer data files and 
databases, and locked file cabinets for storing hard copies of any other study materials. Only 
study personnel who need to track participants for follow-up purposes have access to the 
identifying information for individual study participants. No personally identifiable information 
(protected health information) except the minimum necessary for study purposes are shared with 
co-investigators, and any sharing of data is by encrypted, password-protected data files. In 
addition to the procedures outlined above, confidentiality and privacy are further enhanced as 
each institution maintains research databases behind institution-specific password-protected 
firewalls. 
Blood specimens will be stored in appropriate freezers coded with study-specific identification 
numbers and barcodes with no other identifying information on them. Barcodes include 
information on time of storage and are linked to a password-protected research laboratory 
information management system (RLIMS) database that was built specifically for these purposes. 
Study staff members are trained to follow established confidentiality procedures. Samples will be 
kept in central, secured repository. Should it become necessary to ship samples to collaborating 
investigators for approved sub-analyses, this will be done without any identifying information 
except for study-specific identification numbers. 
Echocardiographic images will be stored on a secured data platform. 
No preliminary or final results will be released or published with identifying information or reported 
on an individual level, and all epidemiologic data will be presented as statistical summaries. No 
statistics will be published based on fewer than 5 subjects, a practice consistent with HIPAA and 
most confidentiality guidelines. 
A description of the plan for data and safety monitoring and adverse event reporting to the IRB, 
the Data and Safety Monitoring Board, the NIH and others, as appropriate, is provided in the Data 
and Safety Monitoring Plan to ensure the safety of subjects.  
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 
• 
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 

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 27 of 28 
CONFIDENTIAL 
be made to obtain permission to collect at least vital status (long term survival status that the 
subject is alive) at the end of their scheduled study period. 
13.1 Institutional Board Review  (IRB) Review 
 
 
13.2 Informed Consent Forms 
A signed consent form will be obtained from each participant.  The consent form will describe the 
purpose of the study, the procedures to be followed, and the risks and benefits of participation. A 
copy will be given to each participant and will be documented in the participant’s record.  
For patients not fluent in English, an interpreter will be present to translate the informed consent 
and for the discussion of the informed consent with the trained study team member. It is already 
a standard of care at Mayo Clinic that all patients considered not fluent enough in English will 
have interpreter services. Thus, this study builds and extends on this practice.  
 
Adults who lack the capacity to consent may not participate in the study.  Other vulnerable adults 
and children will not be included in the study. 
13.3 Participant Confidentiality 
The confidentiality of all participants will be maintained according to the Health Insurance 
Portability and Accountability Act (HIPAA), any special data security requirements, and record 
retention per the sponsor’s requirements. 
Any data, specimens, forms, reports, or records that leave the site will be identified only by a 
participant identification number (Participant ID, PID) to maintain confidentiality.  All records will 
be kept in a locked file cabinet.  All computer entry and networking programs will be done using 
PIDs only. Information will not be released without written permission of the participant, except as 
necessary for monitoring by IRB, the FDA, the NIA, and the OHRP. 
13.4 Study Discontinuation 
The study may be discontinued at any time by the IRB, the OHRP, the FDA, or other government 
agencies as part of their duties to ensure that research participants are protected.  
14. ETHICAL CONSIDERATIONS 
This study is to be conducted according to United States government regulations and Institutional 
research policies and procedures. 
This protocol and any amendments will be submitted to a properly constituted local Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the study.  
The decision of the IRB concerning the conduct of the study will be made in writing to the sponsor-
investigator before commencement of this study. 
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 
study.  This consent form will be submitted with the protocol for review and approval by the IRB 
for the study.  The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed 
by the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent 
 
15. COMMITTEES  

 
 
Version 4.0 
 
 
Revised 02/08/2024. 
Page 28 of 28 
CONFIDENTIAL 
As an all Mayo, phase 2 trial, this study will not convene any committee such as a Steering 
Committee or an Executive Committee, a Publication Committee, or an Adjudication Committee.  
16.PUBLICATIONS OF RESEARCH FINDINGS 
 
 
17.REFERENCES 
1.  Ambrosy AP, Cerbin LP, Armstrong PW, Butler J, Coles A, DeVore AD, Dunlap ME, 
Ezekowitz JA, Felker GM, Fudim M, Greene SJ, Hernandez AF, O’Connor CM, Schulte P, 
Starling RC, Teerlink JR, Voors AA, Mentz RJ. Body Weight Change During and 
After Hospitalization for Acute Heart Failure: Patient Characteristics, Markers of Congestion, 
and Outcomes: Findings From the ASCEND-HF Trial. JACC Heart Fail. 2017;5:1–13.  
2.  Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, 
Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, 
Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, 
O’Connor CM, NHLBI Heart Failure Clinical Research Network. Diuretic strategies in patients 
with acute decompensated heart failure. N Engl J Med. 2011;364:797–805.  
3.  Ahmad T, Jackson K, Rao VS, Tang WHW, Brisco-Bacik MA, Chen HH, Felker GM, 
Hernandez AF, O’Connor CM, Sabbisetti VS, Bonventre JV, Wilson FP, Coca SG, Testani 
JM. Worsening Renal Function in Patients With Acute Heart Failure Undergoing Aggressive 
Diuresis Is Not Associated With Tubular Injury. Circulation. 2018;137:2016–2028.