Cross-over Randomized Controlled Trial of Coenzyme Q10 or Nicotinamide Riboside in Chronic Kidney Disease
Phase: PHASE2
Conditions: Chronic Kidney Disease, Sarcopenia, Frailty
Sponsor: University of Washington

 
 
 
 
 
 
Cross-over Randomized Controlled Trial of  COenzyme Q10 or Nicotinamide Riboside in 
Chronic Kidney Disease (CoNR trial) 
 
 
 
Sponsored by: 
 
National Institute of Diabetes and Digestive and Kidney Diseases 
 
 
Investigators 
Baback Roshanravan, MD MS 
Kidney Research Institute 
University of Washington 
Seattle, WA USA 
 
Bryan Kestenbaum, MD MS 
Kidney Research Institute 
University of Washington 
 
Julio Lamprea, MD PhD 
Department of Medicine 
Division of Cardiology 
Kidney Research Institute  
University of Washington 
 
Ian de Boer, MD MS 
Kidney Research Institute 
University of Washington 
 
Sangeeta Hingorani, MD MPH 
Seattle Childrens Hospital 
 
Jonathan Himmelfarb, MD  
Kidney Research Institute 
University of Washington 
 
NTC03579693 
 
 
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Randomized controlled trial of Coenzyme Q10 and NR in chronic kidney disease 
 
TABLE OF CONTENTS 
 
 
LIST OF ABBREVIATIONS AND ACRONYMS ..............................................................iv 
SCHEMA ...............................................................................................................................v-vi 
 
1.0 
INTRODUCTION............................................................................................................... 1 
1.1 Background and Prior Research ......................................................................................... 1 
1.2 Rationale ............................................................................................................................ 1 
2.0 
STUDY OBJECTIVES AND DESIGN ............................................................................. 3 
2.1 Primary Objectives............................................................................................................. 3 
2.2 Secondary Objectives......................................................................................................... 3 
2.3 Study Design ...................................................................................................................... 3 
3.0 
STUDY POPULATION ..................................................................................................... 3 
3.1 Inclusion Criteria ............................................................................................................... 3 
3.2 Exclusion Criteria .............................................................................................................. 4 
3.3 Recruitment Process........................................................................................................... 4 
3.4 Co-Enrollment Guidelines ................................................................................................. 5 
3.5 Participant Retention .......................................................................................................... 5 
3.6 Participant Withdrawal ...................................................................................................... 6 
4.0 
STUDY TREATMENT/PRODUCT/INTERVENTION ................................................. 6 
4.1 Treatment/Product/Intervention Regimen(s) ..................................................................... 6 
4.2 Treatment/Product/Intervention Supply and Accountability ............................................. 6 
4.3 Adherence Assessment ...................................................................................................... 6 
4.4 Toxicity Management ........................................................................................................ 6 
4.5 Clinical Management of Pregnancy ................................................................................... 6 
4.6 Concomitant Medications .................................................................................................. 7 
5.0 
STUDY PROCEDURES .................................................................................................... 8 
6.0 
SAFETY MONITORING AND ADVERSE EVENT REPORTING .......................... 12 
6.1 Safety Monitoring ............................................................................................................ 12 
6.2 Adverse Event Definitions and Reporting Requirements ................................................ 12 
6.2.1 Adverse Event ........................................................................................................... 12 
6.2.2 Serious Adverse Event .............................................................................................. 13 
6.2.3 Adverse Event Reporting .......................................................................................... 14 
7.0 
STATISTICAL CONSIDERATIONS ............................................................................ 14 
7.1 Review of Study Design .................................................................................................. 14 
7.2 Endpoints ......................................................................................................................... 14 
7.2.1 Primary Endpoints .................................................................................................... 15 
7.2.2 Secondary Endpoints ................................................................................................ 15 
7.3 Accrual, Follow-up, and Sample Size.............................................................................. 16 
7.4 Random Assignment / Study Arm Assignment ............................................................... 16 
7.5 Blinding............................................................................................................................ 16 
7.6 Data Analysis ................................................................................................................... 16 
7.6.1 Primary Analyses ...................................................................................................... 16 
7.6.2 Secondary Analyses .................................................................................................. 17 

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8.0 
HUMAN SUBJECTS CONSIDERATIONS .................................................................. 17 
8.1 Ethical Review ................................................................................................................. 17 
8.2 Informed Consent............................................................................................................. 18 
8.3 Risks ................................................................................................................................. 18 
8.4 Benefits ............................................................................................................................ 18 
8.5 Incentives ......................................................................................................................... 19 
8.6 Confidentiality ................................................................................................................. 19 
8.7 Study Discontinuation ...................................................................................................... 19 
9.0 
LABORATORY SPECIMENS AND BIOHAZARD CONTAINMENT .................... 19 
9.1 Local Laboratory Specimens ........................................................................................... 19 
9.2 Reference Laboratory Specimens .................................................................................... 20 
9.3 Specimen Storage and Possible Future Research Testing ............................................... 20 
10.0 
REFERENCES ............................................................................................................... 21 

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Cross-over Randomized Controlled Trial of  COenzyme Q10 or Nicotinamide Riboside in 
Chronic Kidney Disease (CoNR trial) 
 
 
LIST OF ABBREVIATIONS AND ACRONYMS 
 
 
AE 
 
 
Adverse Event 
ATPmax 
Muscle mitochondrial phosphorylation capacity by 31P Magnetic 
Resonance Spectroscopy (MRS) 
CKD  
 
Chronic kidney disease 
EAE 
 
 
Expedited Adverse Event 
ETC                             Electronic Transport Chain 
EC 
 
 
ethics committee 
eGFR                           Estimated Glomerular Filtration Rate  
FDA  
 
(United States) Food and Drug Administration 
GCP 
 
 
Good Clinical Practices 
IDS                              UW Investigational Drug Services  
IRB 
 
 
Institutional Review Board 
KRI                             Kidney Research Institute  
 
LDMS  
 
Laboratory Data Management System 
LL 
 
 
Local Laboratory 
MRS  
 
31P Magnetic resonance spectroscopy  
NAD+ 
NIDDK 
 
United States) National Institute of Diabetes and Digestive and Kidney 
NIH 
 
 
(United States) National Institutes of Health 
NR 
Nicotinamide Riboside  
ROC  
 
Regulatory Operations Center 
SAE 
 
 
Serious Adverse Event 
 
 
SUSAR 
 
Suspected Unexpected Serious Adverse Reaction 
SOP 
 
 
Standard Operating Procedures 
SSP 
 
 
Study Specific Procedures  
TA 
 
 
Tibialis anterior leg muscle 
TCA  
 
Tricarboxylic acid (Krebs) cycle 
 
 
 
 
 
 
 
 

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Cross-over Randomized Controlled Trial of  COenzyme Q10 or Nicotinamide Riboside in 
Chronic Kidney Disease (CoNR trial) 
 
 
SCHEMA 
 
Purpose:  
Study the impact of oral nicotinamide riboside vs CoQ10 on aerobic 
capacity, muscle performance and mitochondrial metabolism among 
persons with moderate-severe CKD.  
 
Design: 
Randomized, placebo controlled cross-over trial 
 
 
Study Population: 
Adults age 30-79 with moderate-severe CKD eGFR by CKD (EPI equation)  < 
50ml/min/1.73m2  
 
Study Size: 
 30 (10 in each of 3 arms).  
 
Treatment Regimen:  - Nicotinamide riboside 1000mg daily (250mg - 2 tablets twice daily) 
 
 
 
- Coenzyme Q10 1200mg daily (600mg – 1 tablets twice daily) 
 
 
 
- Placebo (sugar pill) 
 
Study Duration: 
1.5-2 year  
 
Primary Objectives:  
• To test if NR or CoQ10 supplementation improves aerobic capacity by cycle ergometry 
testing compared with placebo. 
• To test if NR or CoQ10 improves muscle work efficiency by bicycle ergometry. 
 
Secondary Objectives: 
• To test if NR or CoQ10 improves peripheral blood monocyte bioenergetics health.  
• To test the effects of oral NR or CoQ10 supplementation on metabolic response profile. 
• To test if NR or CoQ10 supplementation reduces inflammatory and oxidative stress 
biomarkers. 
• To test if NR or CoQ10 improves subjective fatigue, self-reported physical function, and 
heart failure symptoms. 
 
Exploratory objective: 
• In-vivo mitochondrial energetics by 31Phosphorus Magnetic Resonance Spectroscopy (MRS) 
investigating phosphorylation capacity (ATPmax) 
 
Study Sites: 
• 
University of Washington Medical Center  
• 
Fred Hutchinson Cancer Center – Prevention Center 
• 
Kidney Research Institute (KRI): Harborview Medical Center,  KRI at Northwest Kidney Centers-
Havilland, KRI at UWMC 
 

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Cross-over Randomized Controlled Trial of  COenzyme Q10 or Nicotinamide Riboside in 
Chronic Kidney Disease (CoNR trial) 
 
 
 
SCHEMA 
 
 
 

 
 
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1.0 
INTRODUCTION 
1.1 
Background and Prior Research 
Sarcopenia is a common complication of chronic kidney disease. Sarcopenia is defined by 
decreased muscle mass or function and is central to the frailty phenotype that is associated with 
disability, hospitalization, and death. Studies have shown that altered metabolism in CKD leads 
to well-described catabolic and pro-inflammatory processes with adverse consequences for 
lipid1, amino acid2, and protein metabolism3,4 that are linked to overall energy metabolism5.  
These events consequently lead to an impaired insulin response, contributing to significant 
comorbidity among patients living with CKD.  
Sarcopenia alters glucose metabolism. Insulin resistance in CKD can contribute to 
catapleurosis, which in turn increases reliance on the muscle amino acid pool for mitochondrial 
tricarboxylic acid-cycle respiratory fuel. These events culminate, ultimately, in muscle 
breakdown, sarcopenia, weakness and fatigue, increasing risk of mobility, disability and frailty. 
CKD and sarcopenia alter metabolic pathways. Metabolomic profiling of CKD compared to 
controls under conditions of fasting and insulin clamp testing reveal marked aberrancy in CoQ10 
biosynthesis pathways and niacinamide metabolism respectively. This suggests impaired 
mitochondrial metabolism as a major contributor in insulin resistance (figure 1). We have 
observed fasting-state pathway differences in ubiquinone (Coenzyme Q) biosynthesis among 
patients with CKD compared to controls, suggesting alteration in the integrity or efficiency of 
the electron transport chain (ETC) of the mitochondria, in turn predisposing to mitochondrial 
oxidant production resulting in insulin resistance6,7. 
Deficiency in CoQ10 levels has been associated with oxidative stress and impaired oral 
glucose tolerance in pre-clinical models8. This may explain the observed uncoupling of muscle 
mitochondrial oxidative phosphorylation and oxidative stress in CKD9-11. CoQ10 administration 
in advanced kidney disease patients improved oxidative stress with reduction in isofuran levels 
(products of lipid peroxidation)11. However, little is known about its effects on oxidative stress 
and mitochondrial function via assessment of mitochondrial bioenergetics using high throughput 
respirometry assessments in moderate-sever CKD not requiring dialysis.  
Nicotinamide Riboside (NR) is implicated in mitochondrial dynamics in those with CKD. 
NAD+ is important in mitochondrial biogenesis, bioenergetics and redox homeostasis through 
NADP+. Indeed, administration of nicotinamide riboside (NR), a natural NAD precursor, has 
been shown to improve insulin sensitivity in obese mice, as well as increase NAD levels, leading 
to augmented mitochondrial sirtuin (SIRT3) activity and improve muscle endurance along with 
muscle mitochondrial content12. Among patients with CKD not treated with dialysis, insulin 
clamp testing revealed marked plasma abnormalities in pathways important for mitochondrial 
TCA cycle function and antioxidant capacity compared with controls. Disruption in insulin 
response was most notable for nicotinamide metabolism among participants with CKD compare 
to controls, with a markedly blunted decrease in nicotinamide after insulin challenge. These 
findings implicate disruption in niacinamide metabolism as a potential mechanism underlying 
impaired insulin resistance and mitochondrial metabolism in CKD.  

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Here we propose a phase 2 placebo controlled randomized cross-over trial of nicotinamide 
riboside and Coenzyme Q10 in CKD investigating the impact on both metabolic and functional 
consequences using targeted metabolomics, assessment of mitochondrial bioenergetics and 
bicycle ergometry. 
 
Figure 1. Left panel: Fasting-state metabolic pathway analysis comparing CKD to controls. Right panel: Metabolic 
pathway differences with insulin challenge comparing CKD to control.  
1.2 
Rationale 
Sarcopenia is common in CKD patients and is associated with adverse metabolic and clinical 
outcomes. Existing evidence and our preliminary data suggest that mitochondrial dysfunction is 
a key mechanism underlying sarcopenia in CKD. However, major gaps exist in our 
understanding of these processes and their physical and social impacts. Altered CoQ10 and NR 
have both been implicated in mitochondrial dysfunction. Preliminary evidence suggests 
supplementation may ameliorate these altered metabolic processes. Addressing these knowledge 
gaps is necessary to shed new light on the pathophysiology of sarcopenia in CKD and suggest future 
interventions that reduce morbidity and mortality. 
 
1.3 
Abstract  
Skeletal muscle dysfunction (sarcopenia) is an under-recognized target organ complication of CKD with 
substantial adverse clinical consequences of disability, hospitalization, and death. Sarcopenia in this 
proposal is defined by impaired metabolism and physical function associated with decreased skeletal 
muscle mass or function. Skeletal muscle tissue relies on mitochondria to efficiently utilize oxygen to 
generate ATP. Impaired mitochondrial energetics is a central mechanism of sarcopenia in CKD. 
Coenzyme Q10 and Nicotinamide Riboside deficiencies have been implicated in altered mitochondria 
function, but greater knowledge is needed. We hypothesize that supplementation with oral CoQ10 and 

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NR will enhance mitochondrial function measured through aerobic capacity, muscle work efficiency, 
and metabolic profile using cycler ergometry and targeted metabolomics. Secondarily, we seek 
to describe the impact of these interventions on ex-vivo measures of mitochondrial metabolism, 
biomarkers of oxidative stress, inflammation and functional outcomes of muscle efficiency by 
cycle ergometry as well as patient reported fatigue among persons with chronic kidney disease. 
Lastly, in-vivo muscle mitochondrial phosphorylation capacity by 31P Magnetic resonance 
spectroscopy (MRS) will test exploratory aspects and descriptive measures of mitochondrial 
function.  
 
 
2.0 
STUDY OBJECTIVES AND DESIGN 
2.1 
Primary Objectives 
The primary objectives of this study are to:. 
• To test if NR or CoQ10 supplementation improves aerobic capacity by cycle 
ergometry testing compared with placebo. 
• To test if NR or CoQ10 improves muscle work efficiency by bicycle ergometry 
 
2.2 
Secondary Objectives 
The secondary objectives of this study are to: 
• To test if NR or CoQ10 improves peripheral blood monocyte bioenergetics health.  
• To test the effects of oral NR or CoQ10 supplementation on metabolic response 
profile. 
• To test if NR or CoQ10 supplementation reduces inflammatory and oxidative stress 
biomarkers. 
• To test if NR or CoQ10 improves subjective fatigue, self-reported physical function, 
and chart failure symptoms. 
 
2.3 
Study Design 
Overview of study design: This is a placebo-controlled, double-blind crossover trial 
with 3 arms: placebo, NR, and CoQ10. There are 2 phases 56 days each separated by a 1-
week washout period. 
A brief screening visit will assess eligibility criteria, and will include informed consent. 
Qualified participants will be randomly assigned (1:1) to 56 days of placebo followed by 
7 days NR or CoQ10, followed another 7 day washout followed by 56 days of either NR 
or CoQ10.   

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Qualified participants will participate in at least 4 study visits, plus a screening visit. An 
optional 31P MRS study visit to assess in vivo muscle mitochondrial phosphorylation 
capacity will be offered to those who qualify. Including the separate MRS visit will 
increase the total visits to 8.  Study outcomes will be assessed at each of these 4 major 
visits.  
Subjects will receive 1000mg of Nicotinamide riboside (Tru Niagen) or coenzyme Q10 
(1200mg/day) for 8 weeks. This dose was chosen based on a review of studies in the 
literature evaluating biological activity. Placebo will consist of identical appearing tablet. 
 
 
3.0 
STUDY POPULATION 
Study participants will be selected from patients with moderate-severe CKD not treated 
with dialysis from the Muscle Mitochondrial Energetics and Dysfunction (MEND) study, 
a cross-sectional clinic-based study of CKD. Additional patients may be recruited from 
nephrology clinics in the University of Washington System including Harborview 
Medical center, and University of Washington Medical Center.  
Participants will be selected for this study from the indicated populations according to the 
criteria in Section 3.1 and 3.2.  They will be recruited, screened, and enrolled as 
described in Section 3.3 [and assigned to a study treatment/intervention group as 
described in Section 7.4]. Issues related to participant retention and withdrawal from the 
study are described in Sections 3.5 and 3.6, respectively. 
Objectives 
Population  
Exposure  
Design 
Outcome 
Primary- To test if NR 
or CoQ10 
supplementation 
improves aerobic 
capacity and muscle 
performance 
Mod-severe CKD with 
eGFR < 50 mL/dL 
(N=30) 
Randomized order  
CoQ10 or NR or 
Placebo  
Placebo-controlled 
double-blind control 
crossover  
VO2max and 
Work efficiency  
Secondary- To test NR 
or CoQ10 on descriptive 
measures of 
mitochondrial and 
metabolic functioning  
Mod-severe CKD with 
eGFR < 50 mL/dL 
(N=30) 
Randomized order 
CoQ10 or NR or 
Placebo 
Placebo-controlled 
double-blind control 
crossover 
-monocyte 
bioenergetics 
(Reserve capacity) 
 
-ATPmax (MRS 
Imaging) 
 
-Blood   
metabolomics & 
biomarkers 
-Fatigue & Heart 
questionnaires  

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3.1 
Inclusion Criteria 
• Adults between 30 and 79 years of age 
• Diagnosis of moderate-severe CKD, defined in this study as an estimated 
glomerular filtration rate (eGFR) of <50ml/min/1.73m2 using the Chronic Kidney 
Disease Epidemiology Collaboration equation 
• 6 minute walking distance<500meters 
3.2 
Exclusion Criteria 
• Pregnant 
• On chronic dialysis 
• Expectation to start dialysis within 6 months  
• Insulin dependent diabetes 
• Severe anemia: hemoglobin <8gm/dL 
• Hyperkalemia: K>5.7 
• Kidney transplantation 
• Weight >300 lbs 
• HIV 
• End stage liver disease with cirrhosis 
• Oxygen-dependent COPD 
• Unable to walk unassisted from room to room in own house 
• Institutionalization,  or inability to consent 
• Use of immunosuppressive medications (i.e. steroids, calcineurin inhibitors) 
• Malignancy requiring active treatment or currently under surveillance at the 
discretion of the investigator 
• Pacemaker 
• Current participation in another interventional trial 
• Non-English speaking 
• Hospitalization for heart attack, stroke, or unstable cardiac chest pain in last 3 
months (e.g. myocardial infarction, unstable angina, cerebrovascular accident) 
• Any severe medical condition that the investigator feels would disqualify a patient 
from aggressive exercise.  
• Baseline systolic blood pressure >170 or diastolic blood pressure >100 
• Persistent or permanent uncontrolled arrhythmia at the discretion of the 
investigator.   
3.3 
Recruitment Process 
Study coordinators will screen records of previous study participants who have agreed to future 
contact and UW specialty clinics based on the aforementioned criteria in 3.1 & 3.2.  
 
Previous Studies: 
• Participants enrolled in the MEND and the Seattle Kidney Study have documented consent 
approving contact regarding participation in future studies. 
 
UW Clinics: 

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• Additional sources of recruitment will include the nephrology clinics in the University of 
Washington System (University of Washington Medical Center, and Harborview Medical 
Center), community based nephrology practices, and self-referrals from the Kidney Research 
Institute Community Connection website.  
 
3.4 
Co-Enrollment Guidelines 
Study participants will not be allowed to enroll in other clinical trials, as the effect of 
Coenzyme Q10 and Nicotinamide Riboside on this population is not clear. 
 
3.5 
Participant Retention 
Every effort to retain enrolled participants will be made throughout the duration of the 
study in order to reduce bias related to loss to follow-up. Strategies for participant 
retention include: 
 
• Thorough explanation of the importance of all 3 study treatment groups to the 
overall success of the study 
• Detailed explanation of the study visit schedule and procedural requirements 
during the informed consent process, with re-emphasis at the end of each study 
visit 
• Use of appropriate and timely visit reminder mechanisms. This includes mid-
treatment phone call to assess participant adherence to regimen and remind 
participants of subsequent follow up visits 
• Compensating participants for their time and effort in the study 
• Immediate and multifaceted follow-up on missed visits 
 
3.6 
Participant Withdrawal 
Participants will be allowed to voluntarily withdraw from the study for any reason and at 
any time. The investigator may withdraw participants from the study in order to protect 
their safety or if they are unwilling or unable to comply with required study procedures 
after consultation with the study sponsors and co-sponsors. Participants also may be 
withdrawn if the study sponsor, government or regulatory authorities, or site IRBs/ECs 
terminate the study before the planned end date. Reasons for withdrawal from the study 
will be recorded and a final evaluation will be made if feasible.  
 
Participants who discontinue treatment but remain in the study will continue to be 
followed-up whenever possible. 
4.0 
STUDY TREATMENT/PRODUCT/INTERVENTION 
4.1 
Treatment/Product/Intervention Regimen(s): 
 

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Participants will be randomized to in treatment order to receive the following medications for 6 
weeks plus an additional 1 week in case of logistical difficulties with scheduling study visits.  
 
• Nicotinamide Riboside (Tru Niagen by Chromodex) at 1000mg/day  in the form 
of two 250mg tablets twice daily. 
• Coenzyme Q10 will be administered at 600mg twice daily.  
• Placebo will consist of identical appearing pill. This will be a double dummy with 
4 tablets appearing identical to NR and 2 tablets appearing identical to CoQ10.  
 
Randomized Tx 
Order 1st, 2nd, 3rd  
Total Dosage QD  
Regimen  
Duration 
Nicotinamide 
Riboside  
1000 mg 
250 mg tabs x2 
BID 
6 weeks (+/- 7 
days) 
Coenzyme Q10 
1200 mg 
600 mg tabs BID  
6 weeks (+/- 7 
days) 
Placebo  
N/A 
BID 
6 weeks (+/- 7 
days) 
 
4.2 
Treatment/Product/Intervention Supply and Accountability 
 
The University of Washington Investigational Drug Services (IDS) will manage the study 
drugs. IDS will manage treatment randomization. Study coordinators will alert IDS 
before a scheduled baseline and subsequent visits and pick up the study drugs for 
administration.  
The IDS pharmacist must maintain complete records of all study drugs/products received 
from the Clinical Research Products Management Center and drug manufacturer and 
subsequently dispensed to study participants. All unused supplies must be returned to the 
Clinical Research Products Management Center after the study is completed or 
terminated. 
4.3 
Adherence Assessment 
Adherence to the study treatment will be assessed by study coordinator phone call 
midway through each treatment arm to assess adherence and inventory method to assess 
remaining medication/placebo at the end of the study.  Adherence will be defined as 
consumption of at least 75% of the prescribed regimen. Up to 36 participants may be 
recruited to compensate for non-adherence or drop-out with the goal of 10 individuals 
completing in each treatment arm. Participants will be asked to bring in unused study 
drugs at each visit to return to IDS.  

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4.4 
Toxicity Management  
Currently, the mechanism whereby Coenzyme Q10 and Nicotinamide Riboside may 
cause harm or toxicity is unknown. There have been studies demonstrating slightly 
decreasing hemoglobin and potassium in healthy controls treated with NR13. In the event 
of moderate or serious adverse effects (as defined in section 6.2) requiring treatment for 
such conditions as nausea, vomiting, or abdominal pain thought to be related to toxicity 
from the study drug, the patient will be withdrawn from the study and adverse events 
reported. 
Mild adverse events that do not requiring treatment and are thought to be potentially 
related to toxicity from the drug will prompt a 50% dose reduction. 
4.5 
Clinical Management of Pregnancy 
All female participants of childbearing age who are sexually active will be asked to use 
contraception during the duration of the study and for 1 month afterwards as the effects 
of Coenzyme Q10 and Nicotinamide Riboside on fetal development are not clear. 
 
Any females who become pregnant during the study period will stop taking the study 
product, but will continue with study procedures with the exception of the MRS 
procedures.   
4.6 
Concomitant Medications 
Enrolled study participants may continue use of all concomitant medications — except 
those listed under criteria for exclusion or treatment discontinuation — during this study.   
All concomitant medications taken or received by participants within the 4 weeks prior to 
study enrollment will be reported on applicable study case report forms. In addition to 
prescribed and over-the-counter medications (vitamins, herbal remedies, and other 
traditional preparations) will be recorded. Alcohol and recreational or street drug use will 
be recorded in clinical progress notes if needed for interpretation/documentation of 
observed participant health status.  Medications used for the treatment of AEs that occur 
during study participation also will be recorded on applicable study case report forms. 
5.0 
STUDY PROCEDURES 
Schedule of visits and procedures 
An overview of the study visit and procedures schedule is presented in table 1. All 
participants will be instructed to avoid altering their level of habitual physical 
activity during the trial. Participants who qualify and agree to 31P MRS will receive an 
additional study visit at UWMC lasting 1-2hrs at baseline and after each treatment arm. 
Presented below is additional information on visit-specific study procedures. Detailed 
instructions to guide and standardize all study procedures will be provided in the section 
titled study procedures/sample collection below. 
 

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Screening visit/practice bicycle visit 
The screening visit will take place within 28days of the baseline visit. Some components 
of the initial screening visit may be performed by telephone or in combination with other 
study visits in order to best accommodate participants’ schedules. The screening visit will 
occur at the prevention center. Study coordinators will obtain informed consent prior to 
any data acquisition or sample collection 
Screening visit procedures:  
• Verification of inclusion and exclusion criteria as outline in sections 3.1 & 3.2 
including  
• Vital signs and anthropometrics  
• 6-minute walk: Participants able to walk 500 meters or more during 6 minutes 
will be excluded from the study 
• Screening labs (if 6 minute walk <500meters or less): A renal panel & Complete 
blood count (CBC) 
• Bicycle ergometry practice: The exercise trainer will help familiarize the participant 
with the bicycle to mitigate significant training effects due to lack of exposure to the 
equipment  
• Questionnaires will be handed out to be returned at the baseline visit. Participants 
may also choose to complete these at the baseline or online via RedCap ITHS 
o Medical History Questionnaire  
o Kansas City Cardiomyopathy Questionnaire 
 
Eligibility for the study will be at the discretion of the principal investigator or study 
clinician after review of the pertinent labs and inclusion/exclusion criteria.  
Baseline visit  
The baseline visit will be the same as visits 2-4 with an additional of medical history and 
anthropomorphic testing. Subject will undergo a baseline evaluation including a detailed 
assessment of demographics, smoking history, medical history, medication inventory, 
vital signs and anthropometrics (height, weight, waist to hip ratio). A pregnancy test will 
be performed on all women of childbearing potential. If the subjects meet the eligibility 
criteria the study coordinator will contact the subjects’ primary physician regarding the 
subjects’ involvement in the trial.  
The study drug dispensed at Baseline visit and Visits 2, 3, 4.The participant will receive 
either placebo or NR or Coenzyme Q10 from the Investigational Drug Service (IDS) and 
instructed on how to appropriately administer the medications. He or she will be 
instructed to take the medication daily starting on the day after the study visit.  
Baseline visit and Post-treatment visits (2, 3, 4) 
The participant will have been required to fast for at least 6 hrs prior to each visit and 
abstain from caffeine or smoking before bicycle ergometry testing. Patient should avoid 
exercise 48hours prior to cycle ergometry. Treatment will be dispensed after cycle 

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ergometry at baseline and post-treatment visits 2,3 and 4. The following data will be 
obtained:   
▪ Vital signs.  
▪ Fasting blood collection for banked plasma and peripheral blood mitochondrial 
energetics.  
▪ Anthropometrics (height and weight and waist to hip ratio) 
▪ Urine pregnancy test will be given to women of child-bearing potential 
▪ Resting energy expenditure (REE) and cycle ergometry will be performed at the 
Prevention center.  
▪ The optional MRS and Muscle Fatigue tests will occur at the diagnostic imaging 
center at UWMC at baseline and in the same week of visits 2, 3 and 4 while 
patient remains on study drug.  Patient should wait avoid heavy exercise for 48hrs 
before MRS. 
▪ Questionnaires will be administered (PROMIS fatigue short form 17, PROMIS 
physical function short form 20a, and Kansas city heart failure questionnaire) 
Procedures/Sample collection:  
An overview of the study visit and procedures schedule is presented in Appendix I. 
Presented below is additional information on visit-specific study procedures and Table 4. 
Physiologic measurements from cycle ergometry: The main outcome of this study is 
aerobic capacity (VO2max) using cycle ergometry. Secondary outcome is muscle 
performance using measures of total work and work efficiency which will be obtained by 
cycle ergometry using standard protocol measuring oxygen uptake starting at 0 watts (W) 
at 60 rotations per minute (rpm) increasing by 30W every 3 minutes until volitional 
exhaustion adapting a prior protocol used in CKD patients14. Approximately 30W of 
activity is required for grocery shopping and 60W is necessary for household chores. 
Work efficiency will be calculated as the work performed/energy expended (VO2) above 
that in cycling 0 watts x 100%. The minimum criteria for a successful efficiency 
calculation will be a rating of perceived exertion (RPE) of 13 (scale 6-20) or 75% of 
predicted maximal heartrate. The minimum goal for successfully achieving a VO2max is 
a RPE of 17 or respiratory exchange ratio≥1. Recovery will consist of pedaling 5 minutes 
at 10 watts and 60rpm. Participants should be fasting for at least 6 hrs prior to this 
test and not exercise for 48hr prior to this test.  
PBMC mitochondrial bioenergetic stress test: Monocytes are specifically selected due 
the strong correlation of their bioenergetics properties with skeletal muscle and cardiac 
bioenergetics in the primate model15. Blood samples will be process using an established 
protocol16,17. Sample collection should be coordinated in advance with Dr. David 
Marcinek (dmarc@uw.edu). 
Blood testing for metabolic response profile (oxidative stress, inflammation, and plasma 
amino acids, metabolites, and electrolytes). Oxidative Stress and Inflammatory 
Biomarkers include: C-reactive protein and IL-6 levels will be determined using the 
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F2-isoprostanes and isofurans will be measured by GC-MS as described by Roberts and 
Morrow at Vanderbilt University (c/o Jorge Gamboa: jorge.gamboa@Vanderbilt.Edu). 
 
Blood Collection:  
• NAD samples will be obtained from fasting whole blood collected in one 2.7ml Blue 
(sodium citrate tube). From the blue tube, after inversion mixing, 0.5ml will be 
pipetted into 2 cryotubes on dry ice. Samples will be immediately frozen on dry ice 
and placed in -80C ASAP. Samples will be sent to Dr. Laura Shireman in clinical 
pharmacology (shireman@uw.edu).  
• EDTA Plasma samples will be sent to University of California at Davis West Coast 
Metabolomics for liquid chromatography high-resolution mass spectrometry (LC-MS) 
for targeted metabolomics analysis. We will perform additional transcriptomics using 
mRNA samples obtained from Paxgene tubes which will also be sent to West Coast 
Metabolomics.  
• Paxgene mRNA will be obtained at baseline and post-intervention visits.  
• Clinical laboratory assays for determination of comprehensive metabolic panel 
(electrolytes, blood urea nitrogen, creatinine, glucose, albumin, total protein, calcium, 
alkaline phosphatase, ALT, AST, total bilirubin), CPK, lactate, triglyceride will be 
performed at the KRI Core Research laboratory. 
Urine collection: Spot urine for metabolomics will be collected at baseline and after 
each treatment period (visits 2-4).  
Mid-intervention visits/phone calls:  
All subjects will receive a phone call by study coordinators 4 weeks (mid-way) into each 
intervention arm to confirm patients are taking their treatment/placebo medication in 
order to ensure adherence. They will also receive a reminder of their subsequent visits. 
 Week 6, 13, 20 (Visit 2, 3, 4): 
The prevention center and Marcinek lab will be contacted to arrange the primary outcome 
of resting energy expenditure, aerobic capacity and secondary outcomes of monocyte 
mitochondrial energetics at the end of each treatment period. Patients will also have 
fasting blood collection and return a 24hr urine collection. If qualified, they will also 
receive a repeat MRS at UWMC during the same week. Patient remain on treatment 
during these visits to ensure drug effect.  
Washout (week 7 and 14): 
After the second visit, the participant will undergo a 1 week washout period prior to 
initiating the subsequent treatment arm for another 6 week period. 
Optional Procedures:  

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A subset of participants (N=20) may choose to undergo the following muscle imaging 
procedures. Subjects will go to the UW DISC lab for testing +/- 3 days from each 
scheduled visit (Baseline – visit 4).  
Magnetic Resonance Spectroscopy: Leg MRS will serve as a secondary outcome and 
optional. All participants will be offered the option to receiving leg MRS. As mentioned 
above, only 4 MRS will be obtained as part of this study (at Baseline, visit 2, 4 and 6). 
MRS will be used to measure phosphorylation capacity (ATPmax) tibialis anterior leg 
skeletal muscle.18 These functional tests assist to perturb the cell physiological state in 
order to measure the contents and dynamics of key metabolic compounds important in 
mitochondrial energy flux. 31P MRS is reliable with a documented coefficient of variation 
for oxidative phosphorylation of 5.1% and has a strong correlation with VO2max.19 
Scheduling of this test should be coordinated with Sophia Liu (sophia21@uw.edu).  
Muscle Fatigue: We will test muscle fatigability at each follow-up visit. We will test the 
TA (tibialis anterior) leg muscle and determine the isometric force generated at 70% of 
maximal voluntary contraction (MVC) against a force transducer. Using labview 
software to measure and record the force-time waveform of each contraction we will 
initiate the protocol at 50 contractions per minute at 70% MVC for one minute. At each 1 
minute increment will increase the contraction rate by 10 contractions per minute and 
reassess the subjects relative perceived exertion on a scale of 1-10 until the patient can no 
longer maintain the contraction waveform.  
 
 
Table 1. Table of study treatments and procedures. Abbreviations: PC – Prevention Center. 
*Performed at UWMC. ** Performed in Marcinek lab. Call lab to arrange collection and processing at same time as the 
bicycle VO2 testing.  

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6.0 
SAFETY MONITORING AND ADVERSE EVENT REPORTING 
6.1 
Safety Monitoring  
All adverse events will be followed by the PI and study personnel until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At 
the last scheduled visit, the investigator will instruct each subject to report any 
subsequent event(s) that the subject, or the subject’s personal physician, believes might 
reasonably be related to participation in this study.  The investigator will follow any 
death or adverse event occurring at any time after a subject has discontinued or 
terminated study participation that may reasonably be related to this study.  An internal 
audit will take place each month of the trial to insure that everything is well documented. 
 
As each of the first five subjects completes the cross-over, we will submit to the IRB a 
report on how the drug was tolerated.  We will report all side effects, adverse events and 
subject concerns.  In the event that one of the first 5 subjects withdraws from the study 
for reasons related to the drug, we will report immediately to the IRB via modification. 
6.2 
Adverse Event Definitions and Reporting Requirements 
6.2.1 Adverse Event 
Safety information will be assessed initially by subject interview. The clinical research 
coordinator is responsible for collecting and recording all clinical data.  As these results 
are collected, all adverse events will be identified and reported to the principle 
Investigators within seven (7) days. Adverse events will be reported as described below 
(section 6.2.3). The principal investigator (PI) is responsible for evaluating each AE and 
for determining whether the AE affects the risk/benefit ratio of the study and whether 
modifications to the protocol and consent form are required.  All IRB-approved protocol 
or consent form revisions that indicate a change in risk for participants will be reported to 
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in a 
timely manner. 
 
Study participants will be provided a telephone number and instructed to contact the 
study clinician to report any AEs they may experience, except for life-threatening events, 
for which they will be instructed to seek immediate emergency care. Where feasible and 
medically appropriate, participants will be encouraged to seek evaluation where the study 
clinician is based, and to request that the clinician be paged or otherwise contacted upon 
their arrival. With appropriate permission of the participant, whenever possible records 
from all non-study medical providers related to AEs will be obtained and required data 
elements will be recorded on study case report forms.  All participants reporting an AE 
will be followed clinically, until the AE resolves (returns to baseline) or stabilizes. 
Study site staff will document on study case report forms all AEs reported by or observed 
in enrolled study participants regardless of severity and presumed relationship to study 
product.  
All adverse events will be graded as follows: 

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      Severity 
0 = No adverse event or within normal limits 
1 = Mild—did not require treatment 
2 = Moderate—resolved with treatment 
3 = Severe—required professional medical attention 
4 = Life-threatening or disabling 
5 = Death 
 
Related to study procedures (there is a reasonable possibility that the experience may 
have been caused by the study procedures) 
0 = Unrelated 
1 = Unknown 
2 = Related 
 
Unexpected event (an AE with specificity or severity not consistent with the risk 
information in the protocol/application or an AE that has not been previously 
observed) 
0 = No 
1 = Yes 
 
Serious (any AE occurring at any dose that results in death; a life-threatening adverse 
drug experience; inpatient hospitalization or prolongation of existing hospitalization; 
a persistent or significant disability/incapacity; a congenital anomaly/birth defect; or 
any important medical event that, based on medical judgment, jeopardizes the subject 
and may require medical or surgical intervention to prevent one of the above 
outcomes) 
0 = No 
1 = Yes 
 
6.2.2 Serious Adverse Event  
Serious adverse event (SAE) will be defined per U.S. Code of Federal Regulations (CFR) 
312.32 and International Conference on Harmonization (ICH), “Good Clinical Practice: 
Consolidated Guidance” (E6) and “Clinical Safety Data Management: Definitions and 
Standards for Expedited Reporting” (E2A), as AE occurring at any dose that: 
• Results in death  
• Is life-threatening 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly/birth defect   
• Requires inpatient hospitalization or prolongation of existing hospitalization  

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This includes important medical events that may not be immediately life-threatening or 
result in death, or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the outcomes listed above. 
Per ICH SAE definition, hospitalization itself is not an adverse event, but is an outcome 
of the event. The following types of hospitalization do not require expedited reporting: 
• Any admission unrelated to an AE (e.g. for labor/delivery, cosmetic surgery, 
administrative, or social admission for temporary placement for lack of place to 
sleep) 
• Protocol-specified admission (e.g. for procedure required by protocol) 
• Admission for diagnosis or therapy of a condition that existed before receipt of 
study agent(s) and has not increased in severity or frequency as judged by the 
clinical investigator 
6.2.3 Adverse Event Reporting 
Any AE that is unexpected, related to study participation, and serious (defined in 
6.2.1) will be reported in writing to the IRB within 7 days of the PI’s first 
knowledge of the event. Any AE that is unexpected, related to study participation, 
and suggests greater risk of harm than previously known or recognized will be 
reported in writing to the IRB within 7 days of the PI’s first knowledge of the 
event.  
 
The PI will review all expedited adverse event reports. In addition, any deviations 
from protocol will be reported to the IRB and copied to the Prevention Center.  
 
A summary of all adverse events and any audit reports will be sent to the IRB.  
Any action resulting in a temporary or permanent suspension of this study (e.g., 
IRB actions, or actions by the investigators or co-investigators) will be reported to 
the appropriate NIDDK program official.  In addition, the NIDDK will be given 
notice of any actions taken by the IRB or regulatory bodies regarding the research 
and any responses to those actions. 
7.0 
STATISTICAL CONSIDERATIONS 
7.1 
Review of Study Design 
We propose a single-center double blind randomized cross-over trial of NR or CoQ10 
supplementation versus placebo. As part of the study there will be a 1-week washout 
between treatment and placebo arms.  

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7.2 
Endpoints 
Primary endpoints are change in aerobic capacity using cycle ergometry. Secondary 
endpoints are change in muscle work efficiency, metabolic response profile and markers 
of oxidative stress and inflammation.  
7.2.1 Primary Endpoints 
Consistent with the primary study objective to test NR and CoQ10 improving aerobic 
capacity, the following endpoints will be assessed: 
• Physiologic measurements from cycle ergometry: The main outcome of this 
study is aerobic capacity (VO2max) using cycle ergometry.  
7.2.2 Secondary and Exploratory Endpoints 
Consistent with the secondary study objective to assess changes in metabolic response 
profile and markers of oxidative stress and inflammation the following endpoints will 
assessed: 
• Muscle performance using measures of total work and work efficiency which 
will be obtained by cycle ergometry using standard protocol measuring 
oxygen uptake starting at 0 watts (W) at 60 rotations per minute (rpm) 
increasing by 25W every 3 minutes until volitional exhaustion adapting a 
prior protocol used in CKD patients14. 25W of activity is required for grocery 
shopping and 50W is necessary for household chores. Work efficiency will be 
calculated as the work performed/energy expended (VO2) above that in 
cycling 0 watts x 100%. The minimum criteria for a successful efficiency 
calculation will be a rating of perceived exertion (RPE) of 13 (scale 6-20) or 
75% of predicted maximal heartrate. The minimum goal for successfully 
achieving a VO2max is a RPE of 17 or respiratory exchange ratio≥1. 
 
• PBMC mitochondrial bioenergetic 
stress test: Monocytes are 
specifically selected due the strong 
correlation of their bioenergetics 
properties with skeletal muscle and 
cardiac bioenergetics in the primate 
model15. Blood samples will be 
process using an established 
protocol16,17. Monocyte will be 
isolated using magnetic-activated 
cell sorting (MACS) and CD14+ 
microbead selection. Bioenergetics 
analysis will be performed using the 
Seahorse Biosciences XF24 
extracellular flux analyzer per protocol20. Max-OCR (maximal respiration) is 
calculated after the addition of FCCP, a mitochondrial uncoupler. RC is 
calculated as the difference of Max-OCR and Basal-OCR (Figure 2).  
Figure 2. Illustration of monocyte bioenergetic stress test to 
determine reserve capacity. Abbreviation: oligo=oligomycin, 
AntiA=antimycin A, FCCP=uncoupler. 
Reserve 
Capacity 
Bioenergetic 
threshold 

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• Improvement in metabolic response profile suggested by:  
 
• Change in targeted metabolomics profile using liquid chromatography 
high-resolution mass spectroscopy (LC-MS) using plasma and urine 
samples 
 
• Oxidative stress biomarkers: Plasma F2-isoprostanes will be measured 
by GC-MS as described by Roberts and Morrow. 
 
• Patient reported outcomes: Patient reported fatigue will be assessed using the 
PROMIS Fatigue Short form 17 and PROMIS Physical function short form 
20a. Heart failure symptoms will be assessed using Kanasas City Heart 
Failure Questionnaire. 
 
 
Exploratory Endpoints 
• Magnetic Resonance Spectroscopy: Leg MRS will serve as a secondary outcome. As 
mentioned above, only 4 MRS will be obtained as part of this study (at Baseline, visit 
2, 4 and 6). MRS will be used to measure phosphorylation capacity (ATPmax) tibialis 
anterior leg skeletal muscle.18 These functional tests assist to perturb the cell 
physiological state in order to measure the contents and dynamics of key metabolic 
compounds important in mitochondrial energy flux. 31P MRS is reliable with a 
documented coefficient of variation for oxidative phosphorylation of 5.1% and has a 
strong correlation with VO2max.19  
• Muscle Fatigue: We will test muscle fatigability at each follow-up visit. We will test 
the TA muscle and determine the isometric force generated at 70% of maximal 
voluntary contraction (MVC) against a force transducer. Using labview software to 
measure and record the force-time waveform of each contraction we will initiate the 
protocol at 50 contractions per minute at 70% MVC for one minute. At each 1 minute 
increment will increase the contraction rate by 10 contractions per minute and 
reassess the subjects relative perceived exertion on a scale of 1-10 until the patient 
can no longer maintain the contraction waveform.  
7.3 
Accrual, Follow-up, and Sample Size 
The overall sample size for this project is 30. We anticipate recruiting 1-2 participants 
weekly for total study duration of 1.5-2 years (Table 2). 
 
 

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Sample size was calculated based on values obtained from an standard deviation of the 
difference of VO2max on bicycle ergometry from a prior study of 2.1ml/kg/min. A total 
of 30 patients will enter this three-treatment crossover study. A total of 30 patients will 
enter this two-treatment crossover study. The probability is 80 percent that the study will 
detect a treatment difference at a two-sided 0.05 significance level, if the true difference 
between treatments is 2.1 (1 SD)ml/kg/min. This is based on the assumption that the 
standard deviation of the difference in the response variables is 2.1 ml/kg/min (Table 3). 
Sample size was calculated using the following sample size calculator: 
http://hedwig.mgh.harvard.edu/sample_size/js/js_crossover_quant.html 
 
  
VO2max 
 
Power 
Minimal detectable difference 
80% 
(n) 
90% 
(n) 
0.5 SD 
34 
44 
0.75 SD 
16 
21 
1 SD 
10 
13 
 
 
 
7.4 
Random Assignment / Study Arm Assignment 
Investigational drug services will be responsible for randomization of participants into 
the two treatment groups. Every effort will be taken to have an appropriate placebo pill 
appearing identical to study agent.  
Order 
N 
Period 1 
Period 2 
Period 3 
Sequence Placebo-CoQ10-NR  
(n=5) 
10 
A 
B 
C 
Sequence Placebo-NR-CoQ10  
(n=5) 
A 
C 
B 
Sequence NR-Placebo-CoQ10 
(n=5) 
10 
B 
A 
C 
Sequence NR-CoQ10-Placebo 
(n=5) 
B 
C 
A 
Sequence CoQ10-Placebo-NR 
(n=5) 
10 
C 
A 
B 
Sequence CoQ10-NR-Placebo 
(n=5) 
C 
B 
A 
Table 2. Study design and sample size. Given the efficient cross-over design, 30 participants will receive 
each treatment by the end of the study. 
Table 3. Total samples size required to detect treatment effects for aerobic capacity bicycle 
ergometry from crossover design. Based on published study demonstrating the effect of a 
12mo combined resistance and aerobic exercise program resulting in an increase of +5.7 
ml/kg/min VO2peak with a standard deviation of the difference of 2. 1ml/kg/min. 

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7.5 
Blinding 
Study participants, investigators, and research coordinators will be blinded to the study. 
The investigational drug pharmacy will receive a receive treatment/placebo designation 
in a sealed envelope on the day of study drug/placebo initiation. Subjects will not be told 
of their assignment. Early unblinding will occur to protect patient safety in the event of 
an adverse event that the investigator believes may be relate to treatment.  
7.6 
Data Analysis  
7.6.1 Primary Analyses 
The major assumption in the cross-over trial is that there is no carryover effect of first 
period into the second period.  The assumption is that a 1-week washout combined with a 
2 month treatment will be sufficient to eliminate any potential carryover effect. The 
statistical model we assumed for continuous data from the 3 × 3 crossover trial. We will 
use ANOVA to estimate sequence effects, treatment effects, and period effects. Given the 
short half-life of these drugs, we estimate that the drug washout will occur over 1 week 
with any residual effects by 3 weeks. According to this model, the coefficient of the 
interaction term between the treatment and time represents the treatment effect.   
Secondary Analyses 
We will assess differences in plasma metabolites using a linear mixed model approach 
with random intercepts, in which the log-transformed metabolite will be regressed on 
treatment type (Placebo vs Coenzyme Q10 or NR), time point (pre vs post) and the 
interaction of the two. We will use metaboanalyst to conduct pathway enrichment 
analysis.   
For differential analysis of transcriptomic data, paired analyses of pre- and post- 
treatment with NR or CoQ10 compared to pre- and post- treatment with placebo will be 
performed using Significance Analysis of Microarrays (SAM) method implemented in 
Multi Experiment Viewer (MeV) application (Saeed et al. 2006; Saeed et al. 2003). 
Genes differentially expressed between two groups with a q-value (False Discovery Rate) 
below 0.05 were considered significant.  
8.0 
HUMAN SUBJECTS CONSIDERATIONS 
The procedures in the study and model informed consent forms for subjects are to be 
reviewed by the UW Human Subjects Division (HSD). 
Subsequent to initial review and approval, the HSD will review the protocol at least 
annually.  The Investigator will make safety and progress reports to the IRB at least 
annually, and within three months of study termination or completion.  These reports will 
include the total number of participants enrolled in the study, the number of participants 
who completed the study, all changes in the research activity, and all unanticipated 
problems involving risks to human subjects or others.  

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8.1 
Informed Consent 
Informed consent will be obtained from each study participant.  Consent forms will 
include the purpose of the study, description of procedures, list of risks and benefits, 
assurance of confidentiality, assurance of withdrawal without prejudice, description of 
reimbursement for trial participation ($325 or $525 if volunteering for MRS plus parking 
and bus fare reimbursement), and a telephone number for answering questions about the 
research.  Patients are also given information regarding their right to privacy for personal 
health information based on HIPAA regulations, and the procedures for data sharing 
using de-identified data will be explained.  Participants will be provided with a copy of 
their informed consent forms if they are willing to receive them. 
8.2 
Risks 
The following stated risks will be reflected in the informed consent form and 
communicated orally to prospective participants at the study site at the time of obtaining 
consent. 
 
NR and CoQ10 have been deemed safe in studies of healthy adults13. Among anuric 
dialysis patients, high dose CoQ10 up to 1800mg was well tolerated11 in most 
individuals. We will be using 1200mg daily in our study, well below the threshold for 
complaints of nausea and abdominal discomfort.  
Potential loss of confidentiality is a risk for all study participants, which is address by 
procedures at the coordinating center described below. 
All patient will have a blood draw regularly during the study for a total of four blood 
draws. The risks of phlebotomy include bleeding/bruising, infection, and discomfort. 
For the MRS study, participants may be at risk if they have implanted or non-removable 
magnetic objects within or on the body, or if loose magnetic items are attracted to the 
magnet while the subject is near or in the magnet bore.  We carefully screen subjects to 
exclude anyone who has implanted or attached magnetic items.  In addition, access to the 
magnet is strictly controlled and all magnetic objects are kept away from the magnetic 
field.  There is no intravenous contrast used in the MR study.  
8.3 
Benefits 
There may be no direct benefits to participants in this study, however, participants and 
others may benefit in the future from information learned from this study. Specifically, 
information learned in this study may lead to the development of a safe and effective 
intervention that reduce risk of cardiovascular events and risk of disability in persons 
with CKD.   
 

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8.4 
Compensation 
Participants will be compensated for their time and effort in this study, and/or be 
reimbursed for travel to study visits and time away from work. Reimbursement amounts 
will be specified in the study informed consent forms.  
8.5 
Confidentiality 
1.  All study-related information will be stored securely at the Kidney Research Institute 
(KRI) at the University of Washington in Seattle.  Access to the KRI is protected by 
individual unit keys to the elevator, the main institute, and individual offices to prevent 
tampering or unauthorized access.  The use of a Local Area Network (LAN) provides two 
additional levels of security in the unlikely event of an unauthorized user finding a 
machine unattended or unlocked.  The LAN restricts access to the Database files via 
passwords, and the Database itself requires a password before files may be opened.   
All study participants are assigned a unique identifier that does not contain identifiable 
information.  
2. All study-related information will be stored securely at the study site. All participant 
information will be stored in locked file cabinets in areas with access limited to study 
staff.  All laboratory specimens, reports, study data collection, process, and 
administrative forms will be identified by a coded number to maintain participant 
confidentiality.  All local databases will be secured with password-protected access 
systems. Forms, lists, logbooks, appointment books, and any other listings that link 
participant ID numbers to other identifying information will be stored in a separate, 
locked file in an area with limited access.  Participant’s study information will not be 
released without the written permission of the participant.   
8.6 
Study Discontinuation 
The study also may be discontinued at any time by the IRB. 
9.0 
 LABORATORY SPECIMENS AND BIOHAZARD CONTAINMENT 
9.1 
Local Laboratory Specimens 
As described in section 5, the following types of specimens will be collected for testing at 
the Kidney Research Institute local laboratory. If the participant provides informed 
consent, his/her specimen will be stored in the KRI repository for additional studies (see 
section 9.2): 
 
• Fasting blood samples – approximately 60ml of blood per visit at baseline 
visit and post-intervention visits during each period of the study.  During the 
study a total of approximately 245 mL will be collected per subject. 
 
 

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Local laboratories will perform Chemistries and pregnancy testing.  
9.2 
Reference Laboratory Specimens 
• Blood for metabolomics testing. Aliquots of EDTA preserved blood will be 
stored at -80°C. All samples will be de-identified.  
• Blood for F2-isofuran and F2-isoprostane assays will be frozen at -80°C and 
sent in bulk to Vanderbilt University (c/o Dr. Jorge Gamboa). 
• EDTA plasma samples and urine samples used for metabolomics and Paxgene 
samples for transcriptomics will be sent at the conclusion of the study to Dr. 
Bob Roshanravan at UC Davis for analysis by West Coast Metabolomics: 
(bob.roshanravan.wrk@gmail.com) 
 
Tube 
Size 
Number of 
tubes 
Aliquots for banking 
Purpose 
Blood Screening only: 
CBC (lavender) 
Renal panel (green) 
3ml 
4ml 
1 
1 
none 
Send to Qwest labs for 
hemoglobin and renal panel 
Blood banking at baseline and after each treatment 
EDTA whole blood 
(lavender) 
10ml 
3 
none 
Fresh for Dave marcinek lab 
EDTA plasma 
(lavender) 
8ml 
2 
0.5ml x 10 
1ml x 3 
 
Metabolomics  
Lipids 
F2 isoprostanes/isofurans for 
Vanderbilt. 
Serum (red) 
6ml 
1 
0.5mlx6 
biochemistry 
ACD (citrated plasma) 
whole blood (blue top) 
2.5ml 
1 
0.5ml x2 on dry ice 
For NAD. Aliquot immediately 
onto tubes chilled on dry ice 
Paxgene tube 
2.5ml 
1 
2.5x1 
Banking 
Urine banking at 
baseline and at end of 
each treatment 
10ml 
 
1mlx5 
Urine metabolomics 
Urine urea nitrogen 
Urine creatinine 
Urine ammonia 
 
9.3 
Specimen Storage and Possible Future Research Testing 
Study site staff will store all blood and urine collected in this study at least through the 
end of the study. In addition, study participants will be asked to provide written informed 
consent for their blood and urine specimens to be stored in the KRI repository after the 
end of the study for possible future testing. The specimens of participants who do not 
consent to long-term storage and additional testing will be destroyed at the end of the 
study. 
 
Table 4. List of blood and urine samples to be collected during study. 

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10.0 REFERENCES 
1. 
Afshinnia F, Rajendiran TM, Soni T, et al. Impaired beta-Oxidation and 
Altered Complex Lipid Fatty Acid Partitioning with Advancing CKD. J Am 
Soc Nephrol. 2018;29(1):295-306. 
2. 
Schefold JC, Zeden JP, Fotopoulou C, et al. Increased indoleamine 2,3-
dioxygenase (IDO) activity and elevated serum levels of tryptophan 
catabolites in patients with chronic kidney disease: a possible link between 
chronic inflammation and uraemic symptoms. Nephrol Dial Transplant. 
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3. 
Deger SM, Hung AM, Gamboa JL, et al. Systemic inflammation is 
associated with exaggerated skeletal muscle protein catabolism in 
maintenance hemodialysis patients. JCI Insight. 2017;2(22). 
4. 
Siew ED, Pupim LB, Majchrzak KM, Shintani A, Flakoll PJ, Ikizler TA. 
Insulin resistance is associated with skeletal muscle protein breakdown in 
non-diabetic chronic hemodialysis patients. Kidney Int. 2007;71(2):146-152. 
5. 
Conjard A, Ferrier B, Martin M, Caillette A, Carrier H, Baverel G. Effects of 
chronic renal failure on enzymes of energy metabolism in individual human 
muscle fibers. J Am Soc Nephrol. 1995;6(1):68-74. 
6. 
Hoehn KL, Salmon AB, Hohnen-Behrens C, et al. Insulin resistance is a 
cellular antioxidant defense mechanism. Proc Natl Acad Sci U S A. 
2009;106(42):17787-17792. 
7. 
Houstis N, Rosen ED, Lander ES. Reactive oxygen species have a causal 
role in multiple forms of insulin resistance. Nature. 2006;440(7086):944-
948. 
8. 
Fazakerley DJ, Chaudhuri R, Yang P, et al. Mitochondrial CoQ deficiency is 
a common driver of mitochondrial oxidants and insulin resistance. Elife. 
2018;7. 
9. 
Roshanravan B, Kestenbaum B, Gamboa J, et al. CKD and Muscle 
Mitochondrial Energetics. Am J Kidney Dis. 2016;68(4):658-659. 
10. 
Gamboa JL, Billings FTt, Bojanowski MT, et al. Mitochondrial dysfunction 
and oxidative stress in patients with chronic kidney disease. Physiol Rep. 
2016;4(9). 
11. 
Yeung CK, Billings FTt, Claessens AJ, et al. Coenzyme Q10 dose-escalation 
study in hemodialysis patients: safety, tolerability, and effect on oxidative 
stress. BMC Nephrol. 2015;16:183. 
12. 
Canto C, Houtkooper RH, Pirinen E, et al. The NAD(+) precursor 
nicotinamide riboside enhances oxidative metabolism and protects against 
high-fat diet-induced obesity. Cell Metab. 2012;15(6):838-847. 
13. 
Airhart SE, Shireman LM, Risler LJ, et al. An open-label, non-randomized 
study of the pharmacokinetics of the nutritional supplement nicotinamide 

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riboside (NR) and its effects on blood NAD+ levels in healthy volunteers. 
PLoS One. 2017;12(12):e0186459. 
14. 
Macdonald JH, Fearn L, Jibani M, Marcora SM. Exertional fatigue in 
patients with CKD. American journal of kidney diseases : the official 
journal of the National Kidney Foundation. 2012;60(6):930-939. 
15. 
Tyrrell DJ, Bharadwaj MS, Jorgensen MJ, Register TC, Molina AJ. Blood 
cell respirometry is associated with skeletal and cardiac muscle 
bioenergetics: Implications for a minimally invasive biomarker of 
mitochondrial health. Redox Biol. 2016;10:65-77. 
16. 
Chacko BK, Kramer PA, Ravi S, et al. The Bioenergetic Health Index: a 
new concept in mitochondrial translational research. Clin Sci (Lond). 
2014;127(6):367-373. 
17. 
Chacko BK, Kramer PA, Ravi S, et al. Methods for defining distinct 
bioenergetic profiles in platelets, lymphocytes, monocytes, and neutrophils, 
and the oxidative burst from human blood. Lab Invest. 2013;93(6):690-700. 
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