CytoSorb® Reduction of FREee Hemoglobin/Acute Kidney Injury (AKI) During Cardiac Surgery (REFRESH II Trial)
Phase: NA
Conditions: Elective Cardiac Surgery
Sponsor: CytoSorbents, Inc

 
CytoSorbents – REFRESH II 
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Rev. F_version 1.1 
 
CYTOSORB® REDUCTION OF FREE HEMOGLOBIN/ACUTE KIDNEY 
INJURY (AKI) DURING CARDIAC SURGERY  
REFRESH II 
 
Sponsor: 
CytoSorbents Corporation 
7 Deer Park Drive, Suite K 
Monmouth Junction, NJ 08852 
Phone: (732) 329-8885 
 
Study Product: 
CytoSorb® Device, 300 mL 
 
IDE # (if applicable): 
G140256 
 
Sponsor Contact(s): 
Peter Nelson, MD 
Office Phone: (732) 329-5420 
Cell: (646) 296-9250 
Investigational Sites/PIs 
List maintained in the Trial Master File 
Clinical Vendors 
A list of clinical vendors utilized in this study is maintained in 
the Trial Master File 
 
Protocol Number: 
2017-001 
 
Date/Version: 
15 September 2020 / Revision F_ version 1.1 
 
This clinical investigation is performed in accordance with applicable guidelines, standards and regulations.   
Confidential Material: 
This document is the property of the Sponsor and is confidential and proprietary. The information contained herein is 
believed to be accurate and complete as of the date of preparation.  The contents of this document may not be 
reproduced without prior expressed consent by the Sponsor. 

 
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TABLE OF CONTENTS 
1. 
SYNOPSIS ......................................................................................................................................................... 6 
2. 
INTRODUCTION .............................................................................................................................................. 16 
2.1 
SUMMARY OF PREVIOUS CLINICAL EXPERIENCE INFORMING STUDY DESIGN: ..................................................................... 18 
2.2 
REFRESH II STUDY DESIGN: .................................................................................................................................... 18 
3. 
INVESTIGATIONAL DEVICE DESCRIPTION ........................................................................................................ 19 
3.1 
INVESTIGATIONAL DEVICE DESCRIPTION ..................................................................................................................... 19 
3.2 
INVESTIGATIONAL DEVICE IDENTIFICATION .................................................................................................................. 21 
3.3 
INVESTIGATIONAL DEVICE ACCOUNTABILITY ................................................................................................................ 21 
3.4 
THE INTENDED USE OF THE INVESTIGATIONAL DEVICE(S). ................................................................................................ 22 
3.5 
INVESTIGATIONAL DEVICE PROCEDURE(S)/TRAINING .................................................................................................... 22 
3.6 
BLINDING ............................................................................................................................................................. 22 
3.6.1 
Maintaining the Study Blind .................................................................................................................... 23 
3.6.2 
Unblinding Procedure .............................................................................................................................. 24 
4. 
STUDY JUSTIFICATION .................................................................................................................................... 24 
5. 
POTENTIAL RISK/BENEFIT ............................................................................................................................... 29 
5.1 
POTENTIAL INVESTIGATIONAL DEVICE BENEFIT ............................................................................................................. 29 
5.2 
INVESTIGATIONAL DEVICE RESIDUAL RISKS .................................................................................................................. 29 
5.3 
RISK MITIGATION/RISK BENEFIT RATIONALE ............................................................................................................... 30 
6. 
INVESTIGATIONAL DESIGN ............................................................................................................................. 31 
6.1 
STUDY OBJECTIVE(S) .............................................................................................................................................. 31 
6.1.1 
Primary Objective(s) ................................................................................................................................ 31 
6.2 
STUDY DESIGN ...................................................................................................................................................... 31 
6.3 
STUDY OUTCOMES ................................................................................................................................................. 32 
6.3.1 
Primary Safety Endpoint .......................................................................................................................... 32 
6.3.2 
Primary Effectiveness Endpoint(s) ........................................................................................................... 32 
6.3.3 
Secondary Safety Endpoints .................................................................................................................... 32 
6.3.4 
Secondary Effectiveness Endpoint(s) ....................................................................................................... 32 
6.3.5 
Exploratory Effectiveness Endpoints ........................................................................................................ 33 
6.4 
SUBJECTS ............................................................................................................................................................. 33 
6.4.1 
Inclusion Criteria ...................................................................................................................................... 33 
6.4.2 
Exclusion Criteria ..................................................................................................................................... 34 
6.4.3 
Informed Consent & Enrollment Procedures ........................................................................................... 36 
6.4.4 
Subject Withdrawal/Discontinuation ...................................................................................................... 36 
7. 
FIELD CLINICAL ENGINEERS ............................................................................................................................ 37 
8. 
STUDY ASSESSMENTS AND PROCEDURES....................................................................................................... 37 
8.1 
AKI DEFINITION, SEVERITY GRADING, AND DURATION .................................................................................................. 37 
8.2 
RECORDING OF URINE OUTPUT ................................................................................................................................. 38 
8.3 
SUBJECT SCREENING ............................................................................................................................................... 39 

 
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8.4 
SCREENING VISIT ................................................................................................................................................... 39 
8.5 
PROCEDURE ASSESSMENTS ...................................................................................................................................... 40 
8.5.1 
Subject Randomization ............................................................................................................................ 40 
8.5.2 
Pre-Procedure .......................................................................................................................................... 40 
8.5.3 
Procedure (CPB Surgery) .......................................................................................................................... 41 
8.5.4 
Sampling during CPB ............................................................................................................................... 47 
8.5.5 
Sampling End of CPB (i.e. pump shut off, post protamine)...................................................................... 47 
8.5.6 
Sample Collection and Storage ................................................................................................................ 48 
8.6 
POST-SURGICAL CARE UNIT (I.E., CCU, ICU) .............................................................................................................. 48 
8.6.1 
Admission to Post-Surgical Care Unit (Treatment and Control Groups) .................................................. 48 
8.6.2 
Post-Surgical Days 1-3 ............................................................................................................................. 49 
8.6.3 
Post-Surgical Day 4 through 7 ................................................................................................................. 50 
8.6.4 
Hospital Discharge ................................................................................................................................... 50 
8.7 
DAY 30 POST-CARDIAC SURGERY ............................................................................................................................. 51 
8.8 
SAFETY/DEVICE ASSESSMENT ................................................................................................................................... 58 
8.8.1 
Adverse Events ........................................................................................................................................ 58 
8.8.2 
Serious Adverse Events ............................................................................................................................ 59 
8.8.3 
Anticipated Adverse Events/Device Related Adverse Events ................................................................... 60 
8.8.4 
Unanticipated Adverse Device Effect ....................................................................................................... 61 
8.8.5 
Device Malfunction/Observations ........................................................................................................... 61 
8.9 
REPORTING PROCEDURES ........................................................................................................................................ 61 
8.9.1 
Investigator Reporting ............................................................................................................................. 61 
8.9.2 
Sponsor Reporting ................................................................................................................................... 62 
9. 
STUDY OVERSIGHT ......................................................................................................................................... 62 
9.1 
CLINICAL EVENTS COMMITTEE .................................................................................................................................. 62 
9.2 
DATA MONITORING COMMITTEE (DMC) ................................................................................................................... 62 
9.3 
CENTRAL LABORATORY............................................................................................................................................ 63 
10. 
STUDY MONITORING ..................................................................................................................................... 64 
10.1 MONITOR TRAINING ............................................................................................................................................... 64 
10.2 SITE/INVESTIGATOR TRAINING .................................................................................................................................. 64 
10.3 SITE MONITORING ................................................................................................................................................. 64 
10.4 REGULATORY AGENCY INSPECTION ............................................................................................................................ 65 
11. 
STATISTICAL CONSIDERATIONS ...................................................................................................................... 65 
11.1 ANALYSIS POPULATIONS .......................................................................................................................................... 65 
11.1.1 
Safety and Tolerability Evaluations: ........................................................................................................ 66 
11.1.2 
Effectiveness evaluations: ....................................................................................................................... 66 
11.2 STATISTICAL POWER AND SAMPLE SIZE DETERMINATION ............................................................................................... 67 
11.2.1 
Interim Analyses ...................................................................................................................................... 68 
11.2.2 
Sample Size Re-estimation ...................................................................................................................... 69 
11.3 STUDY SUCCESS ..................................................................................................................................................... 71 
11.4 TREATMENT OF MISSING OR SPURIOUS DATA.............................................................................................................. 71 
11.5 DISPOSITION AND BASELINE CHARACTERISTICS............................................................................................................. 71 
12. 
DATA HANDLING AND RECORD KEEPING ....................................................................................................... 72 

 
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12.1 DATA MANAGEMENT PROCEDURES ........................................................................................................................... 72 
12.2 DATA RETENTION................................................................................................................................................... 73 
12.3 INVESTIGATOR RECORDS ......................................................................................................................................... 73 
12.4 INVESTIGATOR REPORTS .......................................................................................................................................... 74 
13. 
QUALITY CONTROL AND ASSURANCE ............................................................................................................. 75 
13.1 SITE AND INVESTIGATOR SELECTION ........................................................................................................................... 75 
13.2 PROTOCOL DEVIATIONS .......................................................................................................................................... 75 
13.3 PROTOCOL DEVIATION PROCESS ............................................................................................................................... 75 
13.4 CORRECTIVE/PREVENTIVE ACTION ............................................................................................................................ 76 
14. 
ETHICS/PROTECTION OF HUMAN SUBJECTS ................................................................................................... 76 
14.1 STATEMENTS OF COMPLIANCE .................................................................................................................................. 76 
14.2 INSTITUTIONAL REVIEW BOARD (IRB) ........................................................................................................................ 76 
14.3 INFORMED CONSENT PROCESS ................................................................................................................................. 76 
14.3.1 
Subjects Unable to Read or Write ............................................................................................................ 77 
14.3.2 
New Information ..................................................................................................................................... 77 
14.4 PATIENT CONFIDENTIALITY ....................................................................................................................................... 77 
15. 
PROTOCOL AMENDMENTS ............................................................................................................................. 78 
16. 
TERMINATION OF STUDY OR STUDY SITE PARTICIPATION ............................................................................. 78 
17. 
PUBLICATION POLICY ..................................................................................................................................... 78 
17.1 METHOD AND TIMING OF RELEASE OF PRESPECIFIED CLINICAL ENDPOINT RESULTS FROM THE REFRESH II CLINICAL STUDY ...... 79 
18. 
BIBLIOGRAPHY ............................................................................................................................................... 80 
List of Figures 
FIGURE 1:  CYTOSORB® DEVICE ............................................................................................................................................... 20 
FIGURE 2:  CYTOSORB® 300 ML DEVICE ON CPB CIRCUIT ............................................................................................................ 21 
LIST OF TABLES 
TABLE 1:  DEFINITIONS .......................................................................................................................................................... 12 
TABLE 2: ABBREVIATIONS ...................................................................................................................................................... 13 
TABLE 3: SCHEDULE OF ASSESSMENTS ...................................................................................................................................... 52 
TABLE 4: SCHEDULE OF LABORATORY ASSESSMENTS ................................................................................................................... 55 
TABLE 5: OVERALL POWER FOR THE ORDINAL OUTCOME, THE ANY AKI DICHOTOMOUS OUTCOME (LABELED STAGES 1,2,3 BELOW), AND THE 
MODERATE/SEVERE AKI DICHOTOMOUS OUTCOME (LABELED STAGES 2,3 BELOW). ................................................................ 68 
TABLE 6: PERFORMANCE CHARACTERISTICS FOR GROUP SEQUENTIAL DESIGN WITH SAMPLE SIZE RE-ESTIMATION OPTION FOR BINARY AND 
ORDINAL AKI ENDPOINT ............................................................................................................................................... 71 
TABLE 7. RESPONSIBILITIES FOR PREPARING AND SUBMITTING REPORTS ......................................................................................... 74 

 
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Investigator’s Statement and Signature 
 
Investigator approval: 
I have read this protocol and the Investigator Brochure and agree that the documents contain all the 
necessary information required to conduct the study, and I agree to conduct it as described. I 
understand that this study will not be initiated without appropriate IRB approval and that the 
administrative requirements of the governing body will be fully complied with. 
 
 
 
 
 
 
 
Investigator’s Signature 
 
Date 
 
 
 
 
 
 
Investigator’s Printed Name 
 
 
 
 
 
 
 
 
 
 
 
Site Name 
 
Site # 
 

 
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1. SYNOPSIS 
Sponsor 
CytoSorbents Corporation 
Title 
CytoSorb® REduction of FREe Hemoglobin/Acute Kidney Injury (AKI) 
during Cardiac Surgery (REFRESH II Trial) 
Study device 
CytoSorb® is a sorbent-filled hemoperfusion cartridge that is designed to 
reduce plasma free hemoglobin (pfHb) and other inflammatory mediators 
from blood that are generated during cardiopulmonary bypass in cardiac 
surgery.  
Purpose of study 
To evaluate the safety and performance of the CytoSorb® device to 
decrease the incidence or severity of acute kidney injury (AKI) as defined 
by Kidney Disease Improving Global Outcomes (KDIGO) clinical 
practice guideline definition of acute kidney injury when used 
intraoperatively with cardiopulmonary bypass (CPB) in subjects 
undergoing cardiac surgery. The objective of using CytoSorb® treatment 
in this setting is to provide clinically meaningful improvements in renal 
function by mitigation of intraoperative injury by removal of nephrotoxic 
agents such as pfHb and complement. 
Study design 
Prospective, multi-center, randomized, pivotal double-blinded clinical 
study.  Subjects will be randomized in a 1:1 ratio to either standard of 
care (SOC) alone or standard of care plus treatment with the CytoSorb® 
device, with or without HCA.  The number of patients with and without 
HCA will be assessed in the interim analysis. 
Interim analyses will be carried out for potential (NON-BINDING) early 
stopping for an efficacy or futility conclusion. 
An option to increase sample size (SSR, i.e., Sample Size Re-estimation) 
will be considered.   SSR is based on the second interim analysis (IA) 
results using the conditional probability (CP) to estimate the sample size 
necessary to boost the CP to 88%, assuming the observed response 
proportions are the TRUE underlying proportions. 
To assure proper startup of the sites we will employ a roll in approach for 
up to the first two enrolled and treated subjects from each site for 
training. The roll in subjects will be treated with the CytoSorb® device.  
The data will be used for safety analysis only.   

 
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Study Population 
The population evaluated for effectiveness in the treatment group will 
consist of a primary sub-population and a secondary sub-population.   
• The primary sub-population includes all subjects enrolled and 
randomized to the treatment group who are undergoing valve 
replacement with another procedure (e.g., CABG and valve 
replacement) without Hypothermic Circulatory Arrest (HCA) 
• The secondary sub-population consists of all surgical subjects 
undergoing aortic reconstructions with or without other 
procedures (e.g., CABG, valve replacement) with HCA 
Sample Size 
Up to 420 subjects will be enrolled and randomized at a 1:1 ratio at up to 
40 investigational sites in the United States.  A roll-in cohort of up to 80 
additional subjects may be enrolled in the study and assigned to treatment 
with CytoSorb device.    
Duration of 
participation for 
each patient 
Primary, secondary, and exploratory endpoints will be evaluated on the 
day of cardiac surgery up to Day Seven (7) post-cardiac surgery or 
through hospital discharge, whichever occurs first.  Subjects will be 
followed through 30-day follow-up visit to fully evaluate safety (AEs will 
be followed through study exit and device-related SAEs will be followed 
until a return to a stable state as determined by the investigator). 
Patient treatment 
Two devices, configured into a parallel circuit are placed between the 
oxygenator and the venous reservoir and run as a bypass shunt to the 
main blood flow in a standard heart-lung machine.  The first device will 
be introduced at t=0 (start of CPB).  The second device will be introduced 
at t=90 minutes after the start of CPB. 
Study Objectives: 
To evaluate the safety and performance of the CytoSorb® device to 
decrease the incidence or severity of AKI in the first 48 hours after 
surgery when used intraoperatively with cardiopulmonary bypass (CPB) 
in subjects undergoing cardiac surgery.  The study hypothesis is that, for 
patients at increased risk for AKI based upon use of the Cleveland Clinic 
Score for stratification of the risk of cardiac surgery associated AKI 
(CSA-AKI), the intra-operative usage of the CytoSorb® device in addition 
to the standard of care in a bypass circuit during cardiopulmonary bypass 
will decrease the incidence or severity of AKI per the Kidney Disease 
Improving Global Outcomes (KDIGO) clinical practice guideline 
definition of acute kidney injury. 
Primary 
Effectiveness 
Endpoint 
The primary effectiveness endpoint is the incidence or severity of AKI in 
the first 48 hours after surgery when used intraoperatively with 
cardiopulmonary bypass (CPB) in subjects undergoing cardiac surgery as 

 
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defined by the KDIGO clinical practice guideline through 48 hours post-
cardiac surgery. Assessment of serum creatinine and hourly 
measurements of urine output will be recorded for the first 48 h following 
admission to the ICU.     
The intended primary effectiveness sub-population includes all subjects 
enrolled and randomized to the treatment group who are undergoing 
valve replacement with another procedure (e.g., CABG, valve 
replacement) without Hypothermic Circulatory Arrest (HCA).  Balance 
between patients undergoing cardiac surgery with and without HCA will 
be evaluated during the interim analysis and the primary sub-population 
confirmed. 
Primary Safety 
Endpoint 
The primary safety endpoint of this trial is to evaluate the product safety 
profile through the assessment of device related adverse events during the 
study period. 
Secondary 
Effectiveness 
Endpoints 
Secondary effectiveness endpoints include the following: 
• Change from baseline (defined as the start of CPB) in pfHb 
assessed hourly for the duration of CPB and at the end of CPB; 
• Change from baseline (defined as start of CPB) in Complement 3a 
(C3a) assessed hourly for the duration of CPB and at the end of 
CPB; 
• Severity of AKI through hospital discharge or post-surgical Day 
7, whichever is sooner: 
• Incidence of AKI through hospital discharge or post-surgical Day 
7, whichever is sooner: 
• Change from baseline (defined as pre-procedure) in serum 
creatinine through hospital discharge or post-surgical Day 7, 
whichever is sooner; 
Additionally, the following pharmacoeconomic endpoints are included: 
• Duration of hospital stay, post-surgery 
• Duration of ICU stay, post-surgery 
• Duration of renal replacement therapy, post-surgery 
• Duration of vasopressor use, post-surgery 
• Duration of ventilator use, post-surgery 
Secondary Safety 
Endpoints 
Secondary safety endpoints include the following: 
• Incidence and severity of procedure-related adverse events, 
through 30-days post-cardiac surgery. 
• Incidence of Serious device-related adverse events  

 
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• Incidence and severity of unanticipated adverse device effects 
(UADEs) 
• Change from baseline (pre-procedure) in vital signs (blood 
pressure, pulse and temperature) 
• Change from baseline (pre-procedure) in safety laboratory 
assessments (hematology, coagulation and comprehensive 
metabolic panel) pre- and post-surgery through Day 7 or hospital 
discharge, whichever occurs first, 
• Intra-cardiac surgery arterial blood gas measurements. 
• Post-surgical care unit assessments (SOFA, vasopressor 
requirements, blood product transfusions, ventilation 
requirements, requirement for mechanical support, and renal 
replacement requirements) through hospital discharge or post-
surgical Day 7, whichever occurs first.  
Exploratory 
Effectiveness 
Endpoints 
The following known inflammatory mediators and predictive markers of 
kidney injury will be evaluated either during cardiac surgery or post-
cardiac surgery. 
During cardiac surgery: 
• Change from baseline (defined as start of CPB) in Complement 5a 
(C5a) and inflammatory marker panel assessed hourly during CPB 
and at the end of CPB.  
Post-cardiac surgery days 1-3: 
• Change from baseline (defined as start of CPB) in C5a, 
inflammatory mediator panel, plasma kidney injury markers 
HMGB1 and Cystatin C, urine kidney injury markers NGAL, 
TIMP2, and IGFBP7 on post-surgical Days 1 through 3 
Inclusion Criteria 
 
 
 
 
 
 
 
 
 
 
1. Male or female and ≥18 years of age. 
2. Scheduled for non-emergent surgical procedures requiring CPB with 
full sternotomy: 
a. Any combination of heart valve replacement or valve repair and 
another procedure (e.g., CABG) without HCA; coronary artery 
bypass graft (CABG) alone excluded OR 
b. Aortic reconstruction alone with HCA OR 
c. Aortic reconstruction with any combination of valve repair or 
valve replacement or CABG (but not CABG alone) with HCA  
3. Estimated glomerular filtration rate (eGFR) ≥ 30 ml/min/1.73m2 and 
at least ONE of the following additional risk factors for Cardiac 
Surgery Associated1 (CSA)-AKI: 

 
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a. Age ≥ 75 years 
b. Previous cardiac surgery with sternotomy; 
c. Documented New York Heart Association (NYHA) Class 
III or IV heart failure within 1 year prior to surgery; 
d. Left ventricular ejection fraction (LVEF) ≤ 35% by 
invasive or noninvasive diagnostic cardiac imaging - 
echocardiography, nuclear imaging, computed 
tomography, magnetic resonance imaging or angiography 
performed within 90 days prior to surgery (if LVEF ≤ 35% 
by any invasive or noninvasive imaging procedure, patient 
meets the risk factor); 
e. Insulin-requiring diabetes; 
f. Non-insulin-requiring diabetes AND the presence of ≥ +2 
proteinuria on urinalysis (medical history or dipstick); 
g. Pre-operative anemia (hemoglobin < 11g/dl) 
h. BMI ≥ 30 kg/m2 
Exclusion Criteria 1. 
Weight < 99 lbs. or > 383 lbs.; 
2. 
The presence of AKI (KDIGO criteria) at the time of screening; 
3. 
eGFR < 30 ml/min/1.73m2;  
4. 
Prior organ transplantation; 
5. 
Dialysis dependence; 
6. 
Cardiogenic shock or hemodynamic instability within 48 hours prior 
to surgery  as defined by a systolic BP <80 mm Hg and pulse >120 
beats per minute (bpm) and requirement for inotropes or 
vasopressors or other mechanical devices such as intra-aortic balloon 
counter-pulsation (IABP); or extracorporeal membrane oxygenation 
(ECMO). Short term vasopressor support is allowed during 
induction; however, ongoing requirement for vasopressor support to 
the time initiation of CPB would be excluded; 
7. 
Requirement for any of the following within seven (7) days prior to 
cardiac surgery: 
a. defibrillator or permanent pacemaker, 
b. mechanical ventilation, 
c. intra-aortic balloon counter-pulsation (IABP), 
d. left ventricular assist device (LVAD), 
e. other forms of mechanical circulatory support (MCS) such as 
extracorporeal membrane oxygenation (ECMO); 

 
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8. 
Cardiopulmonary resuscitation within 14 days prior to cardiac 
surgery; 
9. 
Known or history of inadequately treated cancer within the past 5 
years.  Inadequately treated cancer is defined as the continued 
presence or recurrence of cancer; 
10. Known or suspected sepsis at time of screening or within the 30 days 
prior to cardiac surgery;  
11. Known or suspected glomerulonephritis or interstitial nephritis at 
time of screening; 
12. Untreated endocarditis; however, successfully treated endocarditis, 
defined as having completed a full course of antibiotics with no 
evidence of recurrence of infection, is acceptable; 
13. Other current active infection requiring antibiotic treatment including 
Hepatitis B (HBV), Hepatitis C (HCV) or human immunodeficiency 
virus (HIV) infections.  Documented inactive HBV and HCV are 
allowed as well as HIV infections treated with a stable antiviral 
regimen for a minimum of 30 days prior to the date of surgery;  
14. Any other clinically relevant finding or medical history that, based 
upon the determination of the Investigator, may introduce additional 
risk to the patient or confound the results of the study; 
15. Use of stress dosed steroids at the time of surgery, 
immunosuppressant medications to prevent transplant rejection or 
immunosuppressant chemotherapeutic agents; 
16. Presence of acute or chronic pancreatitis; 
17. Patients known to have Child-Pugh Class A Liver disease or with 
alanine aminotransferase (ALT) or aspartate aminotransferase (AST) 
> 2 times the Upper Limit of Normal (ULN); 
18. Any congenital coagulation disorder; 
19. Pregnancy or lactation; 
20. Treatment with an investigational drug or device within 60 days 
prior to surgery; 
21. Inability to comply with the requirements of the study protocol;  
22. Subject has a platelet count of < 50,000 /µL. 
 
 

 
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Table 1:  Definitions 
Arterial Blood Gas 
Assessments 
Intra-procedure, while patient is on CPB 
Post-Procedure, only if arterial line is in place 
Enrolled 
A patient who has provided informed consent to participate in the 
trial is considered to be enrolled. 
Roll-in 
The first two enrolled and treated patients at each site used for 
training purposes.  Roll in patients are treated with the CytoSorb 
device and their data used for safety analysis only. 
Randomized 
A patient who has been randomly assigned (according to a 
validated randomization schedule) in a 1:1 ratio to either standard 
of care (SOC) or SOC with CytoSorb device. 
Intra-Cardiac Procedure 
During CPB, while on pump 
Post-Cardiac Procedure 
Following end of CPB 
Pre-Procedure 
 
Day of the surgery but before induction of general anesthesia, 
exclusive of sedation. 
Screening 
Time-period to determine eligibility, not more than 14 days prior 
to day of cardiac surgery.  When screening laboratory assessments 
are obtained on the day of surgery, they may be substituted for the 
pre-procedure laboratory assessments 
Baseline 
The start of CPB is defined as baseline for pfHb, C3a, C5a, 
inflammatory mediator panel, and markers of kidney injury 
(plasma and urine markers) endpoints. 
Pre-procedure is defined as baseline for all other endpoints. 
Start Of CPB 
Pump on 
End Of CPB 
Pump off, just prior to protamine reversal (± 5 minutes) 
Post-Surgery Care Unit 
Coronary Care Unit, Intensive Care Unit, Step Down Unit 
Post-Surgery Care Unit 
Assessments and Labs 
Day 1 assessments start at or after midnight post-cardiac surgery.  
Assessments and lab blood draw times should be approximately 
the same time each day (see Schedule of Assessments for specific 
assessments and labs, as well as approved windows). 
 

 
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Table 2: Abbreviations 
Abbreviation/Term 
Definition 
ABG 
Arterial blood gas 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
AKI 
Acute kidney injury 
ALT 
Alanine aminotransferase 
APTT 
Activated partial thromboplastin time 
ARDS 
Acute respiratory distress syndrome 
AST 
Aspartate aminotransferase 
AUC 
Area under the concentration by time curve 
BP 
Blood pressure 
C3a 
Serum complement component C3a 
C5a 
Serum complement component C5a 
CABG 
Coronary artery bypass graft 
CFR 
Code of Federal Regulations 
CKD 
Chronic kidney damage 
CPB 
Cardiopulmonary bypass 
CRF 
Case Report Form 
CRO 
Contract research organization 
CRP 
C-reactive protein 
DMC 
Data monitoring committee 
DMP 
Data management plan 
ECG 
Electrocardiogram 
ECMO 
Extracorporeal membrane oxygenation 
eCRF 
Electronic case report form 
EDC 
Electronic data capture 
ESRD 
End-stage renal disease 
FDA 
US Food and Drug Administration 
FIO2 
Fraction of inspired oxygen 
GCP 
Good Clinical Practice 
HB 
Hemoglobin 
HCA 
Hypothermic Circulatory Arrest 
HLM 
Heart-lung machine 
HMGB1 
High mobility group box protein 1 

 
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Abbreviation/Term 
Definition 
HR 
Heart rate 
IABP 
Intra-aortic balloon  
ICH 
International Conference on Harmonization 
ICU 
Intensive care unit 
IDE 
Investigational Device Exemption 
IGFBP7 
Insulin-like growth factor binding protein 7 
INFG 
Interferon Gamma 
IL-2 
Interleukin 2 
IL-4 
Interleukin 4 
IL-5 
Interleukin 5 
IL-6 
Interleukin 6 
IL-10 
Interleukin 10 
IL-12 
Interleukin 12 
INR 
International normalized ratio 
IRB 
Institutional Review Board 
KDIGO 
Kidney Disease: Improving Global Outcome 
group 
NGAL 
Neutrophil gelatinase-associated lipocalin 
NYHA 
New York Heart Association 
OUS 
Outside of the US 
paC02 
Partial pressure of carbon dioxide 
paO2 
Partial pressure of oxygen 
PEEP 
Positive end-expiratory pressure 
pfHb 
Plasma free hemoglobin 
PT 
Prothrombin time 
RBC 
Red blood cell 
SAE 
Serious adverse event 
SCr 
Serum creatinine 
SOC 
System organ class 
SOFA 
Sequential Organ Failure Assessment Score 
SOP 
Standard operating procedure 
TIMP-2 
Tissue inhibitors of metalloproteinases 
TNF-α 
Tumor necrosis factor alpha 
UADE 
Unanticipated adverse device effect 

 
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Abbreviation/Term 
Definition 
US 
United States 
VAD 
Ventricular assist device 
WBC  
White Blood Cell 
 

 
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2. INTRODUCTION 
Cardiac surgery requiring cardiopulmonary bypass (CPB) has been routine in clinical practice for 
over 50 years and numerous technological advancements have taken place over this time. This 
procedure has been lifesaving, by allowing many complex cardiac surgical procedures to take 
place safely. However, despite advances in perfusion, anesthetic and surgical techniques, CPB still 
frequently evokes inflammatory and hemolytic reactions that may lead to worsening of renal 
function and postoperative morbidity. The incidence of renal damage has been estimated between 
10-25% with little improvement despite extensive investigation. Furthermore this rate is higher for 
patients with significant co-morbidities such as diabetes or congestive heart failure3. 
The pathogenesis of cardiovascular surgery associated renal injury is multifactorial, including CPB 
associated intravascular hemolysis (resulting in the generation of pfHb), exposure of blood to CPB 
surfaces during surgery with initiation of the early phase inflammatory response via contact 
activation4 and an acute rise in inflammatory mediators during the procedure including: 
complement activation, the coagulation system, leukocytes, cytokines, chemokines, and adhesion 
molecules. Multiple factors including temperature variation and oxygenation may further escalate 
the immune response.  This combination of processes was described as the Systemic Inflammatory 
Response Syndrome (SIRS) and is associated with frequent complications of renal failure5,6. 
Mitigation of the deleterious effects of renal injury therefore requires a multimodal strategy aimed 
at decreasing circulating factors likely to exacerbate tissue injury during the period of heightened 
risk, i.e., during CPB.  Two well characterized etiologies of worsening renal function are the 
generation of pfHb and activated complement during CPB. 
Circulating levels of pfHb are normally low; however, hemolysis increases dramatically during 
CPB surgery, resulting in increased pfHb.  The extent of hemolysis during CPB surgery is directly 
correlated with both the length of the CPB procedure (> 3 hours) and the complexity of cardiac 
surgery7.  Red blood cells (RBCs) can hemolyze during CPB due to factors such as negative 
pressure cardiotomy suction, blood material interactions, increases in foreign surface to-blood 
volume ratios, shear stress due to high flow rates through artificial blood circuits, and others8.  
The mechanisms whereby hemoglobin is thought to induce renal injury or dysfunction include (a) 
tubular obstruction caused by heme protein precipitation, (b) ischemic injury resulting from 
increased renal vascular resistance and vasoconstriction, and (c) heme iron-driven oxidative 
injury9,10.  By overwhelming the macrophages associated uptake of Haptoglobin-Hb complexes 
high levels of pfHb may lead to inflammation and endothelial, tissue, and organ injury11-13. 
Hemoglobin first reacts with endogenous compounds to form oxygen radicals that induce pro-
oxidant damage14,15. This damage is known to promote a pro-inflammatory cascade and cellular 
interactions through pathways involving activation, generation, or expression of thrombin, 
complement, neutrophils, cell-adhesion molecules, mast cells, and multiple inflammatory 
mediators, including the release of cytokines, IL-1β, IL-6, IL-8, and TNF-α 516. These mediators 

 
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have been shown to be associated with the development of postoperative SIRS, and major post-
operative complications17-19.  
Hemolysis, resulting in release of free hemoglobin (pfHb), has been directly correlated with 
induction of kidney injury16,18. In one study reported in the literature, peak pfHb levels ≥ 64.5 
mg/dL held a significant diagnostic value for the prediction of acute kidney injury (AKI)20. The 
complications of AKI may require increased length of stay and ICU time, prolonged mechanical 
ventilation, increased risk of nosocomial infections, or may increase the risk for systemic 
inflammatory response syndrome (SIRS) and potential progression to organ failure21. Kubota et al. 
noted a protective effect of haptoglobin infusion intraoperatively to reduce the incidence of post-
operative AKI, indicating that the uptake of Haptoglobin-Hb complex by macrophages may be 
protective against the tissue injury associated with pfHb12. Because of this, the removal of pfHb 
during CPB has the potential to significantly reduce the risk of hemolysis-induced organ injury8.  
Activation of the complement alternative pathway also occurs during CPB20 and examination of 
clinical samples and preclinical models has shown that activation of the complement system is a 
critical cause of acute kidney injury20. Eculizumab, an anti-C5 monoclonal antibody inducing 
terminal complement blockade, showed reduced complement activation, inﬂammation, endothelial 
damage, thrombosis, and renal injury markers in an exploratory study of atypical hemolytic uremic 
syndrome (aHUS)22. Precedent for complement inhibition was also established using soluble 
human complement receptor type 1 (sCR1) and heparin bound CPB circuits23. 
By directly causing tissue injury in the post-operative SIRS response, and through adverse 
physiologic changes, pfHb is thought to be a significant contributor in the development of multiple 
organ failure (MOF) in many patients following cardiac surgery.  These complications may require 
increased length of stay and ICU time, prolonged mechanical ventilation, increased risk of 
nosocomial infections, or may increase the risk for systemic inflammatory response syndrome 
(SIRS) and potential progression to organ failure24.  The renal toxicity associated with the 
generation by cardiac surgery of both pfHb and inflammatory mediators (activated compliment 
cascade and inflammatory cytokines) suggests that an intra-operative reduction of these elements 
may reduce the potential for post-operative complications, improve clinical outcomes and reduce 
the risk of renal injury25. 
Despite ongoing efforts to mitigate the effects of CV surgery, only limited progress has been made 
in altering the prevalence of surgically associated renal injury as assessed by the clinically 
accepted definitions of acute kidney injury (AKI) and in long term morbidity associated with 
decreased renal function.  A potential reason may be the failure to prevent the loss of renal 
functional reserve occurring below the threshold of creatinine elevation that defines AKI.  Ishani et 
al21 linked the magnitude of sCr increase post cardiac surgery to increasing rates of chronic kidney 
damage (CKD), progression of kidney disease and death. Similarly, even minimal increases in sCr 
were associated with adverse long-term outcomes Duque-Sosa26 and Lassnigg, et al observed that 
even minimal (0.1 mg/dl) increases in sCr, in the immediate postoperative period, were associated 

 
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with significantly increased mortality, providing an independent risk factor in predicting outcome 
after cardiac surgery27. 
2.1 
Summary of Previous Clinical Experience Informing Study Design: 
CytoSorbents conducted REFRESH I, a prospective, randomized, controlled safety trial enrolling a 
small heterogeneous population, at eight major U.S. cardiac surgery centers to evaluate the safety 
and feasibility of CytoSorb®, a blood purification technology designed as an adjunctive therapy to 
remove inflammatory mediators (i.e., pfHb, activated complement and cytokines) in high risk 
cardiac surgery patients aged 18-80 years of age, where cardiopulmonary bypass (CPB) was 
expected to exceed 3 hours. Subject assessments were performed until subjects were discharged 
from the ICU. Subjects were monitored for AEs through 30 days after the procedure.   
This trial achieved the primary safety endpoint of the study with a favorable adjudication of all 
serious adverse events. There were no significant differences in the rates of adverse events (AEs) 
or serious adverse events (SAEs) between the two groups, including 30-day mortality, and no 
unanticipated adverse device effects (UADEs) were reported. Three subjects (1 Control; 2 Treated) 
died of AEs that were considered by the Independent Physician Adjudicator to be not related to the 
device. Most AEs were related to the pre-existing conditions or to surgical procedures. AEs 
specifically related to the investigational device were infrequent (i.e., involving 2 [8.7%] subjects 
in the Treated arm) and in both instances the subjects recovered without sequelae. 
A detailed description of the REFRESH I study results along with subsequent safety analyses of 
REFRESH I data; safety information derived from clinical applications other than CPB; and 
supporting preclinical assessments may be found in the Investigator Brochure.  The investigator 
should read and understand the Investigator Brochure and use it in conjunction with this protocol 
in the evaluation of risk and benefit for patients being considered for enrollment into this study. 
2.2 
REFRESH II Study design: 
The REFRESH II study is designed to assess the intraoperative use of the CytoSorb® device in 
patients with an increased risk of acute renal failure following open heart surgery3 to decrease the 
circulating presence of nephrotoxic agents (such as pfHb, cytokines,  and activated compliment 
during CPB) in conjunction with standard of care treatment. The study aims to determine whether 
the use of the CytoSorb® device can decrease the incidence or severity of AKI in the 48 hours 
immediately following surgery.  This will be evaluated in a patient population that has been 
enriched for increased risk of cardiac surgery associated AKI and for procedures associated with a 
higher risk for pfHb generation.   
In this study, creatinine and urine output collection will be used to identify acute kidney injury 
(AKI) as defined by the KDIGO clinical practice guidelines. This identification will be augmented 
through the use of additional indicators of renal damage and dysfunction, including assays for 
urinary TIMP2 and IGFBP-7 and serum elevations in HMGB1 and Cystatin C28.    

 
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The CytoSorb® device that will be utilized in this randomized and blinded trial is based on size 
adsorption filtration.  Each CytoSorb® adsorber cartridge contains micro-porous, polystyrene bead 
technology. Earlier in vitro and in vivo studies have shown this to correlate with the removal of 
endogenous mediators of inflammation and pfHb. This product, approved under a CE mark in 
Europe and other countries has been used in over 25,000 critical care cases, including about 6,000 
cardiac surgery cases.  It is believed that the removal of these renal-toxic substances from patient 
blood during surgery will lead to an overall reduction in kidney dysfunction among the patients 
who assigned to the treatment group relative to those who will be on standard of care alone. 
3. INVESTIGATIONAL DEVICE DESCRIPTION 
3.1 
Investigational Device Description 
CytoSorb® is a sorbent-filled hemoperfusion cartridge that is designed to reduce plasma free 
hemoglobin and other inflammatory mediators from blood that are generated during 
cardiopulmonary bypass in cardiac surgery. The device is placed into a parallel bypass circuit 
(between the oxygenator and the venous reservoir) in a standard heart-lung machine. 
CytoSorb® consists of a cylinder and end-cap assembly filled with biocompatible porous polymer 
beads (Figure 1). At either end of the cylinder, a fine mesh screen is placed to retain the polymer 
beads within the device. Each end-cap has a standard dialysis connector, which is compatible with 
standard dialysis tubing.  The polymer beads are composed of a divinylbenzene/polyvinyl 
pyrrolidone co-polymer, where each bead has hundreds of thousands of tightly controlled pores 
and channels that are generated via suspension polymerization.  These pores and channels, in turn, 
enable the porous polymer beads to remove middle molecular weight substances based on pore 
capture (size) and surface adsorption.  
The CytoSorb® device is designed for use in an extracorporeal circuit.  The device can be 
connected on a standard heart-lung machine in a parallel configuration with the CPB circuit. The 
target flow rate through the device is intended to be approximately 300-400 mL/min which is 
about   10-20% of a typical flow rate encountered in CPB.  In this study, two parallel CytoSorb® 
cartridges will be attached to the bypass circuit, and they are connected between the oxygenator 
and cardiotomy reservoir as shown in the Figure 2 below and separate from the main blood flow 
to the patient. These devices will be used as such; for the first 90 minutes of CPB, blood will be 
directed through the first of the two devices.  If and when CPB continues for more than 90 
minutes, the second CytoSorb® device will then be opened to the perfusion circuit.  Blood flow 
through the CytoSorb® circuit is controlled via an adjustable roller clamp distal to the cartridges 
and monitored via ultrasonic flow detection (a Transonic, or equivalent) flow monitor will be 
supplied) to maintain a target blood flow of ~800 mL/min with both devices, or ~400 mL/min with 
the single device.  A minimum flow of ~300 ml/min through the single device, or ~600 ml/min 
through the complete circuit (both devices) is acceptable.  Once the hemoperfusion session is 

 
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complete, remaining blood in the circuit goes back to the patient, if appropriate per hospital 
protocol. 
In addition to the CytoSorb® device, two off-the-shelf disposable connector and tubing sets 
supplied from Molded Products based on their commercial Y-Blood line set CYT800-C (both 
covered by 510k K003712) will be used to connect the CytoSorb® devices to the oxygenator and 
venous reservoir.  A standard roller clamp and disposable hemostats will also be provided.  
  
Figure 1:  CytoSorb® Device 
 

 
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CytoSorb
CytoSorb
CORPOREAL
ARTERIAL LINE
CYTOSORB
DEVICES
HEAT
EXCHANGER
OXYGENATOR
BLOOD
PUMP
VENOUS
RESERVOIR
VENOUS
DRAINAGE
LINE
GAS
IN
GAS
OUT
WATER
IN
WATER
OUT
ROLLER
CLAMP
 
Figure 2:  CytoSorb® 300 mL Device on CPB Circuit 
3.2 
Investigational Device Identification 
The CytoSorb® 300mL device will be used in this study.  It is anticipated that two CytoSorb® 
devices (in parallel) will be used for each subject randomized to the treatment arm. 
3.3 
Investigational Device Accountability 
Each CytoSorb® device will be assigned lot numbers and/or unique serial numbers.  Access to 
investigational devices shall be controlled and the investigational devices shall be used only in the 
clinical investigation and according to the clinical investigation plan. The sponsor will keep 
records to document the physical location of all investigational devices from shipment of 
investigational devices to the investigation sites until return or disposal.  The Principal 
Investigator or an authorized designee shall keep records documenting the receipt, use, return 
and/or disposal of the investigational devices, which shall include: 
• Date of receipt; 
• Identification of each investigational device (lot number/serial number); 
• Expiry date; 
• Date of use; 
• Study identification; 
• Date on which the investigational device was returned, if applicable, and; 
• Date of return of unused, expired or malfunctioning Investigational Intended Use/Current 
Indication for Use 

 
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3.4 
The intended use of the investigational device(s). 
The proposed investigative use of CytoSorb® device is in an extracorporeal circuit for the removal 
of free hemoglobin as an adjunct to the standard of care in subjects undergoing cardiac surgery 
requiring CPB and will only be used as specified by this clinical protocol. 
3.5 
Investigational Device Procedure(s)/Training 
The CytoSorb® device is designed for use in a standard heart-lung machine CPB circuit with an 
arterial pump. In this study, as described in the Instructions for Use (IFU), up-to two CytoSorb® 
cartridges in a parallel configuration will be in a bypass circuit connected between the oxygenator 
and cardiotomy reservoir as shown in Figure 2, and separate from the main blood flow to the 
subject.  Blood flow through this circuit is controlled via an adjustable roller clamp distal to the 
cartridges and monitored via ultrasonic flow detection to maintain flow. A minimum blood flow of 
~ 300 ml through the single device, or ~ 600 ml through the paired devices together is acceptable. 
The circuit containing the CytoSorb® devices will be connected prior to the start of the procedure.  
Blood flow through the first CytoSorb® device will commence when subject goes on CPB.  Flow 
through the second CytoSorb® device will commence at 90 minutes from the start of CPB (at this 
time both CytoSorb® devices will have blood flowing through them).  Use of the CytoSorb® 
devices is stopped at the end of CPB.  Once the CPB procedure is complete the hemoperfusion 
session will be ended, the circuit is flushed with saline, with the return of blood in the circuit back 
to the subject, per the hospital protocol. 
CytoSorb® device training for the device users involved in this study will occur prior to CytoSorb® 
device use and will be documented in a training log. 
3.6 
Blinding 
Blinding to treatment assignment, as implemented in this study will apply only to select study 
personnel and for specific durations.  Blinding of the surgical staff to treatment assignment is 
implemented in this study starting at the point of randomization and extending through the 
duration of the entire study.  This blinding is implemented to minimize bias in surgical care 
decisions that may be introduced by knowledge of treatment assignment.  The potential for 
introduction of bias is most relevant during the surgical procedure where knowledge of treatment 
assignment and prior clinical experience with the investigational device may impact clinical 
decisions such as frequency of platelet or whole blood infusion and assessment of adverse events 
that occur during surgery by medical staff responsible for administering these treatments.  
To minimize bias both subjects and designated site study personnel (e.g. Surgeon, 
Anesthesiologist, OR staff) involved in OR activities will be blinded to the treatment assignment. 
The study coordinator may remain unblinded, however extreme caution should be exercised by the 
study coordinator to prevent inadvertently revealing treatment assignment to individuals making 
clinical decisions on subject care.  

 
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The unblinded team at the site (Perfusionist and study coordinator) will be supplied with a barrier 
to separate the perfusion area from the surgical staff view.  A Field Clinical Engineer (FCE), as 
designated by the Sponsor, may be present to assist with set up of the blind and provide guidance 
during the procedure. 
3.6.1 Maintaining the Study Blind 
The following describes the measures being taken to maintain the study blind. 
a) Subjects: Subjects will not be told their randomization assignment by any site study 
personnel involved in the trial and will receive the same care throughout the trial.  
b) Randomization Assignment: Each site will randomize subjects using the electronic data 
base. After the appropriate information is entered into the electronic case report form 
(eCRF), the randomization function will be activated, and the assignment made (Standard 
of Care or Standard of Care with CytoSorb® Device). This randomization process is 
performed by the unblinded team within 5 business day prior to the procedure, including 
the day of the procedure.  
c) Site Study Personnel: There are two designated teams at each site:  
• Blinded:  These individuals remain blinded from the point of randomization through the 
duration of the study, inclusive of all subjects enrolled at the site. 
o Surgical team 
o Anesthesiologist 
• Unblinded:  These individuals will be aware of treatment assignment and will refrain 
from revealing it to any other study staff for the duration of the study, inclusive of all 
subjects enrolled at the site. 
o Perfusionist  
o Study Coordinator 
o FCE 
The Blinded Team is responsible for administering all pre-, intra- and post-procedure subject 
testing and care as designated by the protocol.  
The Unblinded Team is responsible for those activities and documentation related to the 
procedure, including the selection of the device (sham or CytoSorb®) used at time of procedure, 
and recording the procedure and device study data in the eCRFs and device accountability log. The 
Sponsor will work with each individual site to determine the documentation needed in the 
subjects’ medical records (e.g. procedure notes) to protect the study blind. The Study Coordinator 
on this team remains unblinded to the subject treatment assignment and is particularly responsible 
for: 
1. Obtaining randomization code from EDC system within 5 business days prior to procedure 
including day of procedure  

 
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2. Ensuring appropriate device cartridges are available and in OR suite on procedure day  
3. Completing Device Accountability Log  
4. EDC entry for all data pertaining to treatment assignment and procedure information  
5. EDC entry for any AEs associated with the use of the device or procedure that are assessed 
and any additional EDC entry 
6. Scheduling routine follow-up care/visits for all study subjects 
7. Performing follow-up visits 
3.6.2 Unblinding Procedure  
It is the intention of this study to unblind both the subject and the site study personnel at the 
completion of the study. This will occur after all necessary 30-day follow-up assessments are 
completed and all the data have been collected and verified. 
If the subject develops a condition within the 30-day follow-up window, the subject and team will 
be unblinded only if doing so is necessary to make informed decisions about clinical care.  To the 
extent possible, the surgical team will remain blinded throughout the duration of the study. 
Any subject that is unblinded prematurely for any reason shall continue to be followed in 
accordance with the protocol evaluations outlined. A subject is NOT automatically considered to 
be withdrawn if unblinding occurs earlier than anticipated.  
If the site believes there is reason to unblind either themselves or the subject (significant change in 
subject’s health status related to the possible use of the device, withdrawal or discontinuation of 
study participation), the site will contact the Sponsor to discuss the subject’s circumstances, at 
which time the Sponsor, if in agreement with the site’s request, will approve release of the blinding 
information by the unblinded Sponsor designee. 
4. STUDY JUSTIFICATION 
Cardiac surgery requiring cardiopulmonary bypass (CPB) has been in clinical practice for over 50 
years. This procedure has been lifesaving by allowing many complex cardiac surgical procedures 
to take place safely.  Despite advances however, CPB still frequently evokes inflammatory 
reactions that lead to postoperative morbidity, organ dysfunction and worsening of renal function. 
The inflammatory reaction underlying the pathophysiology of these conditions originates from 
exposure of blood to CPB surfaces during surgery with initiation of the early phase inflammatory 
response via contact activation4. Two specific complications associated with inflammation arising 
from CPB that pose significant clinical burden in post-operative patient care are the risk of 
worsening renal function following cardiac surgery and the potential for hemodynamic instability 
(vasoplegia). 

 
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Worsening renal function following cardiovascular surgery is a frequent complication and is 
associated with significant patient morbidity, complication of post-operative management and 
mortality20,25. Its severity and chronicity have most commonly been assessed using definitions of 
Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) (Kidney Disease: Improving 
Global Outcome group - KDIGO 2012). A retrospective examination of in-hospital mortality and 
length of hospital stay (LOS) in 39,369 broad surgical patients29 showed that AKI was associated 
with a fivefold higher mortality and five days longer LOS. AKI is a common post-operative 
complication occurring in 5-30% of patients following cardiac surgery30, and is associated with a 
more complicated clinical course and with an excessive mortality of up to 80%27. The long-term 
mortality risks associated with AKI after cardiac surgery remain high for 10 years  after the 
procedure, irrespective of other risk factors, even in patients that showed complete renal 
recovery31. However, patients not meeting the formal definition of AKI may have already suffered 
a substantial loss of renal functional reserve; even minimal increases in serum creatinine in the 
immediate post-operative period >0.0 relative to a patient’s pre-operative baseline value are 
associated with significantly increased mortality and provide an independent risk factor in 
predicting outcome after cardiac surgery27. Ishani et al21 linked the magnitude of sCr increase post 
cardiac surgery to increasing rates of CKD, progression of kidney disease and death. Importantly, 
even minimal increases in sCr were associated with adverse long-term outcomes.  Duque-Sosa26 
assessed changes in creatinine as percent increase from baseline to peak creatinine levels after 
cardiac surgery [none (<0%), class I (1%-24%), Class II (25%-49%), Class III (50%99%), or Class 
IV (>100%)]. This is consistent with the observation of an independent association between even 
mild AKI and increased morbidity and mortality.  Thus, avoiding the development of the initial 
injury represents a clinically important objective and while the origins of worsening renal function 
are multifactorial, significant contributors include the increases in levels of inflammatory 
cytokines and circulatory pfHb. 
Vasoplegic Syndrome is characterized by “severe persistent low systemic vascular resistance, 
hypotension, decreased filling pressure, normal or elevated cardiac output, and tachycardia”. CPB 
induced inflammation is associated with activation of the complement alternative pathway and this 
can lead to organ dysfunction and vasoplegic syndrome32. This amplification of the inflammatory 
cascade is considered directly associated with the incidence of vasoplegia33 commonly occurring 
during CPB along with the SIRS, leading to significant increases in tumor necrosis factor alpha 
(TNF-α) and IL-6, pro-inflammatory cytokines, has been observed in some patients undergoing 
CABG with CPB and may play a significant role in vasoplegia34.  
Mitigation of the deleterious effects of renal injury therefore requires a multimodal strategy aimed 
at decreasing factors likely to exacerbate tissue injury during the period of heightened risk, i.e., 
during CPB.  
Two well characterized etiologies of worsening renal function are the generation of pfHb and 
activated complement during CPB. The extent of hemolysis during CPB surgery is directly 
correlated with both the length of the CPB procedure (> 3 hours) and the complexity of cardiac 

 
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surgery7. Red blood cells (RBCs) can hemolyze during CPB due to factors such as negative 
pressure cardiotomy suction, blood to material interactions, increases in foreign surface to-blood 
volume ratios, shear stress due to high flow rates through artificial blood circuits, and others8. 
Hemoglobin is thought to induce worsening renal function through: (a) tubular obstruction caused 
by heme protein precipitation, (b) ischemic injury resulting from increased renal vascular 
resistance and vasoconstriction, and (c) heme iron-driven oxidative injury9,10, leading to 
inflammation and endothelial, tissue, and organ injury11,13. This promotes a pro-inflammatory 
cascade involving activation, generation, or expression of thrombin, complement, neutrophils, cell-
adhesion molecules, mast cells, and multiple inflammatory mediators and includes the release of 
cytokines, IL-1β, IL-6, IL-8, and TNF-α 5,16. Plasma free hemoglobin also accounts for a 
significant portion of the damaging oxidative stress response that can damage other organs 
following cardiac surgery35. By directly causing tissue injury, in the post-operative SIRS response 
and through adverse physiologic changes, pfHb is thought to be a significant contributor in the 
development of multiple organ dysfunction syndrome (MODS) and multiple organ failure (MOF) 
in many patients following cardiac surgery. 
Complement activation within the injured kidney is a proximal trigger of many downstream 
inflammatory events within the renal parenchyma that exacerbate injury to the kidney36. Targeted 
complement inhibition has become a potential strategy for preventing renal ischemia-reperfusion 
injury, end-organ damage and fibrosis in surgery and hemodialysis with both clinical and 
preclinical models suggesting that expression of C3aR and C5aR on both renal and circulating 
leukocytes contributes to the pathogenesis of renal ischemia-reperfusion injury, as well as a role 
for C3a and C5a in contributing to the pathogenesis of renal ischemia reperfusion37. 
Given that pfHb is a known offender causing organ damage in both kidneys and lungs, data 
suggestive of organ function preservation by intraoperative use of  CytoSorb® would be of 
potential clinical benefit18,40 post cardiac surgery. It has been demonstrated in published studies 
that the risk of AKI increases with the length of CPB and that post-procedure AKI is associated 
with increases in pfHb (Billings 2016; Windsant 2010)25,35. As discussed earlier, AKI was based 
solely on the serum creatinine criteria. While none of the resulting Odds Ratios (OR) for 
developing AKI are significantly different from 1, the observed OR (0.260) for patients with a 
valve replacement suggests there may be a benefit associated with CytoSorb® treatment. This 
could be the result of the lower increase in pfHb during CPB observed for the valve replacement 
patients in REFRESH I. Other studies have shown a direct link between development of AKI and 
chronic kidney disease (CKD) which is independently associated with higher mortality. 
Plasma free hemoglobin also accounts for a significant portion of the damaging oxidative stress 
response that can damage other organs following cardiac surgery35. These complications may 
require increased length of stay and ICU time, prolonged mechanical ventilation, increased risk of 
nosocomial infections, or may increase the risk for systemic inflammatory response syndrome 
(SIRS) and potential progression to organ failure24. Because of this, the removal of free 

 
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hemoglobin during CPB has the potential to significantly reduce the risk of hemolysis-induced 
organ injury25.  
Furthermore, the REFRESH I study (see Investigator Brochure) showed that there was a trend for 
an increased risk of AKI associated with larger increases in TIMP-2 x IGFBP-7 from baseline 
(p=0.5822). It has been shown that Urine TIMP-2 x IGFBP-7 [(ng/mL)2/1000] is associated with 
the incidence of AKI.41 A greater increase in Urine TIMP-2/creatinine ratio was seen in the 
Control arm compared to the Treatment arm suggestive of a possible protective effect of treatment 
with CytoSorb®. A recent study demonstrated that significantly (p<0.001) higher levels of these 
markers were observed 4 hours after ICU admission in patients who developed AKI than those 
whom did not develop AKI.42 These markers remained flat or decreased in patients without AKI, 
and started to elevate by the time of ICU admission in those that developed AKI. A reduction in 
pfHb and other inflammatory mediators could potentially be another mechanism by which 
CytoSorb® could decrease the risk of AKI in post cardiac surgery patients.  
Consistent with the effect of device, treatment in the REFRESH I study (see Investigator 
Brochure) also showed a strong trend in decreasing activated complement C3a and C5a during 
surgery as well as other inflammatory markers. This trend was shown in a previous CytoSorb® 
study by Born in 201424. Research has shown that the complement system has a role in inducing 
ischemia reperfusion injury in post cardiac surgery patients43. 
The REFRESH I Clinical Study (see Investigator Brochure), using CytoSorb®, showed 
considerable reductions in both C3a and C5a complement components in subjects undergoing 
elective valve replacement and other cardiac surgeries, relative to control patients. 
This proposed pivotal study will assess whether the CytoSorb® Device (a non-pyrogenic, sterile, 
single-use device designed to remove plasma free hemoglobin and other inflammatory mediators) 
can decrease the incidence or severity of AKI, as defined by KDIGO, when used intraoperatively 
with CPB in subjects undergoing cardiac surgery.  An assessment of renal function characteristics 
will be made during post-cardiac surgery days 1-2 immediately following surgery and will 
examine use of an adjunctive therapy for decreasing cardiovascular surgery renal injury leveraging 
the established features of the CytoSorb® hemoadsorptive device, specifically through adsorption 
of inflammatory mediators including pfHb and complement.  
The primary objective of the study outlined in this protocol will be to examine the ability of 
treatment with CytoSorb® to produce a decrease in the proportion of subjects with AKI. As 
secondary endpoints, this study will assess whether treatment with CytoSorb® can decrease the 
incidence of patients with worsening renal function as reflected by an increase in serum creatinine 
relative to their pre-surgical baseline, and the ability of CytoSorb® to remove significant amounts 
of pfHb and alternative complement pathway inflammatory mediators (C3a, C5a) during cardiac 
surgery requiring CPB. The demonstration of effective removal of hemoglobin and activated 
compliment will be assessed for their relationship to a reduction in post-operative complications 
and preservation of kidney function. 

 
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The REFRESH I study indicated that the valve replacement sub-population showed the strongest 
trend for a device mediated reduction of pfHb concentration (see Investigator Brochure).  An 
analysis of the primary subgroup, patients undergoing valve replacement with another procedure, 
relative to the entire study population will be conducted to confirm this during the run-in phase of 
this adaptive trial.   
In REFRESH I two CytoSorb® devices were introduced in parallel 1 hour after the start of CPB.  
In REFRESH II, we are proposing to introduce the devices sequentially with the first device 
starting at T=0 (start of CPB) and the second device starting at T= 90 minutes after start of CPB.  
Reduction of pfHb for both the 1 hour delayed introduction of CytoSorb® (REFRESH I procedure) 
and the sequential introduction of CytoSorb® (REFRESH II procedure) at time 0 and 90 minutes 
after start of CPB has been modeled in in-vitro testing (see Investigator Brochure).    In both the 1 
hour delayed CytoSorb® introduction post start of CPB (REFRESH I procedure), and the 
sequential introduction of CytoSorb® at time 0 and 90 minutes (REFRESH II procedure) after start 
of CPB, both device configurations perform equivalently with regard to pfHb reduction.  In both 
experiments, hemoglobin (Hb) was infused over the duration of the experiment; therefore, any 
difference between the control and treatment groups demonstrates the effect of CytoSorb® to 
remove pfHb.  The result of the in-vitro testing demonstrates that the CytoSorb® device can 
effectively remove hemoglobin from blood. Initiation of hemofiltration at the start of CPB will 
allow for the adsorption of potentially nephrotoxic inflammatory mediators from the onset of 
bypass.   
 
  
 

 
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5. POTENTIAL RISK/BENEFIT 
5.1 
Potential Investigational Device Benefit 
The observed and potential benefits of using CytoSorb® device intraoperatively during CPB in 
cardiac surgery: 
• Reduction of free hemoglobin generated as a result of the CPB procedure 
• Reduced inflammatory burden generated during the CPB procedure via reduction in C3a and 
C5a 
• Potentially, a decrease in worsening renal function in subjects at significant risk 
• Potentially, a reduction in vasopressor requirements 
• Possible decrease in the amount of time on a mechanical ventilator    
• Possible decrease in hospital stay, post CPB, including time in ICU 
• Reduced risk of systemic inflammatory response syndrome (SIRS) 
5.2 
Investigational Device Residual Risks 
A risk analysis was performed per ISO 14971, Medical devices -- Application of risk management 
to medical devices, to determine the risks associated with CytoSorb®. The risk profile associated 
with the CytoSorb® is expected to be minimal and consistent with other extracorporeal treatments 
currently in clinical use, such as dialysis.  These risks include: 
• Removal of drugs and hormones 
• Allergic response to device materials 
• Reduction in platelet count 
• Reduction in white blood cell count 
• Reduction in proteins (albumin, total protein) which may increase with CPB duration   
• Reductions in albumin may result in a reduction in serum calcium 
• Coagulation within device 
• Infection 
• Blood loss 
• Hypothermia and chills 
• Hemolysis 
• Device leakage 
• Circuit leakage 

 
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• Death 
5.3 
Risk Mitigation/Risk Benefit Rationale 
To evaluate device related risk, a risk analysis was performed in accordance with the harmonized 
International standard EN ISO 14971:2012 “Medical devices - Application of risk management to 
medical devices”.  The results of the analysis indicate that all potential device-related hazards have 
been reduced to an acceptable level.  Mechanical and performance concerns have been reduced by 
extensive human, animal, and bench testing. The device materials have been shown to be 
biocompatible and acceptable for human use through ISO10993 testing and prior human clinical 
studies of the device for removal of beta-2 microglobulin in end-stage renal disease subjects and 
removal of cytokines in the treatment of sepsis. The CytoSorb® 300-ml Device has CE Mark 
approval as an extracorporeal cytokine filter and is believed to pose little or no additional risks 
relative to commercialized blood filter and dialysis devices. 
All attempts will be made to minimize the clinical risks associated with the procedure. Adherence 
to protocol will be stressed by CytoSorbents’ personnel during in-service training.  All subjects 
will be monitored per routine standard of care.  Based upon a re-analysis of data from the 
REFRESH I study (see Investigator Brochure) decreases in serum albumin and total serum calcium 
may be observed in the study population.  Therefore, serum albumin, total serum calcium, and 
ionized calcium will be assessed pre-procedure; hourly for the duration of CPB; at the end of CPB; 
at admission to the post-surgical care unit and during post-operative Day 1.  Administration of 
fluids (i.e. crystalloids) will be recorded pre-procedure, during the surgical procedure and 
following surgery through the end of the first post-operative day.  Likewise, the supplementation 
of albumin and calcium will be recorded during the surgical period and following surgery through 
the end of the first post-operative day. 
Treatment with CytoSorb® was well tolerated in the REFRESH I trial (see Investigator Brochure). 
This trial achieved the primary safety endpoint of the study with a favorable adjudication of all 
serious adverse events. There were no significant differences in the rates of adverse events (AEs) 
or serious adverse events (SAEs) between the two groups, including 30-day mortality, and there 
were no unanticipated adverse device effects (UADEs) reported. 
AEs specifically related to the investigational device were infrequent (i.e., involving 2 [8.7%] 
subjects in the Treated arm with thrombocytopenia) and in both instances the subjects recovered 
without sequelae.  The most frequent SAEs (occurring in ≥ 2 subjects in either treatment arm) were 
atrial fibrillation, thrombocytopenia, coagulopathy, anemia, anemia postoperative, pleural effusion, 
hypotension, malnutrition, and acute kidney injury. There were no appreciable differences in the 
frequency of SAEs between treatment arms. 
Additionally, the Data Monitoring Committee (DMC) will be reviewing safety information on an 
ongoing basis, and this will also provide an additional level of risk mitigation. 

 
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6. INVESTIGATIONAL DESIGN 
6.1 
Study Objective(s) 
6.1.1 Primary Objective(s) 
To evaluate the safety and performance of the CytoSorb® device to decrease the incidence or 
severity of AKI in the first 48 hours after surgery when used intraoperatively with 
cardiopulmonary bypass (CPB) in subjects undergoing cardiac surgery.  The study hypothesis is 
that, for patients at increased risk for AKI based upon use of the Cleveland Clinic Score for 
stratification of the risk of cardiac surgery associated AKI (CSA-AKI), the intraoperative usage 
of the CytoSorb® device in addition to the standard of care in a bypass circuit during 
cardiopulmonary bypass will decrease the incidence or severity of AKI per the Kidney Disease 
Improving Global Outcomes (KDIGO) clinical practice guideline definition of acute kidney 
injury. 
The study intent is that the intraoperative use of the CytoSorb® device, in conjunction with a 
standard of care CPB circuit will decrease the incidence or severity of AKI per the Kidney 
Disease Improving Global Outcomes (KDIGO) clinical practice guidelines definition of acute 
kidney injury as compared to a standard of care control population during the first 48 hours post 
cardiac surgery. 
6.2 
Study Design 
This will be a prospective, multi-center, randomized, pivotal, double-blinded clinical study.  
Subjects will be randomized in a 1:1 ratio to either standard of care (SOC) alone or standard of 
care and treatment with the CytoSorb® device, with or without HCA.  Number of patients with and 
without HCA will be assessed in the interim analysis 
Interim analyses will be carried out for potential (NON-BINDING) early stopping for an efficacy 
or futility conclusion.  
An option to increase sample size (SSR, i.e., Sample Size Re-estimation) will be considered.   SSR 
is based on the second interim analysis results using conditional probability (CP) to estimate the 
sample size necessary to boost the CP to 88%, assuming the observed response proportions are the 
TRUE underlying proportions. 
To assure proper startup of the sites we will employ a roll in approach for up to the first two 
enrolled subjects from each site for training.  All subjects enrolled as roll-in cases are treated with 
CytoSorb® device and are followed per protocol.  The roll-in cases will be analyzed for safety as 
outlined in Section 11.1.1. 
 
 

 
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6.3 
Study Outcomes 
6.3.1 Primary Safety Endpoint 
The primary safety endpoint of this trial is to evaluate the product safety profile through the 
assessment of device related adverse events during the study period.  
6.3.2 Primary Effectiveness Endpoint(s) 
The primary effectiveness endpoint is the incidence or severity of AKI in the first 48 hours after 
surgery when used intraoperatively with cardiopulmonary bypass (CPB) in subjects undergoing 
cardiac surgery as defined by the KDIGO clinical practice guideline through 48 hours post-
cardiac surgery. Assessment of serum creatinine and hourly measurements of urine output will 
be recorded for the first 48 hours following admission to the ICU.  The intended primary 
effectiveness sub-population includes all subjects enrolled and randomized to the treatment 
group who are undergoing valve replacement with another procedure (e.g., CABG, valve 
replacement) without Hypothermic Circulatory Arrest (HCA).  Balance between patients 
undergoing cardiac surgery with and without HCA will be evaluated during the interim analysis 
and the primary sub-population confirmed.   
6.3.3 Secondary Safety Endpoints 
• Incidence and severity of procedure-related adverse events, through 30-days post-
cardiac surgery. 
• Incidence of Serious device-related adverse events 
• Incidence and severity of unanticipated adverse device effects (UADEs) 
• Change from baseline (pre-procedure) in vital signs (blood pressure, pulse and 
temperature) 
• Change from baseline (pre-procedure) in safety laboratory assessments (hematology 
with differential, coagulation panel, and comprehensive metabolic panel) pre- and post- 
cardiac surgery through Day 7 or hospital discharge, whichever occurs first, 
• Intra-cardiac surgery arterial blood gas measurements. 
• Post-surgical Care Unit assessments (SOFA, vasopressor requirements, blood product 
transfusions, ventilation requirements, requirement for mechanical support, and renal 
replacement requirements) through hospital discharge or post-surgical Day 7, 
whichever occurs first. 
6.3.4 Secondary Effectiveness Endpoint(s) 
Secondary effectiveness endpoints include the following: 

 
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• Change from baseline (defined as the start of CPB) in pfHb assessed hourly for the 
duration of CPB and at the end of CPB; 
• Change from baseline (defined as start of CPB) in Complement 3a (C3a) assessed 
hourly for the duration of CPB and at the end of CPB; 
• Severity of AKI through hospital discharge or post-surgical Day 7, whichever is sooner 
• Incidence of AKI through hospital discharge or post-surgical Day 7, whichever is 
sooner 
• Change from baseline (defined as pre-procedure) in serum creatinine through hospital 
discharge or post-surgical Day 7, whichever is sooner; 
Additionally, the following pharmacoeconomic endpoints are included: 
• Duration of hospital stay, post-surgery 
• Duration of ICU stay, post-surgery 
• Duration of renal replacement therapy, post-surgery 
• Duration of vasopressor use, post-surgery 
• Duration of ventilator use, post-surgery 
6.3.5 Exploratory Effectiveness Endpoints 
The following known inflammatory mediators and predictive markers of kidney injury will 
be evaluated either during cardiac surgery or post-cardiac surgery.   
During cardiac surgery: 
• Change from baseline (defined as start of CPB) in C5a and inflammatory marker 
panel assessed hour during CPB an at the end of CPB 
Post-cardiac surgery days 1-3: 
• Change from baseline (defined as start of CPB) in C5a, inflammatory mediator panel, 
plasma kidney injury markers HMGB1 and Cystatin C and urine kidney injury 
markers NGAL, TIMP2, and IGFBP7 on post-surgical Days 1 through 3. 
6.4 
Subjects 
Overview of subject population to include baseline characteristics and factors such as age, gender 
and race.  Include # of subjects required to be included in the clinical investigation.   
 
6.4.1 Inclusion Criteria 
1. 
Male or female and ≥18 years of age. 

 
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2. 
Schedule for non-emergent surgical procedures requiring CPB with full sternotomy: 
a. Any combination of heart valve replacement or valve repair and another procedure 
(e.g., CABG) without HCA, coronary artery bypass graft (CABG) alone excluded 
OR 
b. Aortic reconstruction alone with HCA OR 
c. Aortic reconstruction with any combination of valve repair or valve replacement or 
CABG (but not CABG alone) with HCA  
3. Estimated glomerular filtration rate (eGFR) ≥ 30 ml/min/1.73m2 and at least ONE of the 
following additional risk factors for Cardiac Surgery Associated3 (CSA)-AKI: 
a. Age ≥ 75 years 
b. Previous cardiac surgery with sternotomy; 
c. Documented New York Heart Association (NYHA) Class III or IV heart failure 
within 1 year prior to surgery; 
d. Left ventricular ejection fraction (LVEF) ≤ 35% by invasive or noninvasive 
diagnostic cardiac imaging - echocardiography, nuclear imaging, computed 
tomography, magnetic resonance imaging or angiography performed within 90 days 
prior to surgery. (If LVEF ≤ 35% by any invasive or noninvasive imaging 
procedure, patient meets the risk factor.) 
e. Insulin-requiring diabetes; 
f. Non-insulin-requiring diabetes AND the presence of ≥ +2 proteinuria on urinalysis 
(medical history or dipstick); 
g. Preoperative anemia (hemoglobin < 11g/dl) 
h. BMI ≥ 30 kg/m2 
 
6.4.2 
Exclusion Criteria 
1. 
Weight < 99 lbs. or > 383 lbs.; 
2. 
The presence of AKI (KDIGO criteria) at the time of screening; 
3. 
eGFR < 30 ml/min/1.73m2;  
4. 
Prior organ transplantation; 
5. 
Dialysis-dependence; 
6. 
Cardiogenic shock or hemodynamic instability within 48 hours prior to surgery  as 
defined by a systolic BP <80 mm Hg and pulse >120 beats per minute (bpm) and 
requirement for inotropes or vasopressors or other mechanical devices such as intra-

 
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aortic balloon counter-pulsation (IABP); or extracorporeal membrane oxygenation 
(ECMO).  Short term vasopressor support is allowed during induction; however, 
ongoing requirement for vasopressor support to the time initiation of CPB would be 
excluded; 
7. 
Requirement for any of the following within seven (7) days prior to cardiac surgery: 
a. defibrillator or permanent pacemaker, 
b. mechanical ventilation, 
c. intra-aortic balloon counter-pulsation (IABP), 
d. left ventricular assist device (LVAD), 
e. other forms of mechanical circulatory support (MCS) such as (ECMO); 
8. 
Cardiopulmonary resuscitation within 14 days prior to cardiac surgery; 
9. 
Known or history of inadequately treated cancer within the past 5 years. 
Inadequately treated cancer is defined as the continued presence or recurrence of 
cancer; 
10. Known or suspected sepsis at time of screening or within the 30 days prior to 
cardiac surgery;  
11. Known or suspected glomerulonephritis or interstitial nephritis at time of screening; 
12. Untreated endocarditis; however, successfully treated endocarditis, defined as 
having completed a full course of antibiotics with no evidence of recurrence of 
infection, is acceptable; 
13. Other current active infection requiring antibiotic treatment including Hepatitis B 
(HBV), Hepatitis C (HCV) or human immunodeficiency virus (HIV) infections.  
Documented inactive HVB and HCV are allowed as well as HIV infections treated 
with a stable antiviral regimen for a minimum of 30 days prior to the date of 
surgery;  
14. Any other clinically relevant finding or medical history that, based upon the 
determination of the Investigator, may introduce additional risk to the patient or 
confound the results of the study; 
15. Use of stress dosed steroids at the time of surgery, immunosuppressant medications 
to prevent transplant rejection or immunosuppressant chemotherapeutic agents;  
16. Presence of acute or chronic pancreatitis; 
17. Patients know to have Child-Pugh Class A Liver disease or with alanine 
aminotransferase (ALT) or aspartate aminotransferase (AST) > 2 times the Upper 
Limit of Normal (ULN); 

 
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18. Any congenital coagulation disorder; 
19. Pregnancy or lactation; 
20. Treatment with an investigational drug or device within 60 days prior to surgery; 
21. Inability to comply with the requirements of the study protocol;  
22. Subject has a platelet count of < 50,000 / µL; 
6.4.3 Informed Consent & Enrollment Procedures 
Informed consent shall be obtained in writing from the subject or their legally authorized 
representative and the process shall be documented before any procedure specific to the clinical 
investigation is applied to the subject, except when special circumstances described in Section 
14.3 (Informed Consent Process) apply.  If during the course of the study assessments, a subject 
is found not to be eligible for inclusion in the study, the subject or their representative should be 
notified and the reason for ineligibility documented on the screening log/form. 
The general process for obtaining informed consent shall: 
• Ensure that the principal investigator or his/her authorized designee conducts the 
informed consent process; 
• Include all aspects of the clinical investigation that are relevant to the subject's 
decision to participate throughout the clinical investigation; 
• Avoid any coercion or undue improper influence on, or inducement of, the subject to 
participate; 
• Not waive or appear to waive the subject's legal rights; 
• Use native non-technical language that is understandable to the subject; 
• Provide ample time for the subject to read and understand the informed consent form 
and to consider participation in the clinical investigation; 
• Include personally dated signatures of the subject and the principal investigator or an 
authorized designee responsible for conducting the informed consent process; 
• Provide the subject with a copy of the signed and dated informed consent form and 
any other written information; and, 
• Ensure important new information is provided to new and existing subjects throughout 
the clinical investigation. 
6.4.4 Subject Withdrawal/Discontinuation 
A study subject will be discontinued from participation in the study if: 
• The investigator feels that the subject can no longer fully comply with the 
requirements of the study or if any of the study procedures would not be in the best 
interest of the subject. 

 
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• The subject is lost to follow up.  A subject will be considered “lost to follow-up” and 
terminated from the study when all of the following criteria have been met: 
o Failure to complete the 30-day follow up telephone call without due cause; and 
o Documentation of three unsuccessful attempts to contact the subject via 
telephone and by certified mail. 
• The subject wishes to withdraw their consent for participation in the study.  
7. FIELD CLINICAL ENGINEERS 
Support by a Field Clinical Engineer (FCE), as designated by the Sponsor, may be offered to assist 
with set up of the blind and provide guidance during the procedure.  In instances where the 
Sponsor designated FCE has previously observed set-up of the investigational device and has 
found the unblinded perfusionist(s) skilled and competent to manage study procedures, a waiver of 
FCE assistance may be granted.  All such waivers of FCE assistance will be documented and 
retained in the study file.     
The FCE will observe and proctor the unblinded Perfusionist as he or she assembles the CytoSorb® 
cartridges (2) and peripheral FDA approved components as specified in the Instructions for 
Use.  The unblinded Perfusionist is responsible for the final hookup to the hospital perfusion 
apparatus. 
The CytoSorb® devices will be blinded by placement behind a barrier.  When the device is being 
used, the unblinded Perfusionist will ensure proper flow through the CytoSorb® device.   
Assembly of the blind space may be required in advance should other OR personnel be in the work 
space during set up to preserve knowledge of treatment allocation.  The FCE or unblinded 
Perfusionist ensures the blind is maintained prior to, throughout and post-surgery. 
8. STUDY ASSESSMENTS AND PROCEDURES 
An outline of study assessments, procedures, labs and associated time windows at each visit is 
given in Table 3 and Table 4.  Assessments and procedures that are indicated as Standard of Care 
(SOC) are optional and should be recorded if the assessment or procedure is SOC for that 
institution.  Failure to record an assessment/procedure that is listed as SOC will not be a violation 
of protocol.  Required assessments and procedures (those not designated as SOC) not completed or 
completed outside of specified windows will be recorded as protocol deviation (see Section 13.2).  
Definitions of analysis populations and descriptions of statistical analyses of endpoints is briefly 
described in Section 11 and detailed in the Statistical Analysis Plan (SAP) for the study.   
8.1 
AKI Definition, Severity Grading, and Duration 
Acute kidney injury (AKI) is defined in the KDIGO guidelines as meeting any of the following: 
• Increase in serum creatinine by ≥0.3 mg/dL (≥26.5 µmol/L) within 48 h or; 

 
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• Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to 
have occurred within the prior 7 days or; 
• Urine volume < 0.5 ml/kg/h for 6 hours 
For the purposes of this study, the 48-h referenced in the first part of the definition will be the first 
48 h following admission to the ICU (or equivalent post-surgical placement).  Serum creatinine 
and urine volume (urine output) will be recorded through post-surgical Day 7 or hospital 
discharge, whichever comes sooner.   
Staging of AKI for severity assessment will use the criteria summarized in the table below.  
Staging of AKI may be based on either change in serum creatinine OR changes in urine output.   
Stage 
Serum Creatinine 
Urine Output 
1 
1.5 to 1.9-times baseline or 
≥0.3 mg/dL (≥26.5 µmol/L) 
increase 
< 0.5 mL/kg/h for 6-12 h 
2 
2.0-2.9 times baseline 
< 0.5 mL/kg/h for ≥ 12 h 
3 
3.0 times baseline or 
SCr ≥4.0 mg/dl (≥353.6 
µmol/L) or 
Initiation of renal replacement 
therapy  
< 0.3 mL/kg/h for ≥ 24 h  
or 
Anuria for ≥ 12 h 
 
Duration of AKI will be assessed through post-surgical Day 7 or hospital discharge whichever 
comes sooner.  Duration of AKI is measured as the number of days from the point where the 
patient meets the criteria of AKI per the KDIGO definition until the point where the definition is 
no longer met.   
8.2 
Recording of urine output 
Urine output is recorded at the following intervals: 
• Total urine volume from the start of surgery to the end of CPB  
• Total urine volume from the end of CPB to admission to the ICU 
• Urine volume is recorded each hour for the first 48 h following admission to the ICU.  The 
urine volume is recorded each hour even if the urinary catheter is removed before the full 
48 h have elapsed. 
• After the 48 h from ICU admission has elapsed, collect urine at the following intervals: 
o If the urinary catheter is still inserted, record urine volume every 3 h 
o If the urinary catheter has been removed, record urine volume every 8 h 

 
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8.3 
Subject Screening 
All subjects scheduled to undergo CPB surgery will be assessed for the potential inclusion in the 
study by a research physician, research nurse, or designated study staff.  A pre-Screening Log will 
be used to maintain a cumulative log of all assessed subjects at the site. Should a subject not meet 
eligibility, the reason for non-eligibility will be recorded on the pre-Screening Log. 
Medicare patients who meet the study eligibility criteria will be enrolled into the study.  The 
results of this study are expected to be highly generalizable to the Medicare population. 
8.4 
Screening Visit 
Written informed consent will be obtained from the subject (or legally acceptable representative on 
behalf of the subject) before any study-specific procedures are performed. (Note: Consent by a 
legally acceptable representative is allowed where applicable, and is in accordance with local laws, 
regulations, and ethics committee policy.) Subjects are considered enrolled once they sign the 
informed consent. Screening laboratory samples may be obtained up to 14 days prior to the date of 
surgery, so that results are available for review at the visit.  
Patients are qualified for study participation during the screening period by confirmation of 
meeting all the inclusion criteria and none of the exclusion criteria.  Evaluation of inclusion 
criterion 2 is based upon the intended surgical procedure during the screening period.   During the 
pre-procedure and intra-operative periods, the intended procedure may change due to factors that 
could not be adequately determined or anticipated in advance of the procedures.  These 
day-of-surgery changes to intended procedures may result in completion of a procedure that does 
not align with the eligibility criteria as detailed in inclusion 2.   Since eligibility is assessed based 
on the intended procedure during the screening period, a change on the operative day is not 
considered a protocol deviation.  Patients who have changes to their intended procedures on the 
day of surgery are study subjects and should progress through the study as detailed in the protocol.  
These subjects will be included in the Intent-to-Treat analysis. 
The following procedures will be performed, and results recorded in the electronic Case Report 
Forms (eCRF):   
• The investigator / designee will solicit a written informed consent from the subject (or 
legally acceptable representative on behalf of the subject) for study participation. 
• Eligibility based on inclusion / exclusion criteria will be assessed. 
• Medical history will be reviewed relative to the inclusion/exclusion criteria. 
• Demographic details (age, gender, and race). 
• Prior and concomitant medications taken during the past 60 days inclusive of any IV 
contrast agents administered within 48 hours of the procedure  
• Complete physical examination  
• Vital signs (HR, BP, Temp.) after 5 minutes supine 
• Height and weight 

 
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• Echocardiogram for ejection fraction (if an acceptable method of determining LVEF 
(Section 6.4.1 Inclusion 3d) has not been performed within 90 days of enrollment)  
• NYHA Class 
• eGFR  
• Urine or serum pregnancy test (women of child-bearing age without permanent birth 
control within 7 days prior to the surgery). 
• Blood samples will be drawn for the following assessments:  
o Hematology 
o Coagulation panel 
o Comprehensive metabolic panel (must include total bilirubin and sodium) 
o Serum creatinine 
8.5 
Procedure Assessments 
8.5.1 Subject Randomization 
Subjects will be prospectively randomized.  Randomization must occur prior to the start of CPB 
surgery, but only after the subject provides written informed consent and subject eligibility 
criteria is confirmed.  Randomization should be performed within 5 days of start of the CPB 
surgery to minimize incidence of dropout prior to cardiac surgery and to allow adequate time 
for scheduling with the FCE.  Subjects will be randomly assigned in a one to one (1:1) ratio to 
either the control arm (SOC) or treatment arm (SOC + CytoSorb® device). To ensure even 
distribution of subjects receiving treatment and control, with and without Hypothermic 
Circulatory Arrest (HCA) during procedure, the randomization will be stratified by study center 
and the intended use of HCA as a surgical technique during procedure. 
Neither the investigational sites nor the Sponsor will have access to the randomization 
schedules, and subjects will not be told about their assignment prior to the surgery.  A copy of 
the randomization assignment will be maintained in the subject’s file.  If the subject withdraws 
consent prior to the surgery, the reason for failure to treat as randomization will be recorded in 
the subject’s study records.  Safety data will not be collected for subjects who drop out prior to 
surgery.   
8.5.2 Pre-Procedure 
The following procedures will be performed, and results recorded in the eCRF.  When patient 
screening is completed on the day of surgery, procedures/assessments that are listed to be 
completed again at pre-procedure do not need to be duplicated.  
• Eligibility based on inclusion / exclusion criteria will be confirmed. Subjects who meet 
all inclusion and exclusion criteria will be randomized to either the control arm or to the 
treatment arm; 
• Vital signs; 

 
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• Weight 
• FiO2 (if patient is intubated on mechanical ventilatory support) 
• Sequential Organ Failure Assessment (SOFA) score will be assessed before induction 
of anesthesia; 
• Initiate recording of fluids administration (e.g. crystalloids) 
• Initiate recording of supplementation with calcium and/or albumin 
• Blood samples will be drawn for the following assessments before induction of 
anesthesia:  
o Hematology; 
o Coagulation panel; 
o Comprehensive metabolic panel; 
o ABG (per SOC); 
o Ionized calcium 
o ACT (per SOC); 
o Serum creatinine; 
o Complement C3a and C5a; 
o Inflammatory mediator panel includes Interleukin 2 (IL2), Interleukin 4 (IL4), 
Interleukin 5 (IL5), Interleukin 6 (IL6), Interleukin 10 (IL10), Interleukin 12 (IL12), 
Interferon Gamma (INFG), Tumor Necrosis Factor alpha (TNFA); 
o Kidney injury markers – urine: urine neutrophil gelatinase-associated lipocalin 
(NGAL), insulin growth factor binding protein 7 (IGFBP7), tissue inhibitor of 
metalloproteinases 2 (TIMP2); 
o Kidney injury markers – plasma: high mobility group box 1 protein (HMGB1) and 
Cystatin C; 
o Plasma free hemoglobin (pfHb); 
8.5.3 Procedure (CPB Surgery) 
8.5.3.1 Treatment Arm 
Subjects randomized to the treatment arm will receive standard of care bypass plus treatment 
with one CytoSorb® device at the beginning of CPB.  If and when CPB continues for more 
than 90 minutes of bypass time, a second (parallel configuration) device will be opened to the 
bypass circuit.  Treatment with the CytoSorb® device(s) will continue until the end of CPB.  
Blood flow is to be maintained continuously through the CytoSorb® devices. 
As per the instructions for use (IFU), prior to hemoperfusion, prime and flush the circuit with 
saline or crystalloid solution and prevent any air from entering into the system and clamp 

 
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lines.  During this phase, gently tap the CytoSorb® device to liberate any trapped air.  Also, 
for a short period, the pump speed can be increased to allow for clear identification of any 
possible leaks at the increased pressure/flow rate. Hemoperfusion with CytoSorb® will begin 
at the commencement of CPB flow to the subject. 
CytoSorb® treatment flow rates will be controlled utilizing a roller clamp placed just beyond 
the junction of the outlet-side Y-tube. The flow rate will be measured using a Sponsor 
provided Transonic (or equivalent) ultrasonic flow meter and probe, also placed just beyond 
the junction of the outlet-side Y-tube. The blood flow rate of the device will be adjusted to 
yield an initial target reading of 400 ml/min (minimum above 300 ml/min is acceptable) 
measured beyond the junction of the outlet-side Y-tube.   If/when CPB goes beyond 90 
minutes and the second, parallel CytoSorb unit is brought into play 90 minutes into CPB by 
opening its C-clamp, total flow should be adjusted to yield a target flow rate of 800 ml/min 
(minimum of 600 ml/min is acceptable), as measured beyond the junction of the outflow “Y” 
tube. Because of the parallel nature of the circuit, when using both CytoSorb units, this will 
equate to a target flow rate of 400 ml/min through each device, with an acceptable lowest 
flow rate of 300 ml/min per device. 
Throughout the treatment session, monitoring the CytoSorb device for blood leaks, pressure 
spikes or clots is essential.  Any adverse device events and/or device observations must be 
recorded by indicating the location of leaks or by recording the size of clots present. 
Assessments during procedure: 
At the start of CPB: 
• Blood product transfusions; 
• Record CytoSorb start time; 
• Operational notes (surgery/CPB start time, clamp times); 
• Flow rate in CytoSorb circuit;   
• Adverse events; 
• Administration of fluids will be collected; 
• Supplementation with Calcium or Albumin will be recorded; 
• Concomitant medications will be collected, as needed; 
• FiO2 
• Blood samples will be drawn for the following assessments:  
o ABG; 
o Ionized calcium; 

 
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o Total serum calcium; 
o Serum albumin; 
o ACT (per SOC); 
o Complement C3a and C5a; 
o Inflammatory mediator panel; 
o Plasma free hemoglobin (pfHb); 
Hourly while on CPB: 
• Vasopressor requirements; 
• Administration of fluids will be collected; 
• Supplementation with Calcium or Albumin will be recorded; 
• Flow rate in CytoSorb circuit (record flow rates every 30 minutes during treatment with 
CytoSorb device(s)); 
• Blood product transfusions; 
• Blood samples will be drawn for the following assessments:  
o ABG; 
o Ionized calcium; 
o Total serum calcium; 
o Serum albumin; 
o ACT (per SOC); 
o Complement C3a and C5a; 
o Inflammatory mediators; 
o Plasma free hemoglobin (pfHb); 
90 minutes from start of CPB: 
• Record the start time of the second CytoSorb device and stop time;  
• Blood samples will be drawn for the following assessments:  
o Complement C3a and C5a; 
o Inflammatory mediators; 
o Plasma free hemoglobin (pfHb); 
End of CPB (i.e. pump shut off, prior to protamine): 
• Vital signs; 

 
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• Vasopressor requirements; 
• Administration of fluids will be collected; 
• Supplementation with Calcium or Albumin will be recorded; 
• Record the stop time of the CytoSorb device(s); 
• Blood product transfusions; 
• Record type of surgical procedure(s); 
• Operational notes (surgery/CPB stop time, clamp times); 
• Urine output; 
• Adverse events; 
• Concomitant medications will be collected as needed; 
• FiO2 
• Blood samples will be drawn for the following assessments:  
o Hematology; 
o Coagulation panel; 
o Comprehensive metabolic panel; 
o ABG; 
o Ionized calcium; 
o ACT (per SOC); 
o Serum creatinine; 
o Complement C3a and C5a  ; 
o Inflammatory mediator panel ;  
o Plasma free hemoglobin (pfHb)  ; 
8.5.3.2 Control Arm 
Subjects randomized to the control arm will receive standard of care bypass at the beginning 
of CPB. 
The following procedures will be performed, and results recorded in the eCRF: 
• Eligibility based on inclusion / exclusion criteria will be confirmed. Subjects who meet 
all inclusion and exclusion criteria will be randomized to either the control arm or to the 
treatment arm 

 
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• Vital signs 
• Sequential Organ Failure Assessment (SOFA) score will be assessed before induction 
of anesthesia; 
• Initiate recording of fluids administration (e.g. crystalloids) 
• Initiate recording of supplementation with calcium and/or albumin 
• Blood samples will be drawn for the following assessments:  
o Hematology 
o Coagulation panel 
o Comprehensive metabolic panel 
o ABG   
o Ionized Calcium 
o ACT (per SOC) 
o Serum creatinine 
o Complement C3a and C5a   
o Inflammatory mediator panel    
o Kidney injury markers – urine:  urine NGAL, IGFBP7, TIMP2); 
o Kidney injury markers – plasma:  HMGB1 and Cystatin C;   
o Plasma free hemoglobin (pfHb); 
Assessments during procedure: 
At the start of CPB: 
• Blood product transfusions 
• Operational notes (surgery/CPB start time, clamp times) 
• Administration of fluids will be collected 
• Supplementation with Calcium or Albumin will be recorded 
• Adverse events 
• Concomitant medications will be collected as needed 
• FiO2 
• Blood samples will be drawn for the following assessments:  
o ABG  

 
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o Ionized calcium  
o Total serum calcium 
o Serum albumin 
o ACT (per SOC) 
o Complement C3a and C5a   
o Inflammatory mediator panel   
o Plasma free hemoglobin (pfHb)   
Hourly while on CPB: 
• Vasopressor requirements 
• Administration of fluids will be collected 
• Supplementation with Calcium or Albumin will be recorded 
• Blood product transfusions 
• Blood samples will be drawn for the following assessments:  
o ABG   
o Ionized calcium 
o Total serum calcium 
o Serum albumin 
o ACT (per SOC) 
o Complement C3a and C5a   
o Inflammatory mediator panels   
o Plasma free hemoglobin (pfHb)   
90 minutes from start of CPB: 
• Blood samples will be drawn for the following assessments:  
o Complement C3a and C5a   
o Inflammatory mediator panels   
o Plasma free hemoglobin (pfHb)   
 
End of CPB (i.e. pump shut off, prior to protamine): 
• Vital signs 

 
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• Vasopressor requirements 
• Administration of fluids will be collected 
• Supplementation with Calcium or Albumin will be recorded 
• Blood product transfusions 
• Record type of surgical procedure(s) 
• Operational notes (surgery/CPB stop time, clamp times) 
• Urine output 
• Adverse events 
• Concomitant medications will be collected as needed 
• FiO2 
• Blood samples will be drawn for the following assessments:  
o Hematology 
o Coagulation panel 
o Comprehensive metabolic panel 
o ABG   
o Ionized Calcium 
o ACT (per SOC) 
o Serum creatinine 
o Complement C3a and C5a   
o Inflammatory mediator panels   
o Plasma free hemoglobin (pfHb)   
8.5.4 Sampling during CPB 
Subject blood samples to be drawn from an arterial line during CPB procedure by appropriate 
medical staff per institutional guidance (i.e., anesthesiologist or perfusionist). 
8.5.5 Sampling End of CPB (i.e. pump shut off, post protamine) 
Subject blood samples will be drawn by appropriate medical staff (i.e. anesthesiologist or 
perfusionist) per institutional guidelines, post-cardiac surgery. Note that samples for 
hematology and coagulation assessments should be drawn after the administration of protamine 
at a timepoint consistent with the standard of care for the institution.  
 

 
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8.5.6 Sample Collection and Storage 
Instructions on the process for the collection and storage of the blood and urine samples are 
provided in the Study Laboratory Manual. 
8.6 
Post-Surgical Care Unit (i.e., CCU, ICU) 
Admission to Post-Surgical Care Unit through 7 days or hospital discharge, whichever occurs first 
8.6.1 Admission to Post-Surgical Care Unit (Treatment and Control Groups) 
The following assessments will be performed within one hour after admission to the post-
surgical care unit. 
• Vital signs 
• Weight 
• FiO2 (if the patient is intubated on mechanical ventilatory support) 
• SOFA Score  
• Record vasopressor requirements 
• Blood product transfusions 
• Record need for ventilation and mechanical support  
• Record need for renal replacement  
• Record urine output each hour for the first 48 h after surgery even if catheter is 
removed before 48 h 
• Adverse events 
• Concomitant medications will be collected as needed 
• Administration of fluids will be collected 
• Supplementation with Calcium or Albumin will be recorded 
• Blood samples will be drawn for the following assessments:  
o Hematology 
o Coagulation panel 
o Comprehensive metabolic panel 
o ABG (per SOC) 
o Ionized calcium 
o ACT (per SOC) 

 
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o Serum creatinine 
o Complement C3a and C5a   
o Inflammatory mediator panel Kidney injury markers (plasma):  HMGB1, Cystatin 
C:   
o Kidney injury markers (urine):  NGAL, IGFBP7, TIMP2);  
o Plasma free hemoglobin (pfHb)   
 
8.6.2 Post-Surgical Days 1-3  
• Vital signs 
• Weight 
• FiO2 (if the patient is intubated on mechanical ventilatory support) 
• SOFA Score  
• Record vasopressor requirements 
• Blood product transfusions 
• Record need for ventilation and mechanical support  
• Record need for renal replacement  
• Record urine output each hour for the first 48 h after surgery even if the catheter is 
removed before 48 h   
• Adverse events 
• Concomitant medications will be collected as needed 
• Administration of fluids will be collected (Day 1 only required, SOC thereafter) 
• Supplementation with Calcium or Albumin will be recorded (Day 1 only required, SOC 
thereafter) 
• Blood samples will be drawn for the following assessments:  
o Hematology 
o Coagulation panel (per SOC) 
o Comprehensive metabolic panel 
o Serum creatinine  
o Complement C3a and C5a   
o ABG (per SOC) 

 
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o Ionized Calcium 
o Inflammatory mediator panel   
o Kidney injury markers (plasma):  HMGB1, Cystatin C   
o Kidney injury markers (urine):  NGAL, TIMP2, IGFBP7)  
8.6.3 Post-Surgical Day 4 through 7 
(or hospital discharge, whichever occurs first) (Treatment and Control Groups) 
The following assessments will be performed daily starting on post-surgical day 4 through day 
7, or until hospital discharge, whichever occurs first: 
• Vital signs 
• Weight 
• FiO2 (if the patient is intubated on mechanical ventilatory support) 
• Record vasopressor requirements 
• Blood product transfusions 
• Record need for ventilation and mechanical support  
• Record need for renal replacement 
• Record urine output 
• Adverse events 
• Concomitant medications will be collected as needed 
• Administration of fluids will be collected 
• Supplementation with Calcium or Albumin will be recorded 
• Blood samples will be drawn for the following assessments:  
o Hematology (per SOC) 
o Coagulation panel (per SOC) 
o Comprehensive metabolic panel (per SOC) 
o Serum creatinine  
 
8.6.4 Hospital Discharge 
The following information with be collected at the time of hospital discharge: 
• SOFA Score 

 
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• Record need for ventilation and mechanical support  
• Record need for renal replacement 
• Record urine output 
• Hospital discharge date (to calculate duration of hospital stay) 
• Adverse events 
• Contact information where subject is going if less than 7 days post-cardiac surgery 
• Pertinent concomitant medications 
• Hematology 
• Coagulation panel 
• Comprehensive Metabolic Panel  
• Serum Creatinine 
  
8.7 
Day 30 Post-Cardiac Surgery 
The subjects will be contacted via telephone at 30 days post-cardiac surgery for assessment of the 
following since hospital discharge: 
• Blood product transfusions 
• Adverse events 

 
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Table 3: Schedule of Assessments 
Event 
Screening1 
Procedure (CPB/Surgery) 
Post-Surgery period 
Discharge 
Follow-up 
Pre-Procedure 
(before induction 
of general 
anesthesia) 
Start of CPB 
(±5 minutes) 
 
 
Hourly while 
on CPB  
(±5 minutes) 
End CPB  
(post 
protamine) 
Admission 
to Post-
Surgery Care 
unit 
(+1 hour) 
Daily for Post day 1-3 
Post-Cardiac Surgery 
or Hospital Discharge 
 (whichever is 
sooner)2,5 
Day 4-7 
Post-
Cardiac 
Surgery 
Hospital 
Discharge 
30 Day 
Follow-up 
(±5 days) 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
Demographics,  Height 
X 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
 
 
X 
X 
X 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
Prior Medications (taken within 60 days of 
Screening Visit) 
X 
 
 
 
 
 
 
 
 
 
Concomitant Medications – inclusive of IV 
contrast media administered within 48 h of 
procedure 
 
As Needed 
 
Inclusion/Exclusion Criteria (w/in 14 days of 
surgery) 
X 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Review 
 
X 
 
 
 
 
 
 
 
 
Vital Signs (HR, BP, Temp)3 
X 
X 
 
 
X 
X 
X 
X 
 
 
New York Heart Association (NYHA) 
X 
 
 
 
 
 
 
 
 
 
Echocardiogram (Ejection Fraction)6 
X 
 
 
 
 
 
 
 
 
 
Estimated Glomerular Filtration Rate (eGFR) 
X 
 
 
 
 
 
 
 
 
 
Physical Examination 
X 
 
 
 
 
 
 
 
 
 
SOFA Score (includes FiO2, level of 
hypotension assessment, evaluation of 
 
X7 
 
 
 
X7 
X7 
 
X7 
 

 
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Event 
Screening1 
Procedure (CPB/Surgery) 
Post-Surgery period 
Discharge 
Follow-up 
Pre-Procedure 
(before induction 
of general 
anesthesia) 
Start of CPB 
(±5 minutes) 
 
 
Hourly while 
on CPB  
(±5 minutes) 
End CPB  
(post 
protamine) 
Admission 
to Post-
Surgery Care 
unit 
(+1 hour) 
Daily for Post day 1-3 
Post-Cardiac Surgery 
or Hospital Discharge 
 (whichever is 
sooner)2,5 
Day 4-7 
Post-
Cardiac 
Surgery 
Hospital 
Discharge 
30 Day 
Follow-up 
(±5 days) 
mechanical ventilation and vasopressor 
requirement, MAP, Glasgow Coma Score)7 
Randomization 
 
X4 
 
 
 
 
 
 
 
 
Vasopressor Requirements8 
 
 
 
X 
X 
X 
X 
X 
X9 
 
FiO2 (if patient is intubated on mechanical 
ventilatory support) 
 
X 
X 
 
X 
X 
X 
X 
 
 
Start/Stop Times of CytoSorb Treatment & 
Flow rate every 30 minutes (Treatment arm 
only) 
 
 
X 
X 
X 
 
 
 
 
 
Blood Product Transfusions10 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Ventilation & Mechanical support Requirements 
 
 
 
 
 
X 
X 
X 
X 
 
Renal Replacement Requirements 
 
 
 
 
 
X 
X 
X 
X 
 
Type of Surgical Procedure(s) 
 
 
 
 
X 
 
 
 
 
 
Administration of fluids is recorded11 
 
   X-----------------------------------------------------------------------------------------------------------X 
 
 
Supplementation with Ca and/or Albumin11 
 
   X-----------------------------------------------------------------------------------------------------------X 
 
 
Operational notes (Surgery start & stop times, 
clamp times) 
 
 
X 
 
X 
 
 
 
 
 
 Adverse Events/SAEs 
 
As Needed (from time ICF is signed and subject is enrolled until study exit) 
1 Within 14 days of surgery.  If Screening is completed on the day of surgery, duplicate pre-procedure assessments/procedures do not need to be repeated. 
2 Daily, preferably at the same time each day. 
3 After approximately 5 minutes supine 
4 Randomization can be performed within 5 days prior to the cardiac surgery, but only after informed consent has been obtained. 

 
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5 A minimum of 12 hours from time of admission to Post-Surgery Care Unit to the start of collection of data for daily is required. 
6 Echocardiogram for ejection fraction if an acceptable method (Section 6.4.1, Inclusion 3d) has not been completed within 90 days. 
7SOFA score will be assessed pre-procedure (before induction of anesthesia or sedation); on admission to post-surgical care; daily for 3 days post-procedure; and at Day 7 post-procedure 
or discharge, whichever occurs first). For post-surgical SOFA assessments, the lowest mean arterial pressure (MAP) from the day is used in the SOFA determination. 
8Vasopressor requirements:  the maximum vasopressor dosage will be recorded each day (maximum dose over 1 hour).  
9 Vasopressors will be collected through day 7 if subject is still hospitalized. 
10 Blood transfusions will be collected through 30 days post cardiac surgery. Transfusion type (e.g. whole blood, packed red cells, platelets) will be recorded along with the volume 
administered 
11 Administration of fluids (crystalline) and supplementation with calcium and/or albumin begins at pre-procedure and will continue through the end of post-surgical Day 1.  All 
administration and supplementation will be recorded.  Following Day 1, administration of fluids and supplementation will be recorded as SOC until the point where the treating physician 
discontinues collection.   
 
 
 
 

 
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Table 4: Schedule of Laboratory Assessments 
Event 
Screening1 
Procedure (CPB/Surgery) 
Post-surgical period 
Discharge 
Follow Up 
Pre-procedure 
Day of surgery 
but before 
induction of 
anesthesia 
Start of 
CPB 
 (±5 min) 
Hourly 
while on 
CPB 
 (±5 min) 
90 minutes 
after Start of 
CBP Start of 
Device # 2) 
(±5 min) 
End CPB14 
Off pump and 
post 
protamine 
Admission 
to post-
surgical 
care unit (+ 
1 h) 
Post-
surgical 
Days 1-3 
Post-
surgical 
Days 4-7 or 
discharge, 
whichever is 
sooner 
Hospital 
Discharge 
30-day 
Follow up 
(±5 days) 
Pregnancy Test4 
 
X 
 
 
 
 
 
 
 
 
 
 
Hematology 5, 8 
X 
X2 
 
 
 
X 
X 
X 
SOC 
X 
 
Coagulation 5,8 
X 
X2 
 
 
 
X 
X 
SOC 
SOC 
X 
 
Comprehensive 
Metabolic Panel 5, 9 
X 
X2 
 
 
 
X 
X 
X 
SOC 
X 
 
Serum Creatinine 3,15 
X 
X2 
 
 
 
X 
X 
X 
X 
X 
 
Complement C3a & C5a 
 
X 
X 
X 
 
X 
X 
X 
 
 
 
Arterial Blood Gases13 
(includes PaO2, PaCO2, 
pH, HCO3) 
 
SOC 
SOC 
SOC 
 
SOC 
SOC 
SOC 
 
 
 
Ionized Calcium, Total 
Serum Calcium, Serum 
Albumin 
 
X 
 
X 
X 
 
X 
X 
X 
 
 
 
Activated Clotting Time 
(ACT)10 
 
SOC 
SOC 
SOC 
 
SOC 
SOC 
 
 
 
 
 
 

 
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Event 
Screening1 
Procedure (CPB/Surgery) 
Post-surgical period 
Discharge 
Follow Up 
Pre-procedure 
Day of surgery 
but before 
induction of 
anesthesia 
Start of 
CPB 
 (±5 min) 
Hourly 
while on 
CPB 
 (±5 min) 
90 minutes 
after Start of 
CBP Start of 
Device # 2) 
(±5 min) 
End CPB14 
Off pump and 
post 
protamine 
Admission 
to post-
surgical 
care unit (+ 
1 h) 
Post-
surgical 
Days 1-3 
Post-
surgical 
Days 4-7 or 
discharge, 
whichever is 
sooner 
Hospital 
Discharge 
30-day 
Follow up 
(±5 days) 
Inflammatory 
Mediators11 
 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Kidney Injury Marker- 
Plasma HMGB1, 
Cystatin C 
 
X 
 
 
 
 
X 
X 
 
 
 
Kidney Injury Markers 
(Urine NGAL, TIMP2 & 
IGBFP7  
 
X 
 
 
 
 
X 
X 
 
 
 
Plasma Free Hemoglobin 
(pfHb)5  
 
X 
X 
X 
X 
X 
X 
 
 
 
 
Urine Output 
 
 
 
 
 
X 
X6 
X6 
X6 
X 
X 
1 Within 14 days of surgery. 
2 If Screening is completed on the day of surgery, duplicate pre-procedure assessments/procedures do not need to be repeated. 
3 Daily for each post-surgical day. 
4 Women of child-bearing age without permanent birth control will be evaluated with a urine or serum pregnancy test within 7 days prior to CPB procedure. 
5 Samples to be drawn from an arterial line during cardiopulmonary bypass procedure. (End CPB sample to be drawn by appropriate medical staff per institutional guidance (i.e., 
anesthesiologist or perfusionist) t after CytoSorb Device is stopped at end of CPB) 
 
6 Urine output will be recorded hourly for the first 48 hours even if the urinary catheter is removed before 48 h after surgery.  After 48 hours, urine output will be measured every 3 
hours while the catheter is in place.  Once the catheter is removed, urine output shall be recorded every 8 hours for 7 days or through hospital discharge, whichever occurs first.    
7 Pre-procedure blood samples will be drawn prior to induction of anesthesia.  
8 Hematology includes: Hemoglobin, WBC w/differential, Platelets and Hematocrit. Coagulation panel includes (Activated Partial Thromboplastin Time (APTT), Prothrombin 
Time/International Normalized Ratio (PT/INR), and fibrinogen) 

 
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9 Comprehensive metabolic panel must include sodium and total bilirubin. 
10 Only required as per site’s standard of care. 
11 Inflammatory mediators panel includes Interleukin 2 (IL2), Interleukin 4 (IL4), Interleukin 5 (IL5), Interleukin 6 (IL6), Interleukin 10 (IL10), Interleukin 12 (IL12S), Interferon 
Gamma (INFG), Tumor Necrosis Factor alpha (TNFA) 
13 Values will be collected for the study as long as the patient is intubated on mechanical ventilatory support. If the patient is not intubated on mechanical ventilatory support, they 
are not required for the study. 
14 End of CPB sample is drawn by appropriate medical staff per institutional guidelines (i.e., anesthesiologist or perfusionist) after pump shut off,  
per institution SOC for drawing coagulation panel post administration of Protamine. 
15 All creatinine values for assessment of AKI will be taken from local lab draws (CMP).  At time of lab sample preparations, a backup creatinine sample will be drawn and 
prepared and sent to Central Laboratory for archiving only.   In event of missed Creatinine value, the archive sample will be run by Central Lab. 
 
 
 
 

 
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8.8 
Safety/Device Assessment 
8.8.1 Adverse Events 
Throughout the study, the Investigator or designee will determine adverse event (AE) 
occurrences.  An adverse event is any untoward medical occurrence (signs, symptoms, 
abnormal laboratory findings) in a subject regardless of relationship to the device or procedure.  
Each adverse event is considered to be either anticipated or unanticipated as described below.  
AEs occurring after the initiation of treatment (start of CPB) are considered to be treatment 
emergent.   The site is required to report the classes of Adverse Events that occur in the study, 
described below. 
Any AEs and remedial action required will be recorded in the patient’s source data. The nature, 
time of onset, duration, and severity will be documented, together with an Investigator’s (or 
designee’s) opinion of the relationship to investigational device.  Since the incidence and 
severity of AKI, as defined by KDIGO clinical practice guidelines, are the primary endpoints of 
the study, the presence of AKI should not be reported as an AE in the trial. 
If an AE occurs, appropriate diagnostic and therapeutic measures are to be taken. Follow-up 
evaluations of the patient are to be performed until the patient recovers or until the clinical 
Investigator considers the situation to be no longer clinically significant. 
Adverse events are monitored and registered on the AE form of the eCRF at each visit. 
Whenever possible, a specific diagnosis should be entered as the AE term.  Outcomes and 
severity of the AE are not to be recorded as the AE term.  In absence of a specific diagnosis, an 
individual AE form has to be filled in for each sign or symptom.  Changes from baseline 
laboratory values which are abnormal values and that are classified as clinically significant by 
the investigator must be recorded as AEs.  
Persistent AEs will be entered once in the eCRF until they are resolved or if a new event has to 
be documented due to deterioration. These AEs will be carefully monitored. If an AE is still not 
resolved at the end of the investigation, this will be documented as ongoing. 
For recurrent AEs (i.e., AEs of the same nature, but with a different date of onset), an individual 
AE form has to be completed for each of them. 
Adverse events will be assessed for a relationship to each of the following and relationship 
classified as unrelated, possible, probable, definite or unknown: 
Investigational Device Related Adverse Event:  An adverse event which, in the judgment of 
the Investigator, results as a consequence of the investigational device. 

 
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Surgical Procedure Related Adverse Event:  An adverse event which, in the judgment of the 
Investigator, results as a consequence of the subject's surgical procedure and is not specific to 
the investigational device used. 
Non-Investigational Device Related Adverse Event:  An adverse event which, in the 
judgment of the Investigator, it is reasonable to believe that the event is associated with an 
accessory device used during the surgical procedure and is not specific to the investigational 
device use. 
Adverse events will also be evaluated for severity based on the following definitions: 
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 Activities of Daily Living (ADL)*. 
Grade 3 
Severe: 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting 
self-care ADL**. 
Grade 4*** 
Life-
threatening: 
Life-threatening consequences; urgent intervention indicated. 
Grade 5*** 
Death: 
Death related to AE 
*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. 
***Adverse events that are assigned a severity of life-threatening or death will be recorded as Serious Adverse Events.   
8.8.2 Serious Adverse Events 
A serious adverse event (SAE) is any untoward medical occurrence that meets one or more of 
the following criteria:  
• Led to death 
• Led to a serious deterioration in the health of the subject that: 
▪ Resulted in a life-threatening illness or injury 
▪ Resulted in a permanent impairment of a body structure or body function 
▪ Required in-patient hospitalization or prolongation of existing hospitalization 
▪ Resulted in medical or surgical intervention to prevent permanent impairment to 
body structure or body function 
• Led to fetal distress, fetal death, or congenital abnormality or birth defect. 
 
 
 

 
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8.8.3 Anticipated Adverse Events/Device Related Adverse Events 
A variety of complications are expected to occur in subjects undergoing CPB and cardiac 
surgery, regardless of whether or not CytoSorb is used. These may include, but are not limited 
to: 
Serious, but less common, risks: 
• Bleeding during or after the surgery including bleeding in relation to anticoagulation 
• Blood clots that can cause heart attack, stroke, or lung problems 
• Heparin-induced thrombocytopenia 
• Bypass induced thrombocytopenia 
• Reduction in platelets 
• Infection, including pneumonia  
• Organ injury including: 
− Respiratory damage causing breathing problems or failure to wean from the 
ventilator 
− Cardiac dysrhythmias/arrhythmias  
− Kidney injury 
− Cognitive impairment 
• Death 
Less serious, but more common risks and adverse events: 
• Low-blood pressure 
• Nausea and/or vomiting 
• Chills 
• Allergic response to device materials 
• Reduction in platelet count 
• Reduction in white blood cell count 
• Reduction in proteins (albumin, total protein) 
• Coagulation within device 
• Heparin-induced thrombocytopenia 
Potential Adverse Device Events Related to CytoSorb: 
• Removal of drugs and hormones 
• Allergic response to device materials 
• Reduction in platelet count 
• Reduction in white blood cell count 
• Reduction in proteins (albumin, total protein) which may increase with CPB duration.   
• Reductions in albumin may result in a reduction in serum calcium 

 
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• Coagulation within device 
• Infection 
• Blood loss 
• Hypothermia and chills 
• Hemolysis 
• Device leakage 
• Circuit leakage 
• Death  
8.8.4 Unanticipated Adverse Device Effect 
An unanticipated adverse device effect (UADE) is any serious adverse effect on health or safety 
or any life-threatening problem or death caused by, or associated with the device, if that effect, 
problem, or death was not previously identified in nature, severity, or degree of incidence in the 
investigational plan or application (including a supplementary plan or application), or any other 
unanticipated serious problem associated with a device that relates to the rights, safety, or 
welfare of subjects. 
8.8.5 Device Malfunction/Observations 
If there is a device malfunction or other observation with the CytoSorb device, the Investigator 
(or designee) is required to complete the Device Observation eCRF to notify the Sponsor 
immediately and indicate if the observation resulted in an adverse event and indicate if 
complications are related to the device, procedure or underlying disease.   
In the event of a suspected observation or device problem, the device shall be returned to the 
Sponsor for analysis.  Instructions for returning the investigational device are included in the 
Study Reference Manual. 
If the Investigator cannot determine the cause of the event, it should be classified as unknown. 
8.9 
Reporting Procedures 
8.9.1 Investigator Reporting 
The Investigator at each participating center is ultimately responsible for reporting adverse 
events to the Sponsor or its designee.  The information to be reported on the adverse event 
should include the start date of the adverse event, treatment, resolution, and assessment of both 
the seriousness and the relationship to the investigational device.  The Investigator (or designee) 
is required to complete the adverse event eCRF at each study visit if an adverse event occurs.  
One adverse event eCRF must be completed for each adverse event. Investigators must report 
SAEs/UADEs to the Sponsor within 24 hours of investigational site knowledge of event 

 
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occurrence by entering data into the eCRF. The Investigator should report all serious adverse 
events to the IRB as required. 
If there is a device malfunction or other observation, the Device Observation CRF requires the 
Investigator to notify the Sponsor within 24 hours, indicate if the observation resulted in an 
adverse event and indicate if complications are related to the device, procedure or underlying 
disease. 
In the event of a suspected observation or device problem, the device shall be returned to the 
Sponsor for analysis.  Instructions for returning the investigational device are included in the 
Study Reference Manual. 
8.9.2 Sponsor Reporting 
All adverse events will be reported to the regulatory authority/FDA at least annually. 
9. STUDY OVERSIGHT 
9.1 
Clinical Events Committee 
An independent group of physicians that are not involved in the clinical investigations will act as 
the Clinical Events Committee (CEC) under the direction of the CRO. The CEC will be 
responsible for the review and validation of reported potential ENDPOINT adverse events (i.e. all 
device/procedure related SAEs) that occur within 30 days post procedure per the CEC Charter. 
Policies and procedures governing the work of the CEC will be provided in a CEC Charter.  The 
CEC Charter will be developed prior to the start of study enrollment.   
9.2 
Data Monitoring Committee (DMC) 
The study will utilize a Data Monitoring Committee (DMC) which will be comprised of three (3) 
total members (2 physicians and a biostatistician) with relevant clinical/medical experience with 
the product and/or indication/disease under clinical investigation.  The primary role of the DMC is 
to oversee the safety of subjects enrolled into the study.  The membership of the committee will be 
independent from the investigative sites and study sponsor in order to reduce any potential for 
perception of bias and to remain free from potential conflicts of interest.  In order to oversee the 
safety of subjects as they are enrolled into the study, the DMC will establish a charter including a 
mission statement, operating procedures, and proposed monitoring criteria for the study, including 
any required interim analysis time points for assessing safety and proposed study stopping rules, if 
appropriate. The DMC will meet to ratify their operational charter within a reasonable timeframe 
relative to the enrollment of the first few subjects entering into the study.  Written 
recommendations from the DMC will be provided to the study sponsor. 
 

 
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9.3 
Central Laboratory 
A central laboratory shall be utilized to analyze some of the blood samples, and some of the urine 
samples collected in this study. The sample size and shipping requirements are provided to the 
sites in the Study Laboratory Manual.  All sites will be trained on the collection, preparation, and 
shipping requirements for central laboratory samples. 

 
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10. STUDY MONITORING 
The CRO will monitor and manage the data for the investigational study on behalf of the Sponsor, 
CytoSorbents, Inc. Some co-monitoring and remote data checking will also be done by Sponsor.  
A study specific monitoring plan will be created to ensure protocol compliance and applicable 
regulatory requirements. 
Clinical monitors will verify subject data and ensure compliance is consistent with Good Clinical 
Practice (GCP), clinical protocol and other study requirements, according to the guidelines per the 
Monitoring Plan, set forth in CROs monitoring Standard Operating Procedures (SOPs), and 21 
CRF Part 812. 
10.1 Monitor Training 
The Sponsor and/or designated monitors will be trained appropriately to monitor study progress 
including but not limited to the protocol and eCRFs, and per the Monitoring Plan.   
10.2 Site/Investigator Training 
The Sponsor and CRO shall be jointly responsible for providing training to the Investigator and 
appropriate clinical site personnel on the following topics: 
• Protocol  
• EDC/Database operations 
• Central Laboratory Requirements 
• CytoSorb® Device 
10.3 Site Monitoring 
Completed eCRFs will be verified by the monitor both at the investigational sites and remotely at 
regular intervals throughout the study.  The Investigator will allow the monitor and/or 
representative of the Sponsor, and any regulatory body to review and inspect the study files, 
subject eCRFs, subject medical records and other related study documents as required. 
All eCRFs will be reviewed for completeness and clarity.  Missing or unclear data will be 
investigated by the monitor and will be retrieved, clarified and entered by study personnel as 
necessary throughout the study. CytoSorbents, Inc., or their authorized representative may request 
additional documentation from the Investigator such as physician procedure notes or physician 
written summaries when adverse events are observed and reported. 
 
 

 
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10.4 Regulatory Agency Inspection 
In the event that an Investigator is contacted by a regulatory agency regarding this study, the 
Investigator will notify the Sponsor or its designee immediately.  The Investigator and research 
coordinator must be available to respond to reasonable requests and queries made during the 
inspection process.  The Investigator must provide the Sponsor or designee with copies of all 
correspondence that may affect the review of the current trial (e.g., Form FDA 483, Inspectional 
Observations and Warning Letters).  The Sponsor may provide needed assistance in responding to 
regulatory audits. 
11. STATISTICAL CONSIDERATIONS 
General statistical considerations:  Descriptive statistics will be the mean, standard deviation, 
median, minimum and maximum for continuous variables and count and percent of patients for 
categorical variables.  Statistical analyses will be carried out using SAS Version 9.4 or later and/or 
the R software language. 
11.1 Analysis Populations 
Intent-to-Treat (ITT):  All randomized patients. 
Modified Intent-to-Treat (mITT):  All randomized patients who meet all inclusion criteria through 
the completion of the surgical procedure.  There are two mITT analysis sub-populations defined as 
follows:    
• The primary sub-population includes all subjects enrolled and randomized to the treatment 
group who are undergoing valve replacement with another procedure (e.g., CABG, valve 
replacement) without Hypothermic Circulatory Arrest (HCA).  This is the primary 
population for efficacy analyses. 
• The secondary sub-population consists of all surgical subjects enrolled and randomized to 
the treatment group who are undergoing aortic reconstructions with or without other 
procedures (e.g., CABG, valve replacement) with HCA.  This is a secondary population for 
efficacy analyses. 
The primary analyses on the primary efficacy endpoint will be performed on these subpopulations.  
Subjects will be analyzed according to the treatment to which they were randomized. 
 
Safety:  Comprised of all roll-in and randomized subjects in whom treatment was attempted.  
Safety analysis will be performed on this population; it will also be performed separately on the 
above mITT populations.  Patients will be summarized according to the actual treatment received.   
 

 
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Per Protocol (PP):  Defined as the subset of patients in the mITT sub-population who had no major 
protocol violations.  Efficacy analyses on the two PP sub-populations will be considered 
secondary.  Patients will be analyzed by actual treatment received.  
 
Roll in patients are not randomized and are only included in the safety population. 
11.1.1 Safety and Tolerability Evaluations: 
The following analyses will be conducted on the Safety population and the two mITT sub-
populations. 
Continuous safety data will be summarized with descriptive statistics (arithmetic mean, 
standard deviation [SD], median, minimum, and maximum) by treatment group.  
Categorical safety data will be summarized with frequency counts and percent of patients 
by treatment group.  Adverse events (AEs) will be coded using the most current Medical 
Dictionary for Regulatory Activities (MedDRA®) available.  A by-participant AE data 
listing, including verbatim term, preferred term, system organ class, treatment, severity, 
and relationship to study device will be provided. The number and percent of participants 
experiencing procedure and device related AEs and serious AEs will be summarized by 
treatment group, system organ class, and preferred term.   
Laboratory evaluations and vital signs assessments will be summarized by treatment group 
and protocol specified collection time point.  A summary of change-from-baseline at each 
protocol specified time-point by treatment group will also be presented.  "Shift Tables" will 
be provided to summarize count and percent of patients with changes from baseline normal 
range status (below, within, above) to on/post-treatment normal range status. 
Further details regarding presentation and analysis of safety data will be detailed in the 
statistical analysis plan (SAP). 
11.1.2 Effectiveness evaluations: 
The primary endpoint will be assessed in each modified intent-to-treat (mITT) population 
in step-wise fashion beginning with the primary sub-population.  If a significant beneficial 
effect is met for CytoSorb over control at a one-sided overall 0.025 level of significance, 
then the study will be considered to be a primary endpoint statistical success on this sub-
population and testing will proceed to the secondary sub-population.  Otherwise the study 
will be considered to have statistically failed the primary endpoint.   
We have selected to use a modified intent-to-treat population (mITT) population to avoid 
the consequence of including patients that were excluded from the study after 
randomization due to administrative reasons.   

 
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Use of the mITT population as defined is not anticipated to result in bias or informative 
censoring of the data.  
The primary endpoint (rank order presence and severity of AKI) will be compared between 
treatments with Wilcoxon Rank Sum test.  Continuous endpoints will be assessed via 
ANCOVA with baseline value as covariate.  Binary endpoints will be assessed via 
unconditional exact binomial test.  The primary endpoint will be summarized by subgroup 
factors, e.g., those who receive IV contrast within 48 hours prior to surgery versus those 
who do not.  Additionally, subgroup-by-treatment interaction may be tested via generalized 
ordered categorical model and/or for binary combinations of outcomes (e.g., presence / 
absence of any AKI, and/or severe AKI) by logistic regression.  Details will be in the SAP. 
11.2 Statistical Power and Sample Size Determination 
The REFRESH II study hypothesis is that, for patients at increased risk for AKI based upon use of 
the Cleveland Clinic Score for stratification of the risk of cardiac surgery associated AKI (CSA-
AKI), the intra-operative usage of the CytoSorb device in addition to the standard of care in a 
bypass circuit during cardiopulmonary bypass will decrease the overall incidence and/or 
proportion of acute kidney injury (AKI) by stage as defined by the Kidney Disease Improving 
Global Outcomes (KDIGO) clinical practice guideline definition of acute kidney injury.  The AKI 
Stage is scored as 0, 1, 2 or 3.  AKI Stage of 0 indicates no AKI, and AKI stages 1, 2 and 3 
indicate mild, moderate, and severe AKI, respectively.  Success will be defined by demonstrating a 
shift in distribution toward overall less severe AKI or fewer incidences of AKI in the CytoSorb 
population.   
The distribution of AKI Stage (0, 1, 2, 3) expected in the control group was estimated from prior 
data.  Sample trial outcomes for which power was computed are summarized in Error! Reference s
ource not found. below for total N=267 patients in the primary analysis subgroup ("without 
HCA", randomized 1:1).  The proportion of "without HCA" patients will be at least 2/3 of the total 
sample size 400.  420 patients will be enrolled to account for an expected 5% premature 
withdrawal rate.  Power was computed for comparing binomial proportions of patients with AKI 
Stage 1, 2, or 3 (or i.e., any AKI); proportions with AKI Stage 2 or 3; and for an ordered 
categorical rank test comparing the distribution of AKI Stages 0, 1, 2, 3 between treatments.  Since 
it is uncertain whether CytoSorb will lower the overall AKI rate or that of Stages 2 and 3, the 
ordered categorical test will be primary, i.e., the primary null and alternative hypotheses are 
• H0: π00= π01, π10= π11, π20= π21, π30= π31 
• H1: {π30 ≥ π31 and/or (π20+ π30) ≥ (π21+ π31) and/or (π10+ π20+ π30) ≥ (π11+ π21+ 
π31)} AND one or more of the above is strictly “>” 
where πi0 is the proportion of control patients in AKI level i (i=0, 1, 2 and 3) and where πi1 is the 
proportion of CytoSorb patients in level i.  Note that level i=0 is no AKI.  The test of the null 

 
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hypothesis will be carried out at an overall one-sided 0.025 level of significance using a one-sided 
Wilcoxon Rank Sum test, taking into account the interim analyses as described below.    
11.2.1 Interim Analyses 
Specifically, since the treatment difference could be larger or smaller than expected, interim 
analyses will be carried out for potential (NON-BINDING) early stopping for an efficacy or 
futility conclusion.  
Note that the BLINDED combined AKI incidence rate will be monitored throughout the trial to 
inform on enrichment with patients at higher risk of AKI so as to yield sufficient AKI events to 
improve the expected precision of the treatment comparison. 
 
Table 5: Overall Power for the ordinal outcome, the Any AKI dichotomous outcome (labeled 
Stages 1,2,3 below), and the Moderate/Severe AKI dichotomous outcome (labeled Stages 2,3 
below). 
  
Percent of Patients with Indicated AKI Stage 
AKI Stage --> 
0= no 
AKI 
Stage 
1 
Stage 
2 
Stage 
3 
Stages 1,2,3 
Stages 
2,3 
  
Example 1 
(total 
N=267) 
CytoSorb 
36% 
53% 
10% 
1% 
64% 
11% 
Control** 
24% 
47% 
26% 
3% 
76% 
29% 
power* --> 
0.93 
0.57 
0.96 
  
Example 2 
(total 
N=267) 
CytoSorb 
44% 
40% 
14% 
2% 
56% 
16% 
Control** 
24% 
47% 
26% 
3% 
76% 
29% 
power* --> 
0.96 
0.94 
0.72 
* power to yield statistically significant (alpha=0.025 1-sided) difference between treatments 
with total N "without HCA" patients randomized 1:1 
 
Note that the dichotomous outcomes will be considered secondary.  The Table 5 power 
calculations do not consider the planned interim analyses.  They are presented for reference, and to 
demonstrate the rationale for the primary analysis method based on the ordinal outcome.  Note that 
for example 1, had the primary endpoint been the dichotomous outcome any AKI, power would 
have been only 57%.  For example, 2, had the primary endpoint been the dichotomous outcome 
moderate/severe AKI, power would have been only 72%.  For both examples 1 and 2, power is 
over 90% via the ordinal outcome. 

 
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Simulations were carried out for a Group Sequential Design (GSD) planned for Total N=267 
"without HCA" patients (randomized 1:1), with Interim Analyses (IA) after AKI status (Stage 
0,1,2,3) is determined for 138 (IA1 at ½ total N) and N=200 (IA2 at ¾ total N).  NON-BINDING 
early stopping for efficacy is considered if p<0.001 at IA1 or IA2; and NON-BINDING early 
futility stopping is considered if the Conditional Power (CP) is less than 5%. The final analysis 
requires p<0.0247 1-sided in order to control the overall type 1 error at 0.025 1-sided. 
NOTE: CP is the probability of a statistically significant (alpha=0.0247 1-sided) at the final 
analysis (N=267) if the TRUE underlying between-treatment difference is equal to that observed at 
the IA.  These p-value boundaries for efficacy conclusions control the overall type 1 error at 0.025 
1-sided.   
11.2.1.1 Biomarker Interim Review 
A review of biomarker results will be completed at the time of the interim analysis.  If insufficient 
data exist to enable detection of treatment effect, then the number of patients providing biomarkers 
may be increased.  Methods used to determine the required biomarker sample size increase along 
with the revised number for patients will be detailed in an amendment to the protocol following the 
analysis. 
11.2.2 Sample Size Re-estimation 
An option to increase sample size (SSR, i.e., Sample Size Re-estimation) is also considered.   SSR 
is based on the IA2 results using CP to estimate the sample size necessary to boost the CP to 88%, 
assuming the observed response proportions are the TRUE underlying proportions.  CP is the 
probability of a significant result at final analysis assuming the observed response proportions are 
the TRUE underlying ones.  The design works as follows at the IA: 
• If CP<5%, the trial MAY be stopped for futility 
• If p<0.001 1-sided, the trial MAY be stopped for an early efficacy conclusion 
• If 5% ≤ CP < 50% (unfavorable zone), the trial continues to the planned N=267 
• If 50% ≤ CP < 88% (promising zone), sample size is increased to that required to boost CP 
to 88% 
o If that sample size exceeds N=333, the trial continues to that N=333 
• If CP ≥ 88% and p>0.001 1-sided (favorable zone), the trial continues to N=267 subjects, 
as originally planned 
This is the "promising zone" sample size re-estimation (SSR) design of Mehta & Pocock (2011)44, 
which uses the work of Chen, DeMets, Lan (2004)45 to justify preservation of type 1 error for the 
final analysis based on the combined data from the entire trial.  The power and performance 
characteristics based on 10,000 simulations of this design are summarized in Table 6 below for 6 
TRUE underlying scenarios and associated analyses based on either the binary endpoint of 

 
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proportion of patients with AKI or the corresponding ordered categorical test, each via normal 
approximation.  [NOTE: power and design performance characteristics were computed via Cytel's 
EAST software, which uses normal approximation for GSD calculations and adaptive design 
simulations.  The actual treatment group comparisons on the primary endpoint will be using the 
Wilcoxon Rank Sum test using the GSD stopping boundaries mentioned above; details to be 
specified in the SAP; treatment group comparisons on the dichotomous endpoints will be carried 
out using the chi-square test.] Effect Size (mean difference divided by SD) was computed for the 
two categorical distributions in the table above.  The binary endpoint differences also correspond 
to those of AKI Stages 1, 2, 3 and AKI Stages 2, 3 in Table 5 above.  Note that the ordered 
categorical test preserves the power at over 80% for both distributions, whereas the power for 
binary rate differences less than 0.15 is much less than 80%. 
For the Scenario A in the table below, the statistical design described above was simulated 10,000 
times with responses generated from TRUE underlying response rate 0.76 for control and 0.61 for 
CytoSorb.  92% of those simulations yielded a resultant p-value at one of the 3 analysis (IA1, IA2, 
or final analysis) that was lower than the boundary for that analysis (p<0.001 1-sided for IA1 and 
IA2, and p<0.0247 for the final analysis).  If there was no efficacy conclusion at IA1 and IA2 and 
the IA2 result was "promising" (i.e., 50% ≤ CP < 88%), then the sample size was increased to 
boost CP toward 88%, resulting in power to 97% for those IA2 outcomes.  The average “without 
HCA” sample size across the 10K simulations was 221, and 320 for the subset of simulations that 
yielded a CP in the promising zone.  3% of the simulations yielded a futility result at IA1, 1% at 
IA2, and 4% at the final analysis.  25% of simulations yielded p<0.001 1-sided at IA1 and 22% at 
IA2; 46% of simulations yielded p<0.0247 1-sided at the final analysis.  6% of the simulations 
proceeded past IA2 with IA2 result in the "unfavorable" zone (5% ≤ CP < 50%); 12% in the 
"promising" zone (50% ≤ CP < 88%); and 32% in the "favorable" zone (CP ≥ 88% and IA2 p-
value > 0.001 1-sided).  Those proportions of outcomes represent the estimated probabilities of 
those outcomes for the actual trial. 
Scenarios A, B, C, and D represent GSD+SSR design options based on the proportions of patients 
with AKI (A & B corresponding to Example 1 in Table 5) or with severe AKI (C and D 
corresponding to Example 2 in Table 6); Scenarios E and F (corresponding to the ordered 
categorical examples 1 and 2 in Table 6) represent GSD+SSR design options based on the ordinal 
AKI Stage 0,1,2,3 endpoint.  All scenarios were assessed via normal approximation to those 
respective distributions as listed below in Table 6. 
 
 

 
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Table 6: Performance Characteristics for Group Sequential Design with Sample Size Re-
Estimation Option for binary and ordinal AKI endpoint 
Scenario--> 
A 
B 
C  
D 
E 
F 
TRUE underlying AKI rate control 
0.76 
0.76 
0.29 
0.29 
  
  
TRUE underlying AKI rate CytoSorb 
0.56 
0.64 
0.11 
0.16 
  
  
TRUE underlying Effect Size (ordinal) 
  
  
  
  
0.39 
0.42 
overall power (alpha=0.025 1-sided) 
0.92 
0.55 
0.96 
0.70 
0.88 
0.92 
power if IA2 promising 
0.97 
0.83 
0.97 
0.87 
0.93 
0.95 
average sample size  
221 
237 
215 
243 
227 
219 
average sample size (if IA2 promising) 
320 
323 
318 
322 
324 
324 
Probability of "futility" at IA1 
0.03 
0.19 
0.01 
0.11 
0.05 
0.03 
Probability of "futility" at IA2 
0.01 
0.07 
<0.01 
0.05 
0.02 
0.01 
Probability of "futility" at Final Analysis 
0.04 
0.19 
0.02 
0.14 
0.05 
0.04 
Probability of "efficacy" at IA1 
0.25 
0.05 
0.28 
0.08 
0.21 
0.26 
Probability of no "efficacy" at IA1 but 
efficacy IA2 
0.22 
0.06 
0.25 
0.10 
0.19 
0.22 
Probability "efficacy" at Final Analysis 
0.46 
0.44 
0.43 
0.53 
0.48 
0.44 
Probability IA2 unfavorable 
0.06 
0.21 
0.06 
0.16 
0.09 
0.07 
Probability IA2 promising 
0.12 
0.18 
0.09 
0.19 
0.14 
0.12 
Probability of no “efficacy” at IA2 but 
IA2 favorable 
0.32 
0.24 
0.31 
0.31 
0.30 
0.29 
11.3 Study Success 
An individual study subject will be defined as a success if during the 48 hours following surgery, 
they do not receive a diagnosis of AKI by the KDIGO Guidelines. In contrast, a patient whose 
clinical parameters result in a diagnosis of AKI will be classified according to AKI stage.  Study 
success will be defined by demonstration of a statistically significant shift in distribution of AKI 
Stages 0, 1, 2, 3 toward less severe and/or no AKI with CytoSorb in comparison to standard of 
care.  
11.4 Treatment of Missing or Spurious Data 
Multiple imputation methodology will be used for missing data imputation; details will be in the 
SAP.  
11.5 Disposition and Baseline Characteristics 
Number and percent of patients discontinuing prematurely from the study will be provided by 
treatment group and by reason discontinued.  All data for background and demographic variables 
will be listed by treatment group and subject. Summary statistics will be provided by treatment 
group.  Relevant medical history, current medical conditions, results of laboratory screens, and any 

 
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other relevant information will be summarized by treatment group and listed by treatment group 
and subject 
12. DATA HANDLING AND RECORD KEEPING 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH E6 Section 4.9 and regulatory and institutional requirements for the 
protection of confidentiality of subjects.  As part of participating in a manufacturer-sponsored 
study, each site will permit authorized representatives of the sponsor(s), the sponsor’s designee, 
and regulatory agencies to examine (and when required by applicable law, to copy) clinical records 
for the purposes of quality assurance reviews, audits, and evaluation of the study safety and 
progress. 
Source data are all information, original records of clinical findings, observations, or other 
activities in a study necessary for the reconstruction and evaluation of the trial. 
The Investigator is responsible for ensuring the accuracy, completeness, legibility, and timeliness 
of the data reported.  All source documents should be completed in a neat, legible manner to 
ensure accurate interpretation of data. 
12.1   Data Management Procedures 
Electronic Case Report Forms (eCRFs) will be used to collect all subject data during the course of 
the study, which are part of a database that meets 21 CFR Part 11 requirements. eCRFs must be 
fully completed for each subject and electronically signed by the Investigator when complete.  
Federal Regulations and Good Clinical Practice Guidelines require that Investigators maintain 
information in the study subject’s medical records that corroborate data collected on the eCRFs.  In 
order to comply with these regulatory requirements, the following information should be 
maintained: 
• Medical history/physical condition of the study subject before involvement in the study 
sufficient to verify protocol entry criteria. 
• Dated and signed notes on the day of entry into the study including the study Investigator, 
study name, subject number assigned and a statement that consent was obtained. 
• Dated and signed notes from each study subject visit with reference to the CRFs for further 
information, if appropriate (for specific results of procedures and exams). 
• Information related to adverse events. 
• Study subject’s condition upon completion of or withdrawal from the study. 
• Discharge summaries/procedure reports. 

 
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12.2   Data Retention 
Maintenance of study records should be maintained for a period of two (2) years after the latter of 
two occurrences: 
1. The date when the investigation is terminated or completed, or 
2. The date that the records are no longer needed to support a premarket approval (PMA). 
These documents should be retained for a longer period, however if required by local regulations.  
No records will be destroyed without the written consent of the sponsor, if applicable.  It is the 
responsibility of the Sponsor to inform the Investigator when these documents no longer need to be 
retained. 
12.3   Investigator Records 
Investigators will maintain complete, accurate and current study records.  Investigator records shall 
include the following materials: 
• Correspondence: All significant correspondence with another investigator, an IRB, the 
sponsor, a monitor, or FDA, including required reports.  
• Subject Records: Signed informed consent forms, copies of supporting documents 
(laboratory reports, reports of diagnostic tests, medical records, etc.) and records of 
exposure of each subject to the device.  Informed consent must comply with FDA 
regulations (21 CFR, part 50). 
• Clinical Investigational Plan/Protocol: A current copy of the Clinical Study Protocol and 
amendments including Instructions for Use of the CytoSorb® and copies of the eCRFs. 
• Institutional Review Board (IRB) Information: All information pertaining to IRB review 
and approval of this clinical study including a copy of the IRB letter approving the clinical 
study, a blank informed consent form approved by the IRB, and certification from the IRB 
Chairman that the IRB complies with FDA regulations (21CFR, Part 56), and that the IRB 
approved the clinical study protocol based on the Report of Prior Investigations. 
• Investigator Agreements: Copies of the signed Investigator, Sub-Investigator Agreements 
with accompanying curriculum vitae. Signed Protocol pages. 
• Study documents including Investigational Device Accountability logs (including device 
shipment list/packing lists), Screening and Enrollment Logs, Site Visit Log, 
• Other: Any other records that may be required by applicable state or federal laws. 
 
 

 
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12.4   Investigator Reports 
The Investigator will prepare and submit the following reports: 
Table 7. Responsibilities for Preparing and Submitting Reports 
Type of Report 
Prepared by Investigator 
for 
Time of Notification 
Enrollment Notification eCRF 
Sponsor 
Within 24 hours of the subject 
signing the ICF 
Completion of eCRFs  
Sponsor 
Within 14 working days 
Serious/ Unanticipated Adverse 
Event eCRF 
Sponsor and IRB (as 
required) 
Within 24 hours of knowledge or as 
required by IRB 
Adverse Event (device related or 
not) eCRF 
Sponsor and IRB (as 
required) 
Within 10 working days or as 
required by IRB 
Device malfunction or device 
observation eCRF 
Sponsor 
Within 24 hours of knowledge 
Subject Death 
Sponsor and IRB (as 
required) 
Within 24 hours of knowledge 
Subject Withdrawal 
Sponsor 
Within 24 hours of knowledge 
Withdrawal of IRB or FDA 
Approval 
Sponsor 
Within 24 hours of knowledge 
Protocol Deviations due to 
medical emergencies 
Sponsor and IRB 
Within 24 hours of occurrence or 
knowledge 
Protocol Deviations 
Sponsor and IRB (as 
required) 
Within 5 business days of knowledge 
Informed Consent Not Obtained Sponsor and IRB 
Within 24 hours of knowledge 
Final study report (site) 
Sponsor and IRB 
At time of study closure at site 
Final summary report 
Sponsor, IRB and FDA 
Within six months of study 
completion 
 
 
 

 
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13. QUALITY CONTROL AND ASSURANCE 
13.1   Site and Investigator Selection 
The Sponsor selects qualified investigators with appropriate experience at health care facilities 
with adequate resources to participate in this study.  The investigational sites will be selected using 
combined current assessments of site and investigator qualifications. 
13.2   Protocol Deviations 
An Investigator is not allowed to deviate from the Protocol without the prior written approval of 
the Sponsor, or where there are concerns of patient safety.  Under emergency circumstances, 
deviations from the Protocol to protect the rights, safety and well-being of human subjects may 
proceed without prior approval of the sponsor and the IRB.  Such deviations shall be documented 
and reported to the sponsor and the IRB (as required) as soon as possible. 
A protocol deviation is a failure to comply with the requirements specified within this clinical 
study protocol.  Examples of protocol deviations may include enrollment of a study subject who 
does not meet all of the inclusion/exclusion criteria specified in the protocol, visits performed 
outside of the protocol specified visit window, and missed study visits.  Each investigator shall 
conduct this clinical study in accordance with this clinical study protocol, regulatory body 
regulations, Good Clinical Practices, and any conditions of approval imposed by their IRB.  
All deviations are reviewed and assessed for their impact on subject safety by the Sponsor or 
designee.  The PI and study staff are responsible for knowing and adhering to their IRB reporting 
requirements. 
The protocol deviations for this protocol consist of, but not limited to the following: 
• Failure to obtain subject’s informed consent prior to any study-related activities; 
• Failure to conduct protocol required clinical follow-ups; 
• Failure to conduct protocol required clinical follow-ups within time windows; and, 
• Failure to report serious adverse events according to protocol requirements. 
In the event of any deviation from the protocol, the Investigator will be notified of the site’s non-
compliance.  Corrective actions will be required, if necessary.  Continued protocol deviations 
despite re-education of the study site personnel or persistent protocol deviation may result in 
termination of the site’s study participation.  Subjects enrolled at these sites will continue to be 
followed per the clinical protocol. 
13.3   Protocol Deviation Process 
Investigators must report protocol deviations to the Sponsor within five working days of 
investigational site knowledge of the deviation by entering data into the Case Report Form.  Any 

 
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protocol deviations that affect the rights, safety or well-being of the subject or the scientific 
integrity of the clinical investigation, including those which occur under emergency circumstances 
must be reported within 24 hours to the Sponsor and IRB if required by the IRB. 
13.4   Corrective/Preventive Action 
The Sponsor reserves the right to terminate an investigational site from the study for any of the 
following reasons: 
• Repeated failure to complete Electronic Case Report Forms 
• Failure to obtain Informed Consent 
• Failure to report Serious Adverse Events within 24 hours of knowledge 
• Loss of or unaccountable investigational device inventory 
• Repeated protocol violations 
• Failure to enroll an adequate number of subjects 
14. ETHICS/PROTECTION OF HUMAN SUBJECTS 
14.1 Statements of Compliance 
This clinical investigation shall be conducted in accordance with the ethical principles that have 
their origin in the Declaration of Helsinki, and 21 CFR Part 812, 50, 54, 56. 
The clinical investigation shall not begin until the required approval from the IRB has been 
obtained, if appropriate. 
Any additional requirements imposed by the IRB, or regulatory authority shall be followed. 
14.2  Institutional Review Board (IRB) 
Each participating institution must provide for the review and approval of this protocol and the 
associated informed consent documents and recruitment material by an appropriate IRB.  Any 
amendments to the protocol or consent materials must also be approved before they are placed into 
use. 
14.3   Informed Consent Process 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout an individual’s study participation.  Extensive discussion of risks 
and possible benefits of this therapy will be provided to the subjects and their families. Consent 
forms describing in detail the study interventions/products, study procedures, and risks are given to 
the subject and written documentation of informed consent is required prior to starting 

 
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intervention/ administering study product.  Consent forms will be IRB-approved, and the subject 
will be asked to read and review the document.  Upon reviewing the document, the Investigator 
will explain the research study to the subject and answer any questions that may arise.  The subject 
will sign an informed consent document prior to any procedures being done specifically for the 
study.  The subject should have the opportunity to discuss the study with their surrogates or think 
about it prior to agreeing to participate, unless study timeframes do not allow for such discussions.  
The subjects may withdraw consent at any time throughout the course of the trial.  A copy of the 
informed consent document will be given to the subjects for their records.  The rights and welfare 
of the subjects will be protected by emphasizing to them that the quality of their medical care will 
not be adversely affected if they decline to participate in this study. 
When informed consent of the subject is not possible because of the subject’s medical condition, 
the informed consent of the legally authorized representative, if present, shall be requested.   
If informed consent is not obtained prior to any research procedures being conducted, the 
investigative site must notify the Sponsor and its IRB within 24 hours of knowledge of the 
incident.  
14.3.1 Subjects Unable to Read or Write 
Informed consent shall be obtained through a supervised oral process if the patient or legally 
authorized representative is unable to read or write. An independent witness shall be present 
throughout the process.  The written informed consent form and any other information shall be 
read aloud and explained to the prospective patient or his/her legally authorized representative 
and, whenever possible, shall sign and personally date the informed consent form. The witness 
also signs and personally dated the informed consent form attesting that the information was 
accurately explained, and that informed consent was freely given. 
14.3.2 New Information 
If new information becomes available, that can significantly affect a patient's future health and 
medical care, which information shall be provided to the patient(s) affected in written form.  If 
relevant, all affected subjects shall be asked to confirm their continuing informed consent in 
writing. 
14.4 Patient Confidentiality 
Confidentiality of data shall be observed by all parties involved at all times throughout the clinical 
investigation. All data shall be secured against unauthorized access. 
The privacy of each subject and confidentiality of his/her information shall be preserved in reports 
and when publishing any data.  The Principal Investigator or institution shall provide direct access 
to source data during and after the clinical investigation for monitoring, audits, IRB review and 
regulatory authority inspections. As required, the Principal Investigator or institution shall obtain 

 
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permission for direct access to source documents from the subject, hospital administration and 
national regulatory authorities before starting the clinical investigation. 
15. PROTOCOL AMENDMENTS 
The Protocol, CRFs, ICF and other patient information, or other clinical investigation documents 
shall be amended as needed throughout the clinical investigation, and a justification statement shall 
be included with each amended section of the document.  Proposed amendments to the Protocol 
shall be agreed upon between the Sponsor and Principal Investigator, or the coordinating 
investigator.  The amendments to the Protocol and the subject’s informed consent form shall be 
notified to, or approved by, the IRB and regulatory authorities as required.  For non-substantial 
changes [e.g. minor logistical or administrative changes, change of monitor(s), telephone numbers, 
renewal of insurance] not affecting the rights, safety and well-being of human subjects or not 
related to the clinical investigation objectives or endpoints, a simple notification to the IRB and, 
where appropriate, regulatory authorities can be sufficient.  The version number and date of 
amendments shall be documented. 
16. TERMINATION OF STUDY OR STUDY SITE PARTICIPATION 
The Sponsor may terminate the study at any time.  If the study is terminated prior to the 
completion of expected enrollment for any reason, all participating centers will be notified within 
five working days.  All subjects already enrolled will continue to be followed for the planned 
course of study described in this protocol.  The study shall be terminated following the final 
follow-up visit of the last enrolled patient. 
The Sponsor reserves the right to terminate study site participation and remove appropriate study 
materials at any time.  Specific instances that may precipitate such termination include but are not 
limited to the following: 
• Failure to meet minimum patient enrollment requirements 
• Failure to comply with protocol specified procedures and documentation 
• Failure to comply with Good Clinical Practice 
 
The site Investigator may also discontinue study participation with suitably written notice to the 
Sponsor. 
17. PUBLICATION POLICY 
REFRESH II Study Publication Policy 

 
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CytoSorbents manages its clinical studies in an ethical and rigorously scientific manner, working 
with leading experts in the field, to clearly and publicly demonstrate the benefits, risks, and value 
of the CytoSorb Device to caregivers and study patients alike.  We accept the obligation to 
facilitate publication of medically important clinical data in a timely, objective, accurate, and 
balanced manner, regardless of the outcome of this trial.  To ensure that an accurate record of the 
study data is presented to the public, CytoSorbents understands the need to allow sufficient time 
for careful preparation, analysis, interpretation, and review of study data and reports prior to their 
dissemination. 
17.1 Method and Timing of Release of Prespecified Clinical Endpoint Results from the 
REFRESH II Clinical Study  
o Safety and Efficacy Data generated for all prespecified primary and secondary 
endpoints, shall be compiled, analyzed, reviewed, and published in the following 
manner: 
o Per Section 12.4 of the REFRESH II Protocol, the REFRESH II Principal Investigator 
shall compile and disseminate a clinical summary report that shall be disseminated to 
CytoSorbents (as Sponsor), all participating local and central IRBs, and the FDA. Data 
from this Summary Report shall also be published on the ClinicalTrials.Gov website 
simultaneously. 
o Following database closure, a study publication shall be submitted to a peer reviewed 
journal within 18 months of database closure. In the event that the study is terminated 
early, a publication of this data will be submitted within 12 months of database closure. 
 
 

 
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