Unacylated Ghrelin to Improve FuncTioning in PAD: The GIFT Trial
Phase: PHASE1
Conditions: Peripheral Artery Disease, PAD, Peripheral Arterial Disease
Sponsor: Northwestern University

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 1 of 32
PROTOCOL TITLE:
Unacylated Ghrelin to Improve FuncTioning in PAD:  the GIFT Trial.
PRINCIPAL INVESTIGATOR:
Mary McDermott, MD
Department of General Internal Medicine
312-503-6419
mdm608@northwestern.edu
VERSION NUMBER:
Version #7.
VERSION DATE:
4.4.17
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 2 of 32
Table of Contents
1.0
Objectives .................................................................................................................3
2.0
Background...............................................................................................................4
3.0
Inclusion and Exclusion Criteria ..............................................................................7
4.0
Study-Wide Number of Subjects..............................................................................8
5.0
Study-Wide Recruitment Methods ...........................................................................8
6.0
Multi-Site Research ..................................................................................................8
7.0
Study Timelines........................................................................................................8
8.0
Study Endpoints......................................................................................................10
9.0
Procedures Involved ...............................................................................................10
10.0
Data and Specimen Banking...................................................................................15
11.0
Data and Specimen Management ...........................................................................16
12.0
Provisions to Monitor the Data to Ensure the Safety of Subjects...........................17
13.0
Withdrawal of Subjects*.........................................................................................17
14.0
Risks to Subjects*...................................................................................................18
15.0
Potential Benefits to Subjects .................................................................................19
16.0
Vulnerable Populations...........................................................................................20
17.0
Community-Based Participatory Research.............................................................20
18.0
Sharing of Results with Subjects ............................................................................20
19.0
Setting.....................................................................................................................20
20.0
Resources Available ...............................................................................................20
21.0
Prior Approvals.......................................................................................................21
22.0
Recruitment Methods..............................................................................................21
23.0
Local Number of Subjects ......................................................................................23
24.0
Confidentiality ........................................................................................................23
25.0
Provisions to Protect the Privacy Interests of Subjects ..........................................23
26.0
Compensation for Research-Related Injury............................................................24
27.0
Economic Burden to Subjects.................................................................................24
28.0
Consent Process......................................................................................................24
29.0
Process to Document Consent in Writing...............................................................25
30.0
Drugs or Devices ....................................................................................................25
31.0    References………………………………………………………………………...26
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 3 of 32
1.0
Objectives
1.1
Purpose/ Objectives.
This pilot study will investigate the optimal subcutaneous dose and the 
therapeutic potential of unacylated ghrelin to improve peripheral artery disease 
(PAD)-related brachial artery flow mediated dilation and reduce inflammation.  
Ghrelin is a peptide and hormone that is primarily produced by P/D1 cells of the 
gastric fundus and circulates in both acylated and unacylated forms.  Acylated 
ghrelin acts on the Growth Hormone Secretagogue Receptor (GHSR), increasing 
growth hormone levels, appetite, and insulin resistance (1-4).   Unacylated ghrelin 
was originally thought to be an inactive metabolite.  However, recent evidence 
shows that unacylated ghrelin promotes skeletal muscle cell regeneration, 
improves mitochondrial function, and increases skeletal muscle capillary density 
(5-7).  Unacylated ghrelin also improves brachial artery flow-mediated dilation in 
humans (8).   Unacylated ghrelin has been studied in more than 70 healthy 
humans without adverse effects (4,8-14).  Unacylated ghrelin does not act on 
GHSR and does not increase appetite, or cause insulin resistance (4,8-14).  
However, unacylated ghrelin has never been studied in people with PAD.  In 
addition, unacylated ghrelin has never been administered in a subcutaneous form 
to humans.
The pilot GIFT Trial will obtain preliminary evidence to identify the optimal dose 
of subcutaneously administered unacylated ghrelin in people with PAD. The 
results of this pilot study may be used to design a randomized trial of unacylated 
ghrelin, in subsequent study, to improve functioning and prevent mobility loss in 
older people with PAD.  
Specific Aim.  Because subcutaneously administered unacylated ghrelin has not 
been studied in humans, we will establish the association of increasing doses of 
subcutaneous unacylated ghrelin with circulating levels of unacylated ghrelin and 
brachial artery flow-mediated dilation (FMD) and levels of circulating 
inflammatory biomarkers.  To achieve this aim, six PAD participants age 55 and 
older will receive a single subcutaneous injection of unacylated ghrelin at doses of 
10 ug/kg, 20 ug/kg, and 40 ug/kg, respectively, on three separate days at least one 
week apart.  Unacylated ghrelin levels will be measured at baseline and at defined 
intervals after each subcutaneous injection (30 minutes, 60 minutes, 1.5 hours, 3 
hours, 6 hours, 8 to 12 hours and 24 hours).  Brachial artery FMD will be 
measured at baseline, before the unacylated ghrelin injection, approximately six to 
eight hours, and 24 hours after each unacylated ghrelin injection (8).  Circulating 
levels of inflammatory biomarkers will be measured at baseline and at six hours, 
8-12 hours, and 24 hours after the subcutaneous injection of unacylated ghrelin.  
The lowest dose of subcutaneously delivered unacylated ghrelin that maximizes 
brachial artery FMD, maximizes levels of unacylated ghrelin, and minimizes 
circulating levels of inflammatory biomarkers will be used in future study. 
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 4 of 32
Specific Aim 2. We will assess the safety of increasing doses of unacylated 
ghrelin in six patients with PAD age 55 and older. 
1.2
Hypotheses.
We hypothesize that unacylated ghrelin, administered subcutaneously, will 
increase brachial artery flow-mediated dilation (FMD) and reduce circulating 
levels of inflammatory biomarkers and that higher doses of subcutaneously 
administered unacylated ghrelin will be associated with greater increases in 
brachial artery FMD and lower circulating levels of inflammatory biomarkers.  
2.0
Background
2.1
Relevant experience.
A. Lower extremity peripheral artery disease (PAD) affects 10-15% of 
community dwelling men and women age 65 and older (15-17) and will be 
increasingly prevalent as the U.S. population survives longer with chronic 
disease.  Our prior work demonstrates that men and women with PAD have 
greater functional impairment and more rapid functional decline than those 
without PAD (15,18-24).  The functional impairment documented in PAD is 
associated with loss of independence, increased mortality, and poor quality of 
life (22,25-27).  Recent evidence shows that chronic disability, such as that 
associated with PAD, accounts for more than half of United States health 
burden (28). Furthermore, therapeutic advances have not kept pace with the 
growing burden of disability from chronic disease (28).  Only two 
medications, pentoxifylline and cilostazol, are FDA-approved for treating 
PAD-associated walking impairment.  Of these, pentoxifylline is usually 
ineffective and benefits from cilostazol are modest (29-32).  New therapies are 
urgently needed for patients with PAD.  This pilot study will test the 
therapeutic potential of subcutaneously administered unacylated ghrelin and 
the optimal dose of subcutaneously administered unacylated ghrelin in 
patients with PAD. 
B. Calf skeletal muscle fibers in PAD are damaged.  Electron microscopy 
demonstrates pathologic changes in myofibrils, mitochondria, nuclei, and 
sarcolemma of calf muscle myofibers in patients with PAD (33).  In 34 
participants with PAD and 21 without PAD who underwent calf muscle 
biopsy, PAD participants had 30% higher protein carbonyl content (P<0.001) 
and 40% higher 4-hydroxy-2-nonenal (HNE) levels (P<.001), indicating 
higher calf muscle oxidative stress levels in the PAD participants (33).  More 
severe calf muscle oxidative stress was associated with more severe myofiber 
damage and fewer myofibers (33).  Unacylated ghrelin has the potential to 
promote healthy calf muscle fibers in patients with PAD.
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 5 of 32
C. Calf muscle mitochondria are damaged in PAD.  Skeletal muscle 
mitochondria from PAD patients also demonstrate a quantitative mitochondria 
dysfunction, with reduced energy production (34-36).  One study used 
magnetic resonance spectroscopy to compare the efficiency of mitochondrial 
oxidative phosphorylation in 12 men with PAD and 14 without PAD who 
engaged in submaximal plantarflexion exercise.  After submaximal exercise, 
and controlling for blood flow, the PAD participants had poorer 
phosphocreatine recovery (137 seconds + 41 vs. 44 seconds + 3, P=0.02) and 
poorer adenosine triphosphate (ATP) recovery (60 seconds + 10 vs. 29 
seconds + 2, P=0.02) than patients without PAD (36).  These and other results 
(34,35) demonstrate an intrinsic defect in calf muscle mitochondrial function 
in patients with PAD.  Unacylated ghrelin has the potential to promote 
improved calf muscle mitochondrial function in patients with PAD.
2.2
Significance of the research.
A. Overview of ghrelin.  Ghrelin is a peptide and hormone that circulates in 
acylated and unacylated forms.  Unlike acylated ghrelin (1,3,), unacylated 
ghrelin does not bind to GHSR1a and does not increase appetite or cause 
insulin resistance (4,9,11).  In studies of humans and animals, unacylated 
ghrelin improves endothelial function, regenerates skeletal muscle cells, 
improves mitochondrial function, and increases capillary density (37-42).  In 
summary, unacylated ghrelin has therapeutic effects on skeletal muscle and 
the vasculature without promoting insulin resistance or weight gain. 
B. In a mouse model of hind-limb ischemia, unacylated ghrelin increased 
skeletal muscle regeneration, angiogenesis, and limb strength.  Togliatto 
and colleagues induced hindlimb ischemia in 81 mice and randomized them to 
intra-peritoneal injections of unacylated ghrelin, acylated ghrelin, or saline for 
21 days (37).   Mice who received unacylated ghrelin had significantly more 
skeletal muscle satellite cells (measured by Pax7/MyoD markers), 
significantly more regenerating skeletal muscle fibers, and significantly better 
plantarflexion function in the ischemic limb than mice who received acylated 
ghrelin or saline.  Mice who received unacylated ghrelin had greater increases 
in capillary density in the skeletal muscle of their ischemic limb, compared to 
the other two groups.  Greater increases in satellite cell number in mice who 
received unacylated ghrelin were mediated by P38/MAPK activation (37), 
consistent with previous reports that satellite cell proliferation depends on 
P38/MAPK protein activation.  If these actions occur in humans with PAD, 
results will have major therapeutic implications for PAD patients.  The 
purpose of this pilot study is to preliminarily test whether subcutaneously 
administered unacylated ghrelin improves brachial artery FMD in patients 
with PAD and to identify the most optimal dose of subcutaneously 
administered unacylated ghrelin in patients with PAD.  
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 6 of 32
C. Unacylated ghrelin promotes myocyte regeneration via the p38 pathway.  
In a separate in vitro study, unacylated ghrelin induced differentiation of 
proliferating skeletal myoblasts and promoted their fusion into multi-
nucleated syncytia (7).  A high affinity binding site for deacylated ghrelin was 
identified on C2C12 myoblasts that is distinct from the (GHSR)-1a receptor 
that causes insulin resistance and increased appetite (7).  In summary, 
preliminary evidence from in vitro and animal studies supports our hypothesis 
that unacylated ghrelin may improve functioning by promoting myocyte 
regeneration and differentiation in calf skeletal muscle damaged by PAD-
related ischemia-reperfusion injury.  
D. Unacylated ghrelin and mitochondrial function.  In the hind limb ischemia 
mouse model by Togliatto et al (37), unacylated ghrelin reduced oxidative 
stress in ischemic muscle, by increasing the mitochondrial specific enzyme, 
superoxide dismutase-2 (SOD-2), suggesting improved mitochondrial 
function.  In a rat model of chronic kidney disease, Barazzoni and colleagues 
administered acylated ghrelin or saline subcutaneously to healthy mice for 
four days.  As compared to saline, acylated ghrelin significantly improved 
oxidative metabolism and increased activity of the mitochondrial enzymes 
citrate synthase and COX enzyme (38).  These favorable changes in 
mitochondrial function were not related to increases in appetite, suggesting 
that this beneficial effect may be distinct from the GHSR-1a receptor.  Thus, 
we hypothesize that unacylated ghrelin will improve mitochondrial oxidative 
metabolism in PAD participants. 
E. Unacylated ghrelin improves endothelial function. In vitro study shows that 
unacylated ghrelin inhibits apoptosis of endothelial cells (41).  In rats, 
unacylated ghrelin causes endothelium-dependent vasodilation of the 
mesenteric vascular bed (42). In 12 humans with metabolic syndrome, 
intravenously administered unacylated ghrelin significantly improved 
endothelium-dependent brachial artery FMD within one hour after ghrelin 
infusion (8).  Patients with PAD have significantly impaired brachial artery 
FMD compared to individuals without PAD (43).  Thus, we expect that 
subcutaneously administered unacylated ghrelin will improve FMD in PAD 
patients.
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 7 of 32
Theoretical Framework.  
Figure 1.  Theoretical model for the GIFT Trial
F. The purpose of this pilot study is to preliminarily test whether subcutaneously 
administered unacylated ghrelin improves brachial artery FMD and reduces 
levels of inflammatory biomarkers in patients with PAD and to identify the 
most optimal dose of subcutaneously administered unacylated ghrelin in 
patients with PAD that may have therapeutic activity in people with PAD.  
We will also assess the safety of subcutaneously administered unacylated 
ghrelin in people age 55 and older with PAD.
Importance of the GIFT Study.  Effective therapies are urgently needed to 
prevent mobility loss in older people with PAD.  The GIFT Trial will provide 
evidence for the optimal dose of subcutaneous ghrelin, which can later be used to 
design a pilot trial of unacylated ghrelin in older people with PAD.  
Our proposed work will also facilitate subsequent studies of unacylated ghrelin 
therapy administered in the outpatient setting to older people with chronic 
diseases.
3.0
Inclusion and Exclusion Criteria
3.1
Screening for eligibility.
Recruitment.  We will identify six PAD participants age 55 and older meeting 
eligibility criteria for our proposed pilot study.  For this pilot study, we will 
contact six PAD patients who participated in our previous research studies and 
agreed to be contacted for future research studies conducted by Dr. McDermott.  
Randomized
Peripheral Artery 
Disease
Ischemia reperfusion injury of 
calf skeletal muscle
Walking impairment with 
mobility loss over time
-Increased oxidative 
stress in calf skeletal 
muscle
-Increased 
inflammation
- Skeletal muscle cell degeneration. 
- Impaired mitochondrial function
- Reduced calf muscle perfusion
Unacylated 
ghrelin
Control
Improved 
-Muscle regeneration
-Mitochondrial function.
-Improved endothelial function and muscle perfusion
-Continued skeletal muscle degeneration
-Continued decline in muscle mitochondrial function.
-Continued decline in endothelial function and 
muscle perfusion.
Continued 
mobility loss
Improved 
Mobility
Baseline level of unacylated 
ghrelin followed by subcutaneous 
injection impaired endothelial 
function
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PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 8 of 32
We may also use the Enterprise Data Warehouse to identify six consecutive 
patients with PAD to participate in this pilot study.
3.2
Criteria.
Inclusion Criteria.  All participants will be age 55 and older.  All will have an 
ABI < 0.90 at baseline.  ABI < 0.90 is a well-accepted standard for defining PAD 
(44-47).   In addition, people with a history of lower extremity revascularization 
for PAD will be eligible.
Exclusion Criteria.  
1. Above or below-knee amputation, critical limb ischemia, and wheelchair 
confinement.
2. Cardiovascular event during the previous three months. [Note: Participants who 
have undergone coronary revascularization for a cardiac event during the previous 
three months may still qualify.] 
3. Major medical illnesses including renal disease requiring dialysis, or cancer 
requiring treatment in the previous year. 
4. Participation in another clinical trial or completion of a clinical trial in the 
previous month, unless they were in the control group of the previous trial.  
5. Unwilling to attend nine study visits over approximately six months.
6. Surgery including lower extremity revascularization or orthopedic surgery in 
the previous month or anticipated surgery in the next three months. 
7. Greater than 15 mmHg difference in blood pressure in both arm pressure 
measurements during the ABI, diagnosis of Raynaud’s phenomenon, or unable to 
have the blood pressure checked in both arms.
8.  Blood pressure < 90/50 at baseline.
9. Non-English speaking, a visual impairment that limits ability to read the 
consent, or a hearing impairment that interferes with study participation.
10. In addition to the above criteria, investigator discretion will be used to 
determine if the trial is unsafe or not a good fit for the potential 
participant.   
3.3
Special Populations. 
Vulnerable populations (fetuses, pregnant women, children, prisoners, and 
institutionalized persons) and adults unable to consent will not be included in this 
study.
4.0
Study-Wide Number of Subjects
NA
5.0
Study-Wide Recruitment Methods
NA
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 9 of 32
6.0
Multi-Site Research
NA
7.0
Study Timelines
Each participant’s part in this study will last up to approximately six months. 
Visit 1.
The initial visit will last approximately 2 hours. Informed consent will be 
provided and an ankle brachial index (ABI) measurement will be obtained to 
ascertain eligibility. Questionnaires will be administered to obtain information 
about their health and medical history. The six-minute walk test and the four-
meter walking velocity at usual and fastest pace may be obtained. An 
electrocardiogram (ECG) will be performed and a blood sample will be obtained. 
Blood will be tested for liver and kidney function, electrolytes, and a complete 
blood count (CBC). A physical exam will be performed and medical history will 
be obtained. Height and weight will be measured. Vitals may be obtained. Vitals 
include blood pressure, heartrate, respiratory rate, temperature, and oxygen level.
Visits 2, 5, and 8.
Visits 2, 5, and 8 will last approximately 8-12 hours and will be separated by at 
least one week. We plan to collect data for each dose on all six participants before 
proceeding to the next dose. At visits #2, #5, and #8, respectively, participants 
will receive a subcutaneous injection of unacylated ghrelin of the following doses:
Visit 2: 10ug/kg
Visit 5: 20 ug/kg
Visit 8: 40 ug/kg
Prior to the injection. Prior to the injection, blood will be drawn and measured 
for levels of unacylated ghrelin and acylated ghrelin, inflammatory biomarkers, 
liver and kidney function, electrolytes, and CBC. Blood pressure and pulse will be 
obtained seated and in the standing position. Brachial artery flow-mediated 
dilation (FMD) will be measured. 
30 minutes, 60 minutes, 90 minutes, and 3 hours and 6 hours post-injection. 
A blood sample will be obtained and measured for levels of unacylated ghrelin 
and acylated gherlin. Blood pressure and pulse will be obtained seated and in the 
standing position. A brachial artery FMD may be measured at 6 hours (e.g. if we 
do not see a change in brachial artery FMD 8-12 hours post-injection, we may 
want to move the collection time point to 6 hours).
8-12 hours post-injection. A blood sample will be obtained and measured for 
levels of unacylated ghrelin and acylated gherlin as well as inflammatory markers. 
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 10 of 32
Blood pressure and pulse will be obtained seated and in the standing position. 
Brachial artery FMD may be measured. 
Additional vitals will be obtained at the discretion of the CRU nurse throughout 
the visit. Vitals include blood pressure, heartrate, respiratory rate, temperature, 
and oxygen level. Participants will be administered a questionnaire to assess 
symptoms. Participants may be asked to take their medications in the evening 
rather than the morning on the day of injection visits.
Participants may also be asked to repeat the six-minute walk and/or four-meter 
walks performed at baseline. 
Visits 4 and 7.
At visits 4 and 7, a blood sample will be obtained and tested for liver and kidney 
function, electrolytes, and CBC. The physical exam and medical history may be 
repeated. Weight may be re-measured.
Visits 3, 6, and 9.
Visits 3, 6, and 9 will occur approximately 24 hours after the subcutaneous 
injections given at visits 2, 5, and 8, respectively. A blood sample will be obtained 
and measured for levels of unacylated ghrelin and acylated gherlin as well as 
inflammatory markers and liver and kidney function, electrolytes, and CBC. 
Blood pressure and pulse will be obtained seated and in the standing position. 
Brachial artery FMD will be measured and an ECG will be performed. Vitals may 
be obtained at the discretion of the CRU nurse. Participants will be administered a 
questionnaire to assess symptoms.
Prior to FMD measures, the participant will be asked to consume a low calorie, 
low fat meal provided to the participant by CRU bionutrion services. 
The table below lists timing of the outcome and safety measures.
Measures
Prior to 
Injection
* 
30 
minutes
60 
minutes 
90 
minute
s
3 
hours
6 
hours
8-12 
hour
s
24 
hour
s
Safety Measures
Electrocardiogram
X*
X
Comprehensive 
chemistry panel
X*
X
CBC
X*
X
Pulse and blood 
pressure
X
X
X
X
X
X
X
X
Orthostatic pulse 
and blood pressure
X
X
X
X
X
X
X
X
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PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 11 of 32
Efficacy outcome measures
Unacylated and 
acylated ghrelin 
levels
X
X
X
X
X
X
X
X
Inflammatory 
biomarkers
X
X
X
Brachial artery 
FMD
X
X
X
X
*The ECG, comprehensive chemistry panel (liver and kidney function and 
electrolyes), and CBC will be obtained at visit #1 for the 10 ug/kg dose.  
**The FMD will be performed at either 6 hours or 8-12 hours.
We will test doses of 10 ug/kg, 20 ug/kg, and 40 ug/kg of unacylated ghrelin on 
three separate days for each participant.  These doses were selected based on 
published literature and the experience of our consultants Dr. Jenny Tong, who 
has an ongoing study of intravenously administered unacylated ghrelin in healthy 
people (R01-DK097550) and Dr. Anne Cappola, who has an ongoing study of 
subcutaneously administered acylated ghrelin in older frail people without PAD 
(R21-AG040488).  
Justification for proposed doses of unacylated ghrelin.  Unacylated ghrelin is a 
synthetic 28 amino-acid protein.  The ½ life of intravenously administered 
unacylated ghrelin is 30-34 minutes, which is comparable to but slightly longer 
than the ½ life of insulin and glucagon (9).  In comparison, the ½ life of 
intravenously administered acylated ghrelin is 9 to 11 minutes (9).  A portion of 
intravenously administered acylated ghrelin is converted to unacylated ghrelin (9).  
In contrast, unacylated ghrelin is not converted to acylated ghrelin (9). In healthy 
people, circulating levels of unacylated ghrelin are higher than those of acylated 
ghrelin, in a ratio that is typically 4:1 but ranges from 2:1 to 9:1 (9,11,48). In a 
study of healthy people, a 4X higher dose of intravenously administered 
unacylated ghrelin achieved a CMax that was twelve times higher than that for 
intravenously administered acylated ghrelin (9). Because of the longer ½ life of 
unacylated ghrelin and the substantially greater CMax achieved with unacylated 
ghrelin as compared to acylated ghrelin, we will begin with a subcutaneous 
unacylated ghrelin (10 ug/kg) dose that is comparable to that selected by Dr. 
Cappola for her study of subcutaneously administered acylated ghrelin.  Next, we 
will test a subcutaneous dose of unacylated ghrelin that is 2X the starting dose (20 
ug/kg).  Finally, we will test a subcutaneous dose of unacylated ghrelin that is 4X 
times the starting dose (40 ug/kg).  Four times the starting dose was selected as 
the maximal dose to test because circulating levels of unacylated ghrelin are 
approximately four times higher than circulating levels of acylated ghrelin and 
because of the higher CMax of unacylated as compared to acylated ghrelin 
(9,11,48).  Although the GIFT Trial will administer unacylated ghrelin 
subcutaneously, we anticipate that, similar to intravenous administration, the 
maximum concentration of unacylated ghrelin will be greater than that for 
acylated ghrelin.    
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PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 12 of 32
We anticipate that we will enroll all study subjects within one year of obtaining 
IRB approval. We anticipate that we will complete data collection within thirteen 
months of obtaining IRB approval.
8.0
Study Endpoints
8.1
Primary and secondary study endpoints.
We selected brachial artery FMD as an endpoint because unacylated ghrelin 
increases brachial artery FMD within hours of intravenously administered 
unacylated ghrelin (8). This immediate effect on brachial artery FMD provides a 
short-term therapeutic endpoint for identifying an optimal unacylated ghrelin 
dose.  The brachial artery FMD will be measured at baseline and at six or 8-12 
hours after each dose of unacylated ghrelin is administered.
Additional endpoints for this pilot study include a) circulating levels of 
unacylated ghrelin; b) levels of acylated ghrelin; c) biomarkers of inflammation.
8.2
Primary or secondary safety endpoints.
Unacylated ghrelin has been administered intravenously to more than 70 humans 
without any serious adverse effects (4,8-14).  Two participants in one study 
experienced mild facial swelling after receiving unacylated ghrelin intravenously 
(14). Symptoms resolved within hours (14).  Dizziness was reported in one study 
in which intravenous acylated and unacylated ghrelin were administered 
simultaneously over the short term (12).  However, this adverse effect was not 
observed when unacylated ghrelin was administered alone (12).  We will monitor 
participants for symptoms of facial swelling and dizziness.  We will monitor 
participants for blood pressure and signs of facial swelling. An electrocardiogram 
will be obtained at visit 1 and before the 20 ug/kg and 40 ug/kg injections and 24 
hours after each injection. Renal function, liver function, electrolytes, and CBC 
will be obtained at baseline, before the 20 ug/kg and 40 ug/kg injections, and 
approximately 24 hours after each injection.   
  
9.0
Procedures Involved
9.1
Study design.
STUDY OVERVIEW.  We will identify the lowest subcutaneous dose of 
unacylated ghrelin that maximizes brachial artery flow mediated dilation (FMD).  
These PAD participants will receive three different subcutaneous doses of 
unacylated ghrelin on three different days and will undergo measurement of 
unacylated ghrelin levels prior to the injection and at specified time intervals. 
Each dose will be separated by a wash-out period of > one week.  Data will be 
obtained for all six participants at each dose before moving to the next dose.
We will test doses of 10 ug/kg, 20 ug/kg, and 40 ug/kg of unacylated ghrelin on 
three separate days for each participant.  These doses were selected based on 
published literature and the experience of our consultants Dr. Jenny Tong, who 
has an ongoing study of intravenously administered unacylated ghrelin in healthy 
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

PROTOCOL TITLE: Unacylated Ghrelin to Improve FuncTioning in PAD: the GIFT 
Trial
Page 13 of 32
people (R01-DK097550) and Dr. Anne Cappola, who has an ongoing study of 
subcutaneously administered acylated ghrelin in older frail people without PAD 
(R21-AG040488).  
(See Section 7.0 above).  Justification for proposed doses of unacylated 
ghrelin.  Unacylated ghrelin is a synthetic 28 amino-acid protein.  The ½ life of 
intravenously administered unacylated ghrelin is 30-34 minutes, which is 
comparable to but slightly longer than the ½ life of insulin and glucagon (9).  In 
comparison, the ½ life of intravenously administered acylated ghrelin is 9 to 11 
minutes (9).  A portion of intravenously administered acylated ghrelin is 
converted to unacylated ghrelin (9).  In contrast, unacylated ghrelin is not 
converted to acylated ghrelin (9). In healthy people, circulating levels of 
unacylated ghrelin are higher than those of acylated ghrelin, in a ratio that is 
typically 4:1 but ranges from 2:1 to 9:1 (9,11,48). In a study of healthy people, a 
4X higher dose of intravenously administered unacylated ghrelin achieved a 
CMax that was twelve times higher than that for intravenously administered 
acylated ghrelin (9). Because of the longer ½ life of unacylated ghrelin and the 
substantially greater CMax achieved with unacylated ghrelin as compared to 
acylated ghrelin, we will begin with a subcutaneous unacylated ghrelin (10 ug/kg) 
dose that is comparable to that selected by Dr. Cappola for her study of 
subcutaneously administered acylated ghrelin.  Next, we will test a subcutaneous 
dose of unacylated ghrelin that is 2X the starting dose (20 ug/kg).  Finally, we 
will test a subcutaneous dose of unacylated ghrelin that is 4X times the starting 
dose (40 ug/kg).  Four times the starting dose was selected as the maximal dose to 
test because circulating levels of unacylated ghrelin are approximately four times 
higher than circulating levels of acylated ghrelin and because of the higher CMax 
of unacylated as compared to acylated ghrelin (9,11,48).  Although the GIFT Trial 
will administer unacylated ghrelin subcutaneously, we anticipate that, similar to 
intravenous administration, the maximum concentration of unacylated ghrelin will 
be greater than that for acylated ghrelin.    
Preparation of subcutaneous unacylated ghrelin.  Synthetic unacylated ghrelin 
powder will be supplied by the CS Bio Company and prepared by Northwestern 
Hospital’s pharmacy for subcutaneous injection, using methods successfully 
implemented by Dr. Cappola for subcutaneously administered acylated ghrelin.  
Selecting the dose of unacylated ghrelin for future study.  We will select the 
lowest subcutaneous dose of unacylated ghrelin that maximizes brachial artery 
FMD and minimizes circulating levels of oxidative stress.  We will also use 
unacylated ghrelin levels to select the unacylated ghrelin dose.  In selecting the 
dose, greater increases in brachial artery FMD and lower levels of oxidative stress 
will be prioritized over the level of unacylated ghrelin. For example, if the dose of 
40 ug/kg results in substantially higher levels of unacylated ghrelin compared to 
the dose of 20 ug/kg, but improvement in brachial artery FMD is similar between 
the 20 ug/kg and the 40 ug/kg doses, then we will select a dose of 20 ug/kg for 
use in a possible future trial of unacylated ghrelin in PAD patients.   
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9.2
 Describe all research procedures.
Please see sections 7.0, 8.1, 8.2, and 9.1 above.
Ankle Brachial Index (ABI).  After the participant rests supine for five minutes, 
the right brachial, dorsalis pedis (DP), posterior tibial (PT) and left DP, PT, and 
brachial artery pressures are measured using a hand-held Doppler probe. 
Pressures are measured twice. The ABI is calculated for each leg by dividing the 
average of the DP and PT pressures by the average brachial pressure.  
Questionnaire Administration.  Participants will be administered study 
questionnaires by a trained and certified health interviewer.
Brachial Artery Flow-Mediated Dilation (FMD).   Brachial artery imaging will 
be performed by a Registered Diagnostic Cardiac Sonographer according to 
established protocol (44,45).  Changes in FMD will be read by Dr. James Stein’s 
University of Wisconsin Atherosclerosis Imaging Research Program Core 
Laboratory by a single reader blinded to participant characteristics.  We have 
more than a decade of experience working with Dr. Stein’s reading center 
(44,47,48).  Measurement reproducibility in Dr. Stein’s laboratory has a median 
FMD difference of 0.02% (inter-quartile range: -0.03 to 0.04).  
Six-minute walk.  Participants will be asked to walk back and forth along a 100-
foot hallway for six minutes.  They will be instructed that the purpose of the six-
minute walk test is to measure how long a distance they can walk in six-minutes.  
A script will be read to describe the study procedure.  Participants will be asked 
whether they feel the test is safe to try and whether they have any questions. The 
six-minute walk is a well validated measure of walking endurance that predicts 
mobility loss and mortality in PAD populations (19,22,49,50) and improves in 
response to therapeutic interventions in older people with PAD (49-53).  The 
intra-class correlation coefficient for the test-retest reliability of the six-minute 
walk test among 156 PAD participants in our SILC exercise trial was 0.90 
(p<0.001) when two six-minute walks were completed 1-2 weeks apart (51,54).  
Participants may be asked to perform the six-minute walk at baseline and may be 
asked to repeat it approximately four-eight hours after each subcutaneous ghrelin 
injection.
Four-Meter Walk. Participants are timed walking a four-meter distance in a 
corridor at their usual and fastest pace.  Because of a learning effect, the four-
meter walk is performed twice, and the fastest walk in each set is used in 
analyses.  Participants are read a script by the study coordinator, describing the 
test.  The test is demonstrated for the participant by the study coordinator- both at 
usual and at fastest pace.  Participants may be asked to perform the four-meter 
walk at baseline and may be asked to repeat it approximately four-eight hours 
after each subcutaneous ghrelin injection.
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

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Blood pressure and pulse measurement.  We will monitor blood pressure and 
pulse changes after the unacylated ghrelin injection.  We will measure both sitting 
and standing blood pressure and pulse prior to the injections and at the intervals 
described above.  
Electrocardiogram. An electrocardiogram will be obtained using standard 
procedures at baseline, prior to the 20 ug/kg and 40 ug/kg doses, and 
approximately 24 hours after each injection. 
Blood collection. Participants will have approximately 300 mls of blood drawn 
over the course of the study to test levels of unacylated ghrelin and acylated 
ghrelin, inflammatory biomarkers, CBC, liver and kidney function, and 
electrolytes. Some blood will be stored for possible later analyses. At visits 2, 4, 
and 6 a peripheral intravenous line may be inserted for the purpose of obtaining 
blood samples more easily without multiple venipunctures. 
9.3 Adequacy of protection against risks and methods to minimize potential 
risks.  Overview of protection against risks.  Prior to beginning data collection 
and study interventions, all study coordinators undergo training and are certified 
by Dr. McDermott using a detailed checklist for each data collection element.  
Research coordinators are certified in each element of the study visit including 
obtaining informed consent, administering questionnaires, protecting 
confidentiality of collected data, performing the six-minute walk, and measuring 
the ABI.  Dr. McDermott re-certifies coordinators every six months to ensure 
continued adherence to protocol.  Those not adhering to all aspects of the protocol 
undergo additional training followed by re-certification. 
All research staff members have completed human subjects training required by 
Northwestern’s institutional review board (IRB).  This training includes education 
about the importance of maintaining confidentiality of personal health 
information.  Dr. McDermott or a co-investigator is available to answer questions 
that arise during the informed consent process as needed.  
Participants are asked to sign a study consent form prior to data collection.  The 
research coordinator reviews study procedures, including risks and benefits 
associated with study participation.  The research coordinator answers 
participants’ questions.  Dr. McDermott and other study investigators are 
available to answer participants’ questions.  Both the participant and the 
individual administering the consent form will sign the consent form.  Dr. 
McDermott’s pager, direct telephone line, and home telephone number are 
provided to participants.  
Minimizing risks related to unacylated ghrelin. The six participants who receive 
the three injections of increasing doses of unacylated ghrelin will be observed at 
Northwestern Medical Center for approximately 8-12 hours after each injection.  
Participants will be observed for side effects.  Participants will also return at 24-
hour follow-up for assessment.  The three injections will be separated by intervals 
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

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of at least one week.  Safety will also be monitored by our data safety monitoring 
board (DSMB) (see below).
Minimizing risk related to baseline and follow-up testing.  All study coordinators 
undergo baseline training and are certified by Dr. McDermott before beginning 
data collection.  Training and certification involves ensuring that coordinators are 
trained in methods to help minimize falls.  Dr. McDermott re-certifies 
coordinators every six months to ensure continued adherence to study protocol.  
Those who are not adhering to protocol undergo additional training followed by 
re-certification.    
Minimizing risk related to loss of confidentiality.  The following methods will be 
employed to maintain confidentiality of participants.  First, study recruitment 
letters will be mailed, using IRB-approved methods, only after receiving written 
permission from the participant’s physician.  The personal physician of each study 
participant will have the option of not allowing investigators to contact the 
potential participant.  Lists of potentially eligible participants will be obtained by 
individuals who normally have access to these lists as part of their daily work 
requirements.  Recruitment letters for potential participants identified from 
hospital and outpatient lists are prepared by research staff members whose job is 
to assist study investigators with recruitment.  These research staff members have 
completed training in the ethical conduct of human subject research, including 
maintaining participant confidentiality.  Recruitment letters to potential 
participants identified from medical center lists are mailed in sealed envelopes 
and addressed to the potential participant.  All potential participants who receive 
mailed information about the study after the approval from their physician will 
have the opportunity to call a voice-mail system to ask not to be further contacted 
about this study.  Secondly, only study investigators and key research staff will 
have access to the study database.  Third, participants will be assigned a unique 
study identifier.  Individual names will ultimately be removed from the study 
database and only the unique study identifier will be used to distinguish 
participants in the database.  Fourth, collected data will be maintained in locked 
computer files and file cabinets to which only study investigators have access.  
Collected data will be used only for research purposes.  Any published data will 
not contain any individual identifiers.
Data and Safety Monitoring Board (DSMB).  We have identified three 
individuals:  Dr. William Hiatt, Professor of Medicine at University of Colorado, 
Dr. Lawrence Frohman, Professor of Endocrinology at the University of Illinois at 
Chicago, and Dr. Sally Freels, Professor of Statistics, University of Illinois at 
Chicago who have agreed to serve on the DSMB for the GIFT Trial.  Dr. Hiatt is 
an internationally recognized expert in vascular medicine and is a board-certified 
cardiologist.  Dr. Frohman is an internationally recognized expert in 
endocrinology and is board certified in endocrinology.  Dr. Freels is an 
internationally recognized statistician with expertise and experience with clinical 
trials and also missing data.  All have provided letters of support, agreeing to 
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participate in the GIFT Trial. The DSMB held their first meeting by telephone 
conference on Monday June 27, 2016. The DSMB will meet at least every six 
months during the study or more frequently as requested by the DSMB.  The 
DSMB will convene by telephone conference call to review and approve the 
protocol prior to beginning data collection.  The biostatisticians and data manager 
will work closely with the DSMB to perform interim analyses.  Adverse events 
will be monitored continuously throughout the study and will be reported to the 
DSMB and IRB in a timely manner according to pre-specified requirements.  
Adverse event rates and interim study results will be reviewed and discussed by 
the DSMB at their regularly scheduled meetings.  At least four categories of 
adverse events will be defined:  a)  Death; b) cardiovascular events (myocardial 
infarction, stroke, and coronary arrhythmias) c) lightheadedness/dizziness; d) 
swelling.  We will report all hospitalizations to the DSMB in a timely fashion.  
We will use a designated data collection form to record these events and they will 
be reported to the Institutional Review Board according to local IRB 
requirements.  They will be reported to the DSMB as required by the DSMB 
charter.  As noted above, however, to date unacylated ghrelin has been found to 
have little to no toxicity in humans.
The purpose of this pilot study is to determine the potential therapeutic potential 
of subcutaneously administered unacylated ghrelin.  The purpose is also to 
identify the most optimal dose of subcutaneously administered unacylated ghrelin 
for improving brachial artery flow-mediated dilation and reducing levels of 
inflammation in patients with PAD.  An Investigational New Drug application to 
the FDA has been approved (IND# 130513).
We will use standardized questionnaires to collect data about each study 
participant.  Please see attached data collection forms.  We may use medical 
records to determine whether the patient was diagnosed with PAD prior to study 
enrollment.
10.0
Data and Specimen Banking
10.1 Storage of specimens.
Blood specimens for long-term storage will be stored in a freezer belonging to Dr. 
McDermott's research program at Northwestern University, in the freezer farm in 
the basement of Olson Pavilion.
Specimens will be stored for up to 70 years, after which they will be destroyed.
10.2 Data to be stored or associated with each specimen.
Specimens will be coded; meaning that a key will exist that can link the codes 
back to the direct subject identifiers. Each participant will be assigned a unique 
study ID number that can be traced back to the study participant.  The blood 
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.

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samples that are maintained in long-term storage will be labeled with this unique 
identifier and the date and time of the blood collection. 
10.3 Procedures to release data or specimens.
Only Dr. McDermott has control over release of study data or specimens.  Any 
investigators seeking to analyze blood specimens must contact Dr. McDermott for 
permission.  Each request, if it occurs, will be considered on a case-by-case basis.  
Dr. McDermott will obtain IRB approval prior to releasing any blood specimens 
for analysis, other than those tests specifically named in this application.
11.0
Data and Specimen Management
11.1 Data management.
Data is recorded using preprogrammed instruments and an electronic case report 
form using secure, HIPAA-compliant REDCap database software on servers 
maintained by Northwestern’s Clinical and Translational Sciences Institute. We 
have substantial experience with REDCap. 
Data Safety Monitoring Board (DSMB).   We have identified three nationally 
recognized experts to serve on the DSMB.  
Power Estimates.  The primary aim of the GIFT Trial is to obtain preliminary 
data that will allow us to determine whether there is sufficient ‘signal’ from 
unacylated ghrelin to warrant additional study of unacylated ghrelin in older 
patients with PAD.  In addition, the GIFT Trial will allow us to obtain an estimate 
of effect size and standard deviation of change in our study outcomes when 
unacylated ghrelin is administered to older PAD participants.  Finally, the GIFT 
Trial will allow us to determine the feasibility of administering unacylated ghrelin 
to older patients with PAD.   Because this is a preliminary study, no power 
calculations were performed.
Statistical Analyses. Simple statistics will be performed to assess changes in 
brachial artery FMD over time in response to each unacylated ghrelin injection.  
Simple statistics will also be performed to analyze changes in levels of unacylated 
ghrelin and acylated ghrelin and circulating levels of oxidative stress after each 
subcutaneous injection of unacylated ghrelin.  
11.2 Power analysis.
A power analysis is not applicable, given the exploratory nature of this 
research.
11.3 Steps to secure data to maintain confidentiality during storage, use, 
and transmission.
First, all research assistants must complete training in protection of subject 
privacy and prevention of disclosure of identifying information.
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Second, all data collection forms are maintained in a secure office space.
Third, our study databases are maintained in locked computer files or on secure 
hard-drives that are password protected; to which only authorized staff have 
access. Dr. McDermott or a study manager must provide permission for 
programmers and research assistants to access study databases.
Fourth, a study identification number will be assigned to each participant. This 
identification number will be used to label blood specimens, for example. In 
addition, most pages of our data collection forms will have only the study 
identification number listed (and not the participant's name, for example).
11.4 Quality control
As in our prior studies, health interviewers will be trained by a senior coordinator 
and certified by Dr. McDermott in each component of data collection, using a 
detailed checklist developed for this trial.  Health interviewers are rigorously 
evaluated for adherence to protocol, prior to beginning data collection and every 
six months after initial certification.  
12.0
Provisions to Monitor the Data to Ensure the Safety of Subjects
Serious adverse events will be reported to the DSMB within seven days of 
each serious adverse event.  Adverse event data will be reported to the 
DSMB every six months during the study, and/or as requested by the 
DSMB.  The DSMB will have the ability to stop the study at any time if 
there are concerns about safety.
13.0
Withdrawal of Subjects*
Subjects may withdraw from the research at any time. If they decide to leave the 
research, they should contact the investigator, Dr. Mary McDermott.
If they stop being in the research, already collected data may not be removed from 
the study database. They will be asked whether the investigator can collect data 
from their routine medical care. If the subject agrees, this data will be handled the 
same as research data.
Subjects who withdraw from the study will be replaced by another PAD 
participant(s) who meets eligibility criteria.  The newly enrolled PAD participants 
will begin the study at the dose at which the withdrawn participant would have 
received next, if they had not withdrawn.
14.0
Risks to Subjects*
Overview of the GIFT Trial and anticipated characteristics of study 
participants.  Six participants with PAD age 55 and older will participate in a 
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dose finding study, in which participants will receive three different doses of 
unacylated ghrelin (10 ug/kg, 20 ug/kg, and 40 ug/kg) on three different days.  
Each dose will be separated by at least one week.  Based on our previous work 
involving older participants with PAD, we anticipate that the average age will be 
approximately 76 years, that at least 33% of participants will be minorities, and 
that approximately 50% will be women.  For example, in our recently completed 
SILC randomized controlled clinical trial of exercise in patients with PAD 
participants included 52% women and 45% African-Americans (39).  In general, 
older patients with PAD have a high prevalence of comorbid diseases, particularly 
coronary artery disease, cerebrovascular disease, diabetes mellitus, and 
pulmonary disease.  Thus the patient population is likely to be of generally poorer 
health than that of older men and women without PAD in the general population.  
Inclusion and exclusion criteria are provided in section 3.2.  
Sources of material.  We will collect data on levels of circulating unacylated 
ghrelin at multiple defined time points within a 24-hour period after three 
increasing doses of subcutaneously injected unacylated ghrelin. We will also 
measure brachial artery flow-mediated dilation (FMD) at baseline and  at six or 8-
12 hours after each of the three doses of subcutaneously injected unacylated 
ghrelin.  Information obtained from the levels of circulating unacylated ghrelin 
and the brachial artery FMD will be used to select the dose of subcutaneous 
unacylated ghrelin to use in future trials.
Potential Risks.  
Risks associated with unacylated ghrelin.  As described in section 8.2 above, 
unacylated ghrelin has been administered intravenously to more than 70 humans 
without any serious adverse effects (4,8-14).  Two participants in one study 
experienced mild facial swelling after receiving unacylated ghrelin intravenously 
(14). Symptoms resolved within hours (14).  Dizziness was reported in one study 
in which intravenous acylated and unacylated ghrelin were administered 
simultaneously over the short term (12).  However, this adverse effect was not 
observed when unacylated ghrelin was administered alone (12).   A participant 
who received 10 ug/kg in the pilot study presented 24 hours later in atrial flutter.  
However, this participant had a prior history of atrial fibrillation.    
We will minimize risk by observing study participants for approximately 8-12 
hours after each of the three doses of unacylated ghrelin.  Participants will be 
observed at Northwestern Memorial Hospital and they will be monitored for 
adverse events.  Dr. McDermott will monitor safety and all adverse events will be 
reported to the DSMB and IRB as described below.  The study is being conducted 
under an Investigational New Drug application with the FDA and is linked to 
existing INDs held by Dr. Jenny Tong for intravenously delivered unacylated 
ghrelin and by Dr. Anne Cappola for subcutaneously administered acylated 
ghrelin. 
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Six-minute walk and four-meter walk test.  The walking tests may be 
associated with the risk of falling or coronary ischemia or dyspnea due to heart 
failure or lung disease.  Rarely, falling during the walking tests may result in a 
fracture.  However, the research assistant who will collect these data has been 
trained to prevent falling.  The risk of a fracture secondary to a fall during the 
walking tests is less than 1 in 7,000.
Risks associated with ankle brachial index (ABI) measurement.  The ABI 
measurement consists of measuring systolic blood pressure in each extremity 
using a hand-held Doppler.  The ABI is non-invasive, safe and does not have any 
known lasting side effects.  During the ABI test, participants may experience 
discomfort from the inflated blood pressure cuff.  However, this discomfort 
resolves immediately when the cuff is released.
Risks associated with blood draws.  The potential risks of drawing blood 
include a bruise at the site of vein puncture, inflammation of the vein, and 
infection.  Participants may experience lightheadedness or dizziness or fainting 
after injections. Care will be taken to avoid these complications.  
Risks associated with holding medications for study testing.  Participants may 
be asked to take their medications in the evening rather than in the morning on the 
day of study drug injections.  This change in medication dosing may result in 
higher levels of blood pressure during the day with potentially adverse 
consequences, including increased risk of stroke or need for evaluation in the 
Emergency Department.  However, participants will be carefully monitored for 
their blood pressure level throughout the day.  
Risks associated with questionnaire administration.  Participation includes a 
risk of loss of confidentiality regarding personal health information.  However, all 
research staff has undergone formal human subjects training.  They are trained to 
protect the privacy of research subject participants.  
In addition, administration of unacylated ghrelin may have risks to the subjects 
that are currently unforeseeable.
15.0
Potential Benefits to Subjects
15.1 The potential benefits that individual subjects may experience from 
taking part in the research. 
Potential benefits of the proposed research.  
Participants will receive no direct benefits from study participation.  Information 
from this study may be used to develop a large randomized clinical trial using 
subcutaneously administered unacylated ghrelin to improve walking performance 
in patients with PAD.
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Importance of knowledge to be gained.  PAD is common in older men and 
women (9,10).   The number of older people with PAD is expected to increase as 
the U.S. population lives to older ages and survives longer with chronic disease.  
Our prior work and that of others shows that patients with PAD have greater 
functional impairment, increased rates of functional decline, and increased 
mobility loss compared to persons without PAD (15,18-24).  Recent evidence 
shows that chronic disability, such as that associated with PAD, accounts for more 
than half of United States health burden (28). Furthermore, therapeutic advances 
have not kept pace with the growing burden of disability from chronic disease 
(28).  New therapies are urgently needed for patients with PAD.   If we are able to 
determine the optimal dose of unacylated ghrelin, results will be used to design a 
randomized controlled trial of subcutaneously delivered unacylated ghrelin to 
improve lower extremity functioning and prevent mobility loss in the large and 
growing number of older people who are disabled by PAD.          
15.2 Indicate if there is no direct benefit. Do not include benefits to 
society or others.  
There are no direct benefits.
16.0
Vulnerable Populations
NA
17.0
Community-Based Participatory Research
NA
18.0
Sharing of Results with Subjects
Participants will receive results of their ankle brachial index (ABI) test results 
immediately after this testing is completed.  They will be provided with a “result 
letter” at the end of their baseline visit.  They will not be provided with other 
study results, because these results are not clinically relevant at this time (i.e. 
levels of unacylated ghrelin are not clinically relevant.  Short term changes in 
brachial artery FMD are not clinically relevant, and the clinical significance of 
short term changes in measures of oxidative stress are unclear).
19.0
Setting
The research will be conducted at Northwestern Memorial Hospital. 
20.0
Resources Available
Collaborating sites.  
Dr. James Stein (University of Wisconsin) is internationally recognized for his 
expertise measuring vascular function (i.e. flow-mediated dilation).  Dr. Stein 
directs the University of Wisconsin Atherosclerosis Imaging Research Program 
(UW AIRP), and has served as the reading center for multiple NIH-funded 
studies, including MESA (51,55,56).   Dr. Stein’s AIRP will read the brachial 
artery flow-mediated dilation results. 
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Drs. Michael H. Criqui (University of California at San Diego), Jack M. Guralnik 
(University of Maryland), and Luigi Ferrucci (National Institute on Aging) have 
worked with Dr. McDermott on PAD studies of functional impairment for over 
eleven years and bring expertise in functional assessment, PAD, and clinical trials 
to the study team.  Dr. Anne Cappola (study consultant) is Associate Professor at 
University of Pennsylvania and a board-certified endocrinologist.  She is currently 
leading a pilot randomized trial of subcutaneously administered acylated ghrelin 
in older, frail men and women (R21-AG040488).  Her experience administering 
subcutaneous acylated ghrelin to older, frail individuals will be extremely helpful 
for the successful execution of the GIFT Trial.  Dr. Jenny Tong (study consultant) 
is Associate Professor at the University of Cincinnati.  Dr. Tong has extensive 
experience studying the pharmacodynamics of intravenously administered 
acylated ghrelin and unacylated ghrelin in humans.  Dr. Tong’s experience 
administering intravenous acylated and unacylated ghrelin in humans will also be 
particularly valuable to GIFT Trial investigators. 
21.0
Prior Approvals
NA
22.0
Recruitment Methods
22.1 When, where, and how potential subjects will be recruited.
PAD participants will be identified from among individuals with PAD who have 
participated previously in research conducted by Dr. McDermott and/or who have 
expressed an interest in participating in future studies conducted by Dr. 
McDermott.
In addition, some PAD participants may be identified from among consecutive 
patients diagnosed with PAD in the non-invasive vascular laboratory at 
Northwestern Medical Group (NMG). Dr. Mark Eskandari is medical director of 
the non-invasive vascular laboratory at NMG and will assist with identifying 
potential participants from the non-invasive vascular laboratory. As director of the 
vascular laboratory at NMG, Dr. Eskandari formally reads many of the non-
invasive vascular laboratory tests. He maintains all non-invasive vascular test 
results in his vascular laboratory. As director of the vascular laboratory, Dr. 
Eskandari could conceivably contact the patients whose test results are maintained 
in his laboratory. However, Dr. Eskandari prefers that the contact of potential 
participants in studies come from the physicians referring him for testing. Lists of 
patients who have undergone lower extremity arterial testing in the non-invasive 
vascular laboratory are generated monthly and e-mailed from NMG to Dr. 
McDermott using an encrypted file. A research assistant, working on behalf of Dr. 
Eskandari, will contact referring physicians of potential participants identified 
from the vascular laboratory via fax, phone, page, or electronic message (EPIC or 
e-mail), to ask for permission to contact their patient about the study. If a reply is 
not received within three weeks, up to five letters are mailed from Dr. McDermott 
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about the research study. We have substantial experience with our recruitment 
methods for our previous or ongoing studies.
We also propose to obtain lists of consecutive patients with a diagnosis of lower 
extremity peripheral arterial disease and individuals at high risk for peripheral 
artery disease from Northwestern’s Enterprise Data Warehouse (EDW). EDW 
lists will be obtained by an individual who is employed by the Division of 
General Internal Medicine who has received training and permission to obtain the 
lists from the EDW.
Similar methods will be used as those described above, in which the patient’s 
physician will be contacted via fax, telephone, page, or electronic message (EPIC 
or email) to ask for permission to contact their patient about the study. If a reply is 
not received within three weeks, up to five letters are mailed from Dr. McDermott 
about the research study.  
In the recruitment letters, recipients are asked to call us if they are interested in 
participation or if they do not want to be contacted further. Potential participants 
who do not call us within three weeks of the first mailed recruitment letter may be 
telephoned by study staff and invited to participate.
22.2 Source of subjects. 
Please see details regarding “source of subjects” in section 22.0 and 22.1.
22.3 Methods that will be used to identify potential subjects. 
Please see details regarding methods used to identify potential subjects in sections 
22.0 and 22.1.
22.4 Amount, timing, and method of any payments to subjects. 
Participants will receive up to $150 for taking part in this research study. 
Participants will be paid in cash after completing visits 3, 6, and 9.    
Participants will be given assistance and/or reimbursement for expenses related to 
travel such as parking, bus/train fare, taxi fare, and mileage, if requested. A 
receipt will be required for taxi fare reimbursement. Participants will be provided 
up to $50 per visit for travel reimbursement. If they require the use of our taxi 
service, we will estimate the fare on www.taxifarefinder.com. A one-way fare 
estimate must be less than or equal to $25.00 (i.e. round trip of $50) in order for 
the study to provide taxi service.
23.0
Local Number of Subjects
We will identify six PAD participants age 55 and older. We anticipate that we 
will have up to 20 screen failures. 
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24.0
Confidentiality
NA
25.0
Provisions to Protect the Privacy Interests of Subjects
Questionnaires will be administered in an enclosed space by a trained and 
certified research assistant.  Dr. McDermott personally certifies study participants 
in data collection to help ensure that participants are treated with the highest level 
of professionalism.  The study drug injection and phlebotomy will also take place 
in an examination room with the door closed to ensure optimal privacy. 
All research staff undergo training (human subjects training) in the protection of 
participant confidentiality and privacy.  Research staff have access to medical 
records only for the purpose of conducting research that is approved by the IRB.
26.0
Compensation for Research-Related Injury
If the subject needs medical care because of taking part in this research study, 
they should contact the investigator and medical care will be made available. 
Generally, this care will be billed to the subject, their insurance, or other third 
party. Northwestern University has no program to pay for medical care for 
research-related injury.
27.0
Economic Burden to Subjects
NA
28.0
Consent Process
The “SOP: Informed Consent Process for Research (HRP-090)” will be followed. 
Participants will be consented by a research assistant who has been trained and 
certified by Dr. McDermott in obtaining informed consent. Prior to attending their 
first study visit, a research assistant will explain the study to potential participants 
by telephone. When a potential participant arrives to the medical center for study 
participation, the research assistant will explain the full details of the research 
study, including risks and benefits. The informed consent process will take place 
first at initial study visit at Northwestern. 
Potential participants will be provided plenty of time to read the consent form. 
The research assistant will answer study questions. However, if the participant 
would like more time to discuss the research study with their physician or family 
member, they will be allowed to do so. In this case, the study visit will not 
proceed. Dr. McDermott or another study investigator at Northwestern is also 
available to answer any questions that participants may have about the research.
Non-English speaking subjects, subjects who are not yet adults, cognitively 
impaired adults, and adults unable to consent will not be eligible for participation.
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29.0
Process to Document Consent in Writing
The “SOP: Written Documentation of Consent (HRP-091): will be followed. 
30.0
Drugs or Devices
Northwestern Hospital’s pharmacy will prepare syringes of varying doses of 
unacylated ghrelin. 
An Investigational New Drug application has been approved by the FDA 
(IND# 130513). Dr. McDermott is the holder of the IND.
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31.0
 References
1.  Broglio F, Arvat E, Benso A, Gottero C, Muccioli G, Papotti M, van der Lely AJ, 
Deghenghi R, Ghigo E.  Ghrelin, a natural GH secretagogue produced by the stomach, 
induces hyperglycemia and reduces insulin secretion in humans.  J Clin Endocrinol 
Metab 2001;86:5083-6. PMID: 11600590.
2.  Akamizu T, Takaya K, Irako T, Hosoda H, Teramukai S, Matsuyama A, Tada H, 
Miura K, Shimizu A, Fukushima M, Yokode M, Tanaka K, Kangawa K.  
Pharmacokinetics, safety, and endocrine and appetite effects of ghrelin administration in 
young healthy subjects.  Eur J Endocrinol 2004;150:447-55. PMID: 15080773.
3. van der Lely AJ, Tschop M, Heiman ML, Ghigo E. Biological, physiological, 
pathophysiological, and pharmacological aspects of ghrelin. Endocr Rev 2004;25:426-57. 
PMID: 15180951.
4.  Tong J, Davis HW, Summer S, Benoit SC, Hague A, Bidlingmaier M, Tschop MH, 
D’AlessioD. Acute administration of unacylated ghrelin has no effect on basal or 
stimulated insulin secretion in healthy humans. Diabetes 2014 Feb 18. [Epub ahead of 
print]. PMID: 24550190.
5.  Filigheddu N, Gnocchi VF, Coscia M, Cappelli M, Porporato PE, Taulli R, Traini 
S, Baldanzi G, Chianale F, Cutrupi S, Arnoletti E, Ghè C, Fubini A, Surico N, Sinigaglia 
F, Ponzetto C, Muccioli G, Crepaldi T, Graziani A. Ghrelin and des-acyl 
ghrelin promote differentiation and fusion of C2C12 skeletal muscle cells. Mol Biol 
Cell 2007;18:986-94. PMID: 17202410 PMCID: PMC1805095.
6.  Baldanzi G, Filigheddu N, Cutrupi S, Catapano F, Bonissoni S, Fubini A, Malan 
D, Baj G, Granata R, Broglio F, Papotti M, Surico N, Bussolino F, Isgaard J, Deghenghi 
R, Sinigaglia F, Prat M, Muccioli G, Ghigo E, Graziani A. Ghrelin and des-acyl ghrelin 
inhibit cell death in cardiomyocytes and endothelial cells through ERK1/2 and PI 3-
kinase/AKT. J Cell Biol 2002;159:1029-37. PMID: 12486113 PMCID: PMC2173981.
7.  Porporato PE, Filigheddu N, Reano S, Ferrara M, Angelino E, Gnocchi VF, Prodam 
F, Ronchi G, Fagoonee S, Fornaro M, Chianale F, Baldanzi G, Surico N ,Sinigaglia 
F, Perroteau I, Smith RG, Sun Y, Geuna S, Graziani A. Acylated and unacylated ghrelin 
impair skeletal muscle atrophy in mice.
J Clin Invest 2013;123:611-22.PMID: 23281394 PMCID: PMC3561827.
8.  Tesauro M, Schinzari F, Iantorno M, Rizza S, Melina D, Lauro D, Cardillo C. Ghrelin 
improves endothelial function in patients with metabolic syndrome. Circulation 
2005;112:2986-92. PMID: 16260640.
9.  Tong J, Dave N, Mugundu GM, Davis HW, Gaylinn BD, Thorner MO, Tschöp 
MH, D'Alessio D, Desai PB.  The pharmacokinetics of acyl, des-acyl, and total ghrelin in 
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healthy human subjects. Eur J Endocrinol 2013;168:821-8. PMID: 23482590. PMCID: 
PMC3740531.
10.  Ozcan B, Neggers SJ, Miller AR, Yang HC, Lucaites V, Abribat T, Allas S, Huisman 
M, Visser JA, Themmen AP, Sijbrands EJ, Delhanty PJ, van der Lely AJ.  Does des-acyl 
ghrelin improve glycemic control in obese diabetic subjects by decreasing acylated 
ghrelin levels?  Eur J Endocrinol 2013;170:799-807. PMID: 23864339.
11.  Broglio F, Gottero C, Prodam F, Gauna C, Muccioli G, Papotti M, Abribat T, van der 
Lely AJ, Ghigo E.  Non-acylated ghrelin counteracts the metabolic but not the 
neuroendocrine response to acylated ghrelin in humans.  J Clin Endocrinol Metab 
2004;89:3062-5. PMID: 15181099.
12.  Kiewiet RM, van Aken MO, van der Weerd K, Uitterlinden P, Themmen AP, 
Hofland LJ, de Rijke YB, Delhanty PJ, Ghigo E, Abribat T, van der Lely AJ. Effects of 
acute administration of acylated and unacylated ghrelin on glucose and insulin 
concentrations in morbidly obese subjects without overt diabetes. Eur J Endocrinol 
2009;161:567-73. PMID: 19628651.
13.  Broglio F, Benso A, Gottero C, Prodam F, Gauna C, Filtri L, Arvat E, van der Lely 
AJ, Deghenghi R, Ghigo E. Non-acylated ghrelin does not possess the pituitaric and 
pancreatic endocrine activity of acylated ghrelin in humans. J Endocrinol Invest  
2003;26:192-6. PMID: 12809167.
14.  Benso A, St-Pierre DH, Prodam F, Gramaglia E, Granata R, van der Lely AJ, Ghigo 
E, Broglio F. Metabolic effects of overnight continuous infusion of unacylated ghrelin in 
human. Eur J Endocrinol 2012;166:911-6. PMID: 22379116.
15.  McDermott MM, Fried L, Simonsick E, Ling S, Guralnik JM.  Asymptomatic 
peripheral arterial disease is independently associated with impaired lower extremity 
functioning: the women’s health and aging study.  Circulation 2000;101:1007-1012. 
PMID: 10704168.
16.  Newman AB, Siscovick DS, Manolio TA, Polak J, Fried LP, Borhani NO, Wolfson 
SK. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. 
Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation 
1993;88:837-834. PMID: 8353913. 
17.  Vogt MT, Cauley JA, Newman AB, Kuller LH, Hulley SB. Decreased ankle/arm 
blood pressure index and mortality in elderly women. JAMA 1993;270:465-469. PMID: 
8320785.
18. McDermott MM, Greenland P, Liu K, Guralnik JM, Criqui MH, Dolan NC, Chan C, 
Celic L, Pearce WH, Schneider JR, Sharma L, Clark E, Gibson D, Martin GJ.  Leg 
symptoms in peripheral arterial disease: associated clinical characteristics and functional 
impairment.  JAMA 2001;286:1599-606. PMID: 44585483.
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19.  McDermott MM, Greenland P, Liu K, Guralnik JM, Celic L, Criqui MH, Chan C, 
Martin GJ, Schneider J, Pearce WH, Taylor LM, Clark E.  The ankle brachial index is 
associated with leg function and physical activity: the Walking and Leg Circulation 
Study. Ann Intern Med 2002;136:873-83. PMID: 12069561.
20.  McDermott MM, Liu K, Greenland P, Guralnik JM, Criqui MH, Chan C, Pearce 
WH, Schneider JR, Ferrucci L, Celic L, Taylor LM, Vonesh E, Martin GJ, Clark E.  
Functional decline in peripheral arterial disease: associations with the ankle brachial 
index and leg symptoms. JAMA 2004;292:453-61. PMID: 15280343.
21.  McDermott MM, Guralnik JM, Tian L, Liu K, Ferrucci L, Liao Y, Sharma L, Criqui 
MH.  Associations of borderline and low normal ankle-brachial index values with 
functional decline at 5-year follow-up: the WALCS (Walking and Leg Circulation 
Study).  J Am Coll Cardiol 2009;53:1056-62. PMID: 19298919. PMCID: PMC3215766.
22.  McDermott MM, Guralnik JM, Tian L, Ferrucci L, Liu K, Liao Y, Criqui MH. 
Baseline functional performance predicts the rate of mobility loss in persons with 
peripheral arterial disease. J Am Coll Cardiol 2007;50:974-82. PMID: 17765125. 
PMCID: PMC2645658.
23.  McDermott MM, Ferrucci L, Guralnik JM, Dyer A, Liu K, Pearce WH, Clark E, 
Liao Y, Criqui.  Leg symptoms and rates of mobility decline in peripheral arterial 
disease.  J Am Geriatr Soc 2010;58:1256-1262. PMID:  20550604. 
24.  Gardner AW, Montgomery PS, Killewich LA. Natural history of physical function in 
older men with intermittent claudication. J Vasc Surg 2004;40:73-8. PMID: 15218465.
25.  Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr 
PA, Wallace RB. A short physical performance battery assessing lower extremity 
function: association with self-reported disability and prediction of mortality and nursing 
home admission. J Gerontol 1994;49:M85-94. PMID: 8126356.
26.  Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity 
function in persons over the age of 70 years as a predictor of subsequent disability. N 
Engl J Med 1995;332:556-61. PMID: 7838189.
27.  Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV, Studenski 
S, Berkman LF, Wallace RB. Lower extremity function and subsequent disability: 
consistency across studies, predictive models, and value of gait speed alone compared 
with the short physical performance battery. J Gerontol A Biol Sci Med Sci 
2000;55(4):M221-31. PMID: 10811152.
28.  U.S. Burden of Disease Collaborators. The state of US health, 1990-2010: burden of 
diseases, injuries, and risk factors. JAMA 2013;310:591-608. 
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Page 30 of 32
29.  Girolami B, Bernardi E, Prins MH, Ten Cate JW, Hettiarachchi R, Prandoni P, 
Girolami A, Buller HR.  Treatment of intermittent claudication with physical training, 
smoking cessation, pentoxifylline, or nafronyl:  a meta-analysis.  Arch Intern Med 
1999;159:337-45. PMID: 10030306.
30.  Dawson DL, Cutler BS, Meissner MH, Strandness DE Jr.  Cilostazol has beneficial 
effects in treatment of intermittent claudication:  results from a multicenter, randomized, 
prospective, double-blind trial.  Circulation 1998;98:678-86. PMID: 9715861.
31.  Money SR, Herd JA, Isaacsohn JL, Davidson M, Cutler B, Heckman J, Forbes WP.  
Effect of cilostazol on walking distances in patients with intermittent claudication caused 
by peripheral vascular disease.  J Vasc Surg 1998;27:267-74. PMID: 9510281.
32.  Beebe HG, Dawson DL, Cutler BS, Herd JA, Strandness DE Jr, Bortey EB, Forbes 
WP.  A new pharmacological treatment for intermittent claudication:  results of a 
randomized, multicenter trial.  Arch Intern Med 1999;159:2041-50. PMID: 10510990.
33.  Weiss DJ, Casale GP, Koutakis P, Nella AA, Swanson SA, Zhu Z, Miserlis D, 
Johanning JM, Pipinos II.  Oxidative damage and myofiber degeneration in the 
gastrocnemius of patients with peripheral arterial disease.  J Transl Med 2013;11:230. 
PMID: 24067235. PMCID: PMC3849592.
34.  Pipinos II, Judge AR, Zhu Z, Selsby JT, Swanson SA, Johanning JM, Baxter BT, 
Lynch TG, Dodd SL. Mitochondrial defects and oxidative damage in patients with 
peripheral arterial disease. Free Radic Biol Med 2006;41:262-9. PMID: 16814106.
35.  Pipinos II, Sharov VG, Shepard AD, Anagnostopoulos PV, Katsamouris A, Todor A, 
Filis KA, Sabbah HN. Abnormal mitochondrial respiration in skeletal muscle in patients 
with peripheral arterial disease. J Vasc Surg 2003;38:827-32. PMID: 14560237.
36.  Anderson JD, Epstein FH, Meyer CH, Hagspiel KD, Wang H, Berr SS, Harthun NL, 
Weltman A, Dimaria JM, West AM, Kramer CM. Multifactorial determinants of 
functional capacity in peripheral arterial disease: uncoupling of calf muscle perfusion and 
metabolism. J Am Coll Cardiol 2009;54:628-35. PMID: 19660694 PMCID: 
PMC2768062. 
37. Togliatto G, Trombetta A, Dentelli P, Cotogni P, Rosso A, Tschöp MH, Granata 
R, Ghigo E, Brizzi MF. Unacylated ghrelin promotes skeletal muscle regeneration 
following hindlimb ischemia via SOD-2-mediated miR-221/222 expression. J Am Heart 
Assoc 2013;2:e000376. PMID: 24308935 PMCID: PMC3886736.
38.  Barazzoni R, Zhu X, Deboer M, Datta R, Culler MD, Zanetti M, Guarnieri G, Marks 
DL. Combined effects of ghrelin and higher food intake enhance skeletal 
muscle mitochondrial oxidative capacity and AKT phosphorylation in rats with chronic 
kidney disease. Kidney Int 2010;77:23-8. PMID: 19890275. PMCID: PMC2857601.
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39.  Andrews ZB, Erion D, Beiler R, Liu ZW, Abizaid A, Zigman J, Elsworth JD, Savitt 
JM, DiMarchi R, Tschoep M, Roth RH, Gao XB, Horvath TL. Ghrelin promotes and 
protects nigrostriatal dopamine function via a UCP2-dependent mitochondrial 
mechanism. J Neurosci 2009;29:14057-65. PMID: 19906954. PMCID: PMC2845822.
40.  Xu Z, Lin S, Wu W, Tan H, Wang Z, Cheng C, Lu L, Zhang X.  Ghrelin prevents 
doxorubicin-induced cardiotoxicity through TNF-alpha/NF-kappaB pathways and 
mitochondrial protective mechanisms. Toxicology 2008;247:133-8. PMID: 18400355.    
41.  Moazed B, Quest D, Gopalakrishnan V. Des-acyl ghrelin fragments evoke 
endothelium-dependent vasodilation of rat mesenteric vascular bed via activation of 
potassium channels.  Eur J Pharmacol 2009;604:79-86. PMID: 18957289.
42.  Baldanzi G, Filigheddu N, Cutrupi S, Catapano F, Bonissoni S, Fubini A, Malan D, 
Baj G, Granata R, Broglio F, Papotti M, Surico N, Bussolino F, Isgaard J, Deghenghi R, 
Sinigaglia F, Prat M, Muccioli G, Ghigo E, Graziani A. Ghrelin and des-acyl ghrelin 
inhibit cell death in cardiomyocytes and endothelial cells through ERK1/2 and PI 3-
kinase/AKT. J Cell Biol 2002;159:1029-37. PMID: 12486113 PMCID: PMC2173981.
43.  Kiani S, Aasen JG, Holbrook M, Khemka A, Sharmeen F, LeLeiko RM, Tabit 
CE, Farber A, Eberhardt RT, Gokce N, Vita JA, Hamburg NM. Peripheral artery disease 
is associated with severe impairment of vascular function. Vasc Med 2013;18):72-8. 
PMID: 23509089. PMCID: PMC3694333.
44.  Lijmer JG, Hunink MG, van den Dungen JJ, Loonstra J, Smit AJ. ROC analysis of 
noninvasive tests for peripheral arterial disease.  Ultrasound Med Biol 1996;22:391-8. 
PMID: 8795165.
45. Bernstein EF, Fronek A.  Current status of noninvasive tests in the diagnosis of 
peripheral arterial disease.  Surg Clin North Am 1982;62:473-87. PMID: 7089825.
46. Fung YC. Biodynamics – Circulation. New York: Springer-Verlag; 1984. Blood flow 
in arteries: pressure and velocity waves in large arteries and the effects of geometric 
nonuniformity; pp. 133–136.
47. Yao JS. New techniques in objective arterial evaluation.  Arch Surg 1973;106:600-4. 
PMID: 4572350.
48.  Hosada H, Kojima M, Kangawa K. Biological, physiological, and pharmacological 
aspects of ghrelin. J Pharmacol Sci 2006;100:398-410. PMID: 16612045.
49.  McDermott MM, Tian L, Liu K, Guralnik JM, Ferrucci L, Tan J, Pearce WH, 
Schneider JR, Criqui MH. Prognostic value of functional performance for mortality in 
patients with peripheral artery disease. J Am Coll Cardiol 2008;51:1482-9. PMID: 
18402904. PMCID: PMC2459324.
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50.  McDermott MM, Liu K, Ferrucci L, Tian L, Guralnik JM, Liao Y, Criqui MH. 
Decline in functional performance predicts later increased mobility loss and mortality in 
peripheral arterial disease. J Am Coll Cardiol 2011;57:962-70. PMID: 21329843 PMCID: 
PMC3222682
51.  McDermott MM, Ades P, Guralnik JM, Dyer A, Ferrucci L, Liu K, Nelson M, 
Lloyd-Jones D, Van Horn L, Garside D, Kibbe M, Domanchuk K, Stein JH, Liao Y, Tao 
H, Green D, Pearce WH, Schneider JR, McPherson D, Laing ST, McCarthy WJ, Shroff 
A, Criqui MH. Treadmill exercise and resistance training in patients with peripheral 
arterial disease with and without intermittent claudication: a randomized controlled trial. 
JAMA 2009;301:165-74. PMCID: PMC3268032
52.  McDermott MM, Liu K, Guralnik JM, Criqui MH, Spring B, Tian L, Domanchuk K, 
Ferrucci L, Lloyd-Jones D, Kibbe M, Tao H, Zhao L, Liao Y, Rejeski WJ. Home-based 
walking exercise intervention in peripheral artery disease: a randomized clinical trial. 
JAMA 2013;210:57-65. PMID: 23821089.
53.  Montgomery PS, Gardner AW. The clinical utility of a six-minute walk test in 
peripheral arterial occlusive disease patients. J Am Geriatr Soc 1998;46:706-11. PMID: 
9625185.
54.  McDermott MM, Domanchuk K, Dyer A, Ades P, Kibbe M, Criqui MH. Recruiting 
participants with peripheral arterial disease for clinical trials: experience from the Study 
to Improve Leg Circulation (SILC). J Vasc Surg 2009;49:653-659. PMID: 19135834.
55. Yeboah J, Folsom AR, Burke GL, Johnson C, Polak JF, Post W, Lima JA, Crouse JR, 
Herrington DM.  Predictive value of brachial flow-mediated dilation for incident 
cardiovascular events in a population-based study: the multi-ethnic study of 
atherosclerosis. Circulation 2009;120:502-9. PMID: 19635967. PMCID: PMC2740975.
56.  Domanchuk K, Ferrucci L, Guralnik JM, Criqui MH, Tian L, Liu K, Losordo 
D, Stein J, Green D, Kibbe M, Zhao L, Annex B, Perlman H, Lloyd-Jones D, Pearce W, 
Taylor D, McDermott MM. Progenitor cell release plus exercise to improve functional 
performance in peripheral artery disease: the PROPEL Study. Contemp Clin Trials 
2013;36:502-9. PMID: 24080099. PMCID: PMC3939047.
IRB #: STU00202400 Approved by NU IRB for use on or after 12/14/2018 through 12/13/2019.