A Double-blind, Randomised, Placebo-controlled Study to Assess the Effect of SNF472 on Progression of Cardiovascular Calcification on Top of Standard of Care in End-stage-renal-disease (ESRD) Patients on Hemodialysis (HD)
Phase: PHASE2
Conditions: Cardiovascular Diseases, Cardiovascular Abnormalities, Calcifications, Vascular, Endstage Renal Disease, ESRD, Coronary Artery Calcification
Sponsor: Sanifit Therapeutics S. A.

SNF472 
 
Laboratoris Sanifit 
SNFCT2015-05 Amendment 5 
 
 
Clinical Study Protocol 
 
 
 
 
01-MAR-2019 
Confidential 
Page 1 
Clinical Study Protocol 
A double-blind, randomised, placebo-controlled study to assess 
the effect of SNF472 on progression of cardiovascular 
calcification on top of standard of care in end-stage-renal-
disease (ESRD) patients on haemodialysis (HD)  
SNFCT2015-05 
 
Development Phase: 
Phase 2b 
Investigational Product: 
SNF472 
Indication: 
CVC in ESRD 
Sponsor: 
Laboratoris Sanifit 
Palma de Mallorca, Spain 
EudraCT Number 
2016-002834-59 
IND Number 
116437 
Protocol Date: 
Version 05, 01-MAR-2019 
Amendment History: 
Date 
Amendment Number 
Amendment Type 
Region 
26-JUL-2016 
Initial Protocol 
Not applicable 
Global 
31-JUL-2017 
01 
Substantial 
Global 
31-OCT-2017 
1.1 
Country-specific 
US 
29-MAR-2018 
02 
Substantial 
Global 
27-JUN-2018 
03 
Non-substantial 
Global 
22-OCT-2018 
04 
Substantial 
Global 
01-MAR-2019 
05 
Substantial 
Global 
 
Conduct: In accordance with the ethical principles that originate from the Declaration of Helsinki and 
that are consistent with International Council for Harmonisation Guidelines on Good Clinical Practice 
(ICH E6 GCP) and regulatory requirements as applicable. 

SNF472 
 
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CONFIDENTIAL INFORMATION 
This document is the sole property of Laboratoris Sanifit. This document and any and all information 
contained herein has to be considered and treated as strictly confidential. This document shall be used 
only for the purpose of the disclosure herein provided. No disclosure or publication shall be made 
without the prior written consent of Laboratoris Sanifit. 
SPONSOR’S PROTOCOL APPROVAL SIGNATURE PAGE  
Amendment 5 
Sponsor:  Laboratoris Sanifit 
I have read and understand the contents of this clinical protocol for Study No. SNFCT2015-
05 and agree to meet all obligations of the Sponsor as detailed in all applicable regulations 
and according to Good Clinical Practice (ICH E6 GCP). 
Alex Gold, MD 
Chief Medical Officer 
Laboratoris Sanifit 
 
 
 
 
Signature 
 
Date (DD-MMM-YYYY) 
 
 
 
 

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Clinical Study Protocol 
 
 
 
 
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PRINCIPAL/COORDINATING INVESTIGATOR’S AGREEMENT  
AMENDMENT 5 
I have read and understand the contents of this clinical protocol for Study No. SNFCT2015-05 dated and 
will adhere to the study requirements as presented, including all statements regarding confidentiality. In 
addition, I will conduct the study in accordance with current International Council for Harmonisation of 
Technical Requirements for Pharmaceuticals for Human Use Guideline for Good Clinical Practice and 
applicable regulatory requirements: 
 
 
Principal/Coordinating Investigator Name 
 
 
 
Principal/Coordinating Investigator Signature 
 
Date (DD-MMM-YYYY) 
 
 
 

SNF472 
 
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Clinical Study Protocol 
 
 
 
 
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PROTOCOL AMENDMENT 5 SUMMARY OF CHANGES 
 
1) Section 10.7: Additional analyses of the dataset used for the futility analyses will be 
conducted in the event of an equivocal result of the futility analysis indicating borderline 
conditional power of the study. These analyses will include primary and secondary 
endpoints, demographic and background characteristics, key subgroups, and PK/PD 
correlations with efficacy. Details will be provided in the SAP. 
Rationale: To assist the Sponsor in decision making regarding future clinical 
development of SNF472.  
2) New Appendix 7 containing the summary of changes for the previous version of the 
protocol (Amendment 4). 
3) Revisions of amendment number and date throughout. 
 
 

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Clinical Study Protocol 
 
 
 
 
01-MAR-2019 
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PROTOCOL SYNOPSIS  
Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
Title of Study:  A double-blind, randomised, placebo-controlled study to assess the effect of 
SNF472 on progression of cardiovascular calcification on top of standard of care in end-
stage-renal-disease (ESRD) patients on haemodialysis (HD) 
Protocol Number:  SNFCT2015-05 
EudraCT: 2016-002834-59 
IND Number: 116437 
Number of Patients and Study Centre(s): Approximately 270 patients in approximately 75 
centers in 3 countries 
Indication:  Cardiovascular Calcification (CVC) in ESRD  
Objectives: 
The primary objective is to assess the effect of 2 dose levels of SNF472 (300 mg and 
600 mg) compared to placebo on the progression of coronary artery calcium volume score 
over a 12-month (52 weeks) period in ESRD patients on HD. 
The secondary objectives are to: 
• assess change from baseline (Week 1, Day 1) in coronary artery calcium (CAC)/Agatston 
score 
• assess the number of patients with <15% progression in CAC/Agatston score 
• assess the change from baseline in thoracic aorta calcification score 
• assess the change from baseline in aortic valve calcification score 
• assess the occurrence of the composite safety endpoint: death from cardiovascular 
causes, myocardial infarction (MI), stroke, or heart failure 
• assess change in biomarkers as signals for treatment efficacy/response 
• assess changes in bone mineral density (BMD) 
• describe the long-term safety profile of SNF472 in this target population 
 
The exploratory objective is to assess changes from baseline in pulse pressure, systolic blood 
pressure (SBP), and diastolic blood pressure (DBP). 
 
Methodology: This is a randomised, double-blind, placebo-controlled, phase 2b study to 
evaluate the effects of 2 dose levels of SNF472 on progression of cardiovascular calcification 

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Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
(CVC) as measured by calcium volume and CAC scores in ESRD patients on HD. The 
randomization will be stratified by baseline CAC score category. 
Endpoints: 
The primary endpoint is the change in coronary artery calcium volume scores between 
baseline (Week 1, Day 1) and Week 52 measured by computed tomography (CT) scan. 
 
The secondary endpoints are:  
• change from baseline in CAC/Agatston score at Week 52 
• number of patients with <15% progression in CAC/Agatston at Week 52 
• change from baseline in thoracic aorta calcification score at Week 52 
• change from baseline in aortic valve calcification score at Week 52 
• incidence of composite safety endpoint that include death from cardiovascular causes, 
MI, stroke, or heart failure 
• mortality rate (all-cause and CV) 
• change from baseline in levels of selected biomarkers including C-reactive protein (CRP) 
• changes in BMD between baseline and 52 weeks 
• safety of SNF472 in terms of incidences of adverse events (AE) and serious adverse 
events (SAE) and clinically relevant changes from baseline in laboratory and ECG 
parameters 
 
The exploratory endpoints are changes from baseline in pulse pressure, SBP, and DBP at 
Week 28 and Week 52 in all patients and in the subgroup of patients with hypertension at 
baseline.  
Criteria for Inclusion: 
1. female or male patients, 18 to 80 years (inclusive) of age at randomisation 
2. CAC score of 100 to 3500 AU (Agatston Units) inclusive within a 4-week period prior to 
randomisation as measured by a multi-detector CT scanner 
3. patients who are EITHER ≥ 55 years OR have a history of diabetes mellitus at 
randomisation 
4. patients on HD for ≥ 6 months prior to randomisation 
5. willing and able to understand and sign the informed consent 
Criteria for Exclusion: 
1. scheduled date for kidney transplant from a known living donor 

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Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
2. weight above 300 lbs (136 kg) 
3. hospitalisation in the previous 3 months prior to randomisation for unstable angina, MI, 
stroke, transient ischaemic attack, amputation or peripheral or coronary bypass surgery 
4. history of unstable heart failure in the previous 3 months, defined as an unplanned 
presentation to a hospital or dialysis treatment facility with signs/symptoms of acute 
pulmonary edema and requiring ultrafiltration therapy 
5. history of cancer that has been in remission for < 5 years prior to randomisation. A 
history of basal cell carcinoma or Stage 1 squamous cell carcinoma of the skin is allowed 
6. pregnant or trying to become pregnant, currently breast-feeding, or of child-bearing 
potential (including peri-menopausal women who have had a menstrual period within 
one year) and not willing to practice birth control using a double barrier method (criteria 
apply to women only) at least 30 days post last dose of study medication 
7. hypocalcaemia defined as a serum calcium below 8.0 mg/dL (or 2.0 mmol/L) for the 
serum calcium most proximal to screening per patient’s medical records 
8. extreme elevation in serum phosphorous, defined as a serum phosphorous above 
10 mg/dL (or 3.23 mmol/L) within the last 2 months proximal to screening per patient’s 
medical records 
9. uncontrolled hypertension defined as any 2 or more consecutive post-dialysis diastolic 
blood pressure (DBP) > 100 mmHg within the last 2 months proximal to screening 
10. expected survival < 2 years in the Investigator’s medical opinion 
11. known active drug or alcohol abuse within 1 year of randomisation  
12. use of other investigational drugs within 30 days of randomisation 
13. non-compliance with dialysis treatment which, in the opinion of the Investigator, 
evidenced by either repeated missed dialysis treatments or significant non-compliance 
with the patient’s medication regimen 
14. Inability to comply with all required study procedures and schedule, inability to speak 
and read in the protocol-derived language of that patient's clinical site, or unwillingness 
or inability to give written informed consent 
Test Product, Dose and Mode of Administration: 
A single intravenous (IV) dose of one of two dose levels of SNF472 (300 mg and 600 mg) 
delivered in conjunction with each HD session (3 times weekly) over 52 weeks.  
Reference Therapy, Dose and Mode of Administration:   
Placebo, administered as SNF472 
Study Duration: 28 + 3 days screening; 52-week treatment period; follow-up at Week 56. 
Statistical Methods: 
 Approximately 270 patients are planned to be randomised. 

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Clinical Study Protocol 
 
 
 
 
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Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
The primary endpoint is the absolute change in coronary artery calcium volume score from 
baseline to Week 52. The primary analysis will use an analysis of covariance (ANCOVA) 
model to compare each of the 2 dose levels of SNF472 to the placebo group. The dependent 
variable will be the difference between log 52-week and log baseline calcium volume scores, 
with log baseline calcium volume score and treatment group as explanatory variables. This 
analysis will be stratified for the randomization stratification factor, i.e. baseline 
CAC/Agatston score. 
A non-binding interim futility analysis will be conducted when approximately N=120 
subjects (63% of N=190) have provided Week 52 data on the primary endpoint. PK and PD 
analyses will also be conducted at the time of the interim analysis. 
 

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SCHEDULE OF ASSESSMENTS 
A total of 159 visits (2 screening visits followed by 3 dialysis sessions per week x 52 weeks and 1 follow-up visit 1 month post-dose) 
are scheduled throughout the study. Table 1.1 shows key visits where intensive data collection is performed. For other visits, standard 
of care assessments should be performed. If also participating in Sub-Study, please see additional Schedule of Sub-Study 
Assessments in Appendix 1. 
Table 1.1 
Schedule of Assessments and Study Activities at Key Visits 
Procedures 
Screeninga  
28 + 3 days 
Double Blind Treatment Period 
Wk 56 or 1 
month after 
last dose 
 
 
156 VISITS: Study Drug Infusion Administered at Each HD Session (3x Weekly)k 
 
Key Evaluation Visits (Preferably at Mid-Week Dialysis Sessions) 
Week 
Step 1a Step 2a Wk 1 Wk 2 Wk 4 
Wk 6 Wk 10 Wk 16 Wk 22 Wk 28 Wk 34 Wk 40 Wk 46 
Wk 
52/ETm  
 
Day 
 
 
1 
8 
(±3 d) 
22 
(±3 d) 
36 
(±3 d) 
64 
(±3 d) 
106 
(±3 d) 
148 
(±3 d) 
190  
(±3 d) 
232 
(±3 d) 
274 
(±3 d) 
316 
(±3 d) 
358 
(±3 d) 
 
Informed consentb 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility, 
inclusion/exclusion 
criteriac 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
CT scan for calcium 
scores for screeningd 
and endpoints 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
DEXA for BMDe 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Evaluation of CT scan at Step 1 must be completed before proceeding to Step 2 
Medical history, 
demographics 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam, 
including height and 
weight  
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 

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Procedures 
Screeninga  
28 + 3 days 
Double Blind Treatment Period 
Wk 56 or 1 
month after 
last dose 
 
 
156 VISITS: Study Drug Infusion Administered at Each HD Session (3x Weekly)k 
 
Key Evaluation Visits (Preferably at Mid-Week Dialysis Sessions) 
Week 
Step 1a Step 2a Wk 1 Wk 2 Wk 4 
Wk 6 Wk 10 Wk 16 Wk 22 Wk 28 Wk 34 Wk 40 Wk 46 
Wk 
52/ETm  
 
Day 
 
 
1 
8 
(±3 d) 
22 
(±3 d) 
36 
(±3 d) 
64 
(±3 d) 
106 
(±3 d) 
148 
(±3 d) 
190  
(±3 d) 
232 
(±3 d) 
274 
(±3 d) 
316 
(±3 d) 
358 
(±3 d) 
 
Treatment history, 
current and prior 
medication 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancyf 
 
X 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
12-lead ECG (including 
QTc)g 
 
X 
 
 
 
 
X 
 
 
X 
 
X 
 
X 
 
Vital signsh 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Randomisation 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Haematology, 
coagulation, and 
chemistryi 
 
X 
 
 
 
X 
 
 
X 
 
X 
 
X 
 
PTH, TSAT, ferritin 
 
X 
 
 
 
 
 
 
 
 
 
 
X 
 
Plasma PK samplingj 
 
X  
 
 
 
X 
 
X 
 
 
 
 
X 
 
Biomarkers samplingj 
 
X 
 
 
 
X 
 
X 
 
 
 
 
X 
 
Blinded study drug 
infusion (3x weekly)k 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Post-dialysis weight 
 
X 
 
 
 
X 
 
 
X 
 
X 
 
X 
 
Change in concomitant 
medicationsl 
 
X 
 
X 
 
X 
 
 
X 
 
 
 
X 
 
AE assessment 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X (SAEs 
only) 

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AE: adverse event; BL: Baseline; BMD: bone mineral density; CAC: coronary artery calcium; CT: computed tomography; DEXA: dual-energy x-ray 
absorptiometry; ECG: electrocardiogram; ET: early termination; PK: pharmacokinetic(s); PTH: parathyroid hormone; SAEs: serious adverse events; TSAT: 
transferrin saturation; Wk: week 
a 
Screening will proceed in 2 steps: Step 1 will involve informed consent followed by the CT scan for CAC score and BMD by DEXA for Screening. Only 
those patients who are eligible in Step1 can proceed to Step 2. 
b 
Patients will provide written informed consent before any clinical study-specific procedures are performed. 
c 
The inclusion/exclusion criteria will be assessed for each patient at Screening and will be confirmed again on Day 1 prior to randomisation. 
d 
CT scan of coronary artery using a multi-detector CT with at least 64 slices to quantify calcium scores for Step 1 screening. Only patients who meet the 
inclusion criterion of CAC score of 100 to 3500 AU (Agatston Units) will proceed to Screening Step 2. 
e 
BMD will be measured by DEXA at the same visits at the CT scan. 
f 
For females of child-bearing potential, serum pregnancy test. 
g 
ECG will be performed at Screening and post-dialysis at the visits indicated. 
h 
Vital signs include heart rate, respiratory rate, blood pressure and body temperature post-dialysis. These are recorded for the study at key visits only. 
Standard of care vital signs assessments are not being recorded into study database at each HD visit. 
i 
Blood samples will be collected pre-dose via the dialysis port for haematology, coagulation, and chemistry tests. 
j 
Only for patients at participating sites, the PK and biomarker samples will be collected via the dialysis port at pre-dose and at 3 hrs (~10 minutes before 
end of infusion) on the assessment day. Biomarkers may include but are not limited to fetuin A, FGF23, MGP, sclerostin, phosphorus (phosphate), 
pharmacodynamics (PD), and GDF15. No genetic testing will be performed. 
k 
The treatment period is 52 weeks, and study treatment is administered at each HD session (3x weekly following the standard procedure established by the 
nephrologist). Intravenous doses of either SNF472 or matching placebo will be administered to patients in conjunction with each HD session (see 
Section 5.5). Except for Baseline (Day 1), intensive data collection visits are recommended to be done on the 2nd dialysis session of each week (mid-
week HD session).  
l 
Record change in concomitant medications relative to previous assessment visit; only prescription medications are to be recorded. 
m 
The early termination (ET) visit will replace the Week 52 visit if the patient terminated the study earlier than planned. PK and biomarker samples will be 
collected during this visit if the post-baseline samples haven’t been collected prior to early termination. A CT scan for calcium quantification and BMD by 
DEXA should be done. If not feasible for this visit, the site must make all efforts to set an appointment for a CT scan and DEXA. In addition, sites must 
encourage patients to report for the follow-up visit. 
 

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TABLE OF CONTENTS 
PRINCIPAL/COORDINATING INVESTIGATOR’S AGREEMENT  AMENDMENT 5 .....3 
PROTOCOL AMENDMENT 5 SUMMARY OF CHANGES .................................................4 
PROTOCOL SYNOPSIS ..........................................................................................................5 
SCHEDULE OF ASSESSMENTS ............................................................................................9 
TABLE OF CONTENTS .........................................................................................................12 
LIST OF IN-TEXT FIGURES .................................................................................................18 
LIST OF IN-TEXT TABLES ..................................................................................................18 
LIST OF ABBREVIATIONS ..................................................................................................19 
1 INTRODUCTION .............................................................................................................22 
1.1 
Indication/Background to the Disease ...................................................................22 
1.1.1 
Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) ..22 
1.1.2 
Vascular Calcification ................................................................................23 
1.1.3 
Cardiovascular Calcification in CKD and ESRD ......................................23 
1.1.4 
Current Treatments ....................................................................................24 
1.1.5 
Current Treatment Guidelines ....................................................................25 
1.2 
Investigational Product SNF472 ............................................................................25 
1.2.1 
Nonclinical Data ........................................................................................26 
1.2.2 
Pharmacology ............................................................................................27 
1.2.3 
Clinical Experience ....................................................................................27 
1.2.4 
Potential Risks ...........................................................................................28 
1.3 
Coronary Artery Calcification Scores ....................................................................29 
1.4 
Rationale for the Study ..........................................................................................29 
2 STUDY OBJECTIVES ......................................................................................................30 
2.1 
Primary Objective ..................................................................................................30 
2.2 
Secondary Objectives .............................................................................................30 
2.3 
Exploratory Objective ............................................................................................30 
3 STUDY DESIGN...............................................................................................................31 
3.1 
Study Design Overview .........................................................................................31 
3.2 
Study Endpoints .....................................................................................................31 
3.2.1 
Primary Endpoint .......................................................................................31 
3.2.2 
Secondary Endpoints .................................................................................31 
3.2.3 
Exploratory Endpoints ...............................................................................32 
4 SELECTION OF PATIENTS ............................................................................................32 
4.1 
Inclusion Criteria ...................................................................................................32 

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4.2 
Exclusion Criteria ..................................................................................................33 
4.3 
Re-screening and Screen Failures ..........................................................................33 
5 STUDY TREATMENTS ...................................................................................................34 
5.1 
Investigational Drugs .............................................................................................34 
5.2 
Dose Rationale .......................................................................................................34 
5.3 
Treatment Assignment ...........................................................................................35 
5.3.1 
Randomisation ...........................................................................................36 
5.3.2 
Patient Identification ..................................................................................36 
5.4 
Blinding, Packaging, and Labeling ........................................................................36 
5.4.1 
Blinding .....................................................................................................36 
5.4.2 
Unblinding .................................................................................................36 
5.4.3 
Packaging ...................................................................................................37 
5.5 
Administration of Investigational Medicinal Products ..........................................37 
5.6 
Supplies and Accountability ..................................................................................38 
5.7 
Compliance ............................................................................................................38 
6 STUDY PROCEDURES AND SCHEDULE ....................................................................39 
6.1 
Description of Study Days .....................................................................................39 
6.1.1 
Screening (28 + 3 days) .............................................................................39 
6.1.1.1 
Step 1 .................................................................................................39 
6.1.1.2 
Step 2 .................................................................................................39 
6.1.2 
Treatment Period ........................................................................................40 
6.1.2.1 
Week 1 ...............................................................................................40 
6.1.2.2 
Weeks 1 to 52 (3x weekly) ................................................................40 
6.1.2.3 
Week 2 (preferably at mid-week HD session) ...................................41 
6.1.2.4 
Week 4 (preferably at mid-week HD session) ...................................41 
6.1.2.5 
Week 6 (preferably at mid-week HD session) ...................................41 
6.1.2.6 
Week 10 (preferably at mid-week HD session) .................................41 
6.1.2.7 
Week 16 (preferably at mid-week HD session) .................................41 
6.1.2.8 
Week 22 (preferably at mid-week HD session) .................................42 
6.1.2.9 
Week 28 (preferably at mid-week HD session) .................................42 
6.1.2.10 
Week 34 (preferably at mid-week HD session) .................................42 
6.1.2.11 
Week 40 (preferably at mid-week HD session) .................................42 
6.1.2.12 
Week 46 (preferably at mid-week HD session) .................................43 
6.1.2.13 
Week 52 (preferably at mid-week HD session) / Early 
Termination ....................................................................................43 
6.1.2.14 
Early Termination ..............................................................................44 

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6.1.3 
Follow-up Visit (Week 56 or 1 month after last dose) ..............................44 
6.2 
Methods of Evaluation ...........................................................................................44 
6.2.1 
Efficacy Assessments .................................................................................44 
6.2.1.1 
CT Scan ..............................................................................................44 
6.2.1.2 
Calcium Scores ..................................................................................44 
6.2.1.3 
Cardiovascular Events and Mortality .................................................44 
6.2.2 
Pharmacokinetics .......................................................................................44 
6.2.3 
Biomarkers .................................................................................................45 
6.2.4 
Safety Assessments ....................................................................................45 
6.2.4.1 
Adverse Events ..................................................................................45 
6.2.4.2 
Bone Mineral Density ........................................................................46 
6.2.4.3 
Medical History .................................................................................46 
6.2.4.4 
Physical Examination .........................................................................46 
6.2.4.5 
Vital Signs ..........................................................................................46 
6.2.4.6 
Electrocardiograms ............................................................................46 
6.2.4.7 
Laboratory Evaluations ......................................................................46 
6.2.4.8 
Pregnancy ...........................................................................................47 
6.2.5 
Collection Schedule for Biological Samples .............................................47 
6.2.5.1 
Blood ..................................................................................................47 
6.2.5.2 
Sample Handling, Shipment and Retention .......................................48 
6.2.6 
Prior and Concomitant Treatments ............................................................48 
6.3 
Restrictions and Precautions ..................................................................................48 
6.3.1 
Dietary and Fluid Restrictions ...................................................................48 
6.3.2 
Contraception Requirements ......................................................................48 
7 ADVERSE EVENTS .........................................................................................................49 
7.1 
Definitions ..............................................................................................................49 
7.1.1 
Adverse Event ............................................................................................49 
7.1.2 
Serious Adverse Event ...............................................................................49 
7.1.3 
Adverse Event by Severity or Intensity .....................................................50 
7.1.4 
Relationship between Adverse Events and Investigational Product ..........50 
7.2 
Haemodialysis-Related Events ..............................................................................51 
7.3 
Period of Observation ............................................................................................51 
7.4 
Documentation and Reporting of Adverse Events .................................................51 
7.4.1 
Documentation and Reporting of Adverse Events by Investigator ...........51 
7.4.1.1 
Recording of Adverse Events ............................................................51 
7.4.1.2 
Reporting of Adverse Events .............................................................52 

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7.4.2 
Reporting of Adverse Events by Sponsor ..................................................53 
7.5 
Data and Safety Monitoring Board ........................................................................53 
8 DISCONTINUATION AND WITHDRAWALS ..............................................................53 
8.1 
Removal of Patients from the Study ......................................................................53 
8.2 
Replacement of Patients .........................................................................................54 
8.3 
Withdrawal of Samples ..........................................................................................54 
9 EMERGENCY PROCEDURES ........................................................................................54 
9.1 
Emergency Sponsor Contact ..................................................................................54 
9.2 
Emergency Identification of Investigational Products ...........................................54 
10 STATISTICAL METHODS ..............................................................................................54 
10.1 
General Statistical Considerations .........................................................................54 
10.1.1 
Analysis Sets ..............................................................................................54 
10.1.2 
Subgroups and Subsets ..............................................................................55 
10.1.3 
Covariates and Strata .................................................................................55 
10.2 
Demographics and Background Characteristics ....................................................55 
10.2.1 
Demographics ............................................................................................55 
10.2.2 
Disease Characteristics ..............................................................................55 
10.2.3 
Disposition .................................................................................................55 
10.2.4 
Exposure and Compliance .........................................................................56 
10.2.5 
Concomitant Therapies ..............................................................................56 
10.3 
Efficacy Analyses ..................................................................................................56 
10.3.1 
Primary Efficacy Analysis .........................................................................56 
10.3.2 
Missing Data ..............................................................................................57 
10.3.3 
Multiple Comparisons / Multiplicity .........................................................57 
10.3.4 
Secondary and Exploratory Analyses ........................................................57 
10.4 
Safety Analyses ......................................................................................................58 
10.4.1 
Adverse Events ..........................................................................................58 
10.4.2 
Bone Mineral Density ................................................................................58 
10.4.3 
Clinical Laboratory Evaluation ..................................................................58 
10.4.4 
Vital Signs ..................................................................................................58 
10.4.5 
ECG............................................................................................................59 
10.4.6 
Physical Findings and Other Observations Related to Safety ...................59 
10.5 
Other Statistical Analyses ......................................................................................59 
10.6 
Determination of Sample Size ...............................................................................60 
10.7 
Interim Analysis .....................................................................................................60 
10.8 
Changes in the Conduct of the Study or Planned Analysis ...................................61 

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11 REGULATORY, ETHICAL AND LEGAL OBLIGATIONS ..........................................61 
11.1 
Good Clinical Practice ...........................................................................................61 
11.2 
Informed Consent ...................................................................................................61 
11.3 
Patient Confidentiality and Disclosure ..................................................................62 
11.4 
Protocol Amendments ............................................................................................62 
11.5 
Approval of the Clinical Study Protocol and Amendments ...................................62 
11.6 
Ongoing Information for Independent Ethics Committee/ Institutional Review 
Board ......................................................................................................................62 
11.7 
Closure of the Study ...............................................................................................63 
11.8 
Record Retention ...................................................................................................63 
12 DATA MANAGEMENT, MONITORING AND AUDITS .............................................63 
12.1 
Study Monitoring ...................................................................................................63 
12.2 
Data Capture and verification ................................................................................63 
12.3 
On-Site Audits .......................................................................................................64 
13 DOCUMENTATION AND USE OF STUDY FINDINGS ..............................................64 
13.1 
Documentation of Study Findings .........................................................................64 
13.2 
Use of Study Findings ............................................................................................64 
13.3 
Study Report, Publication Policy and Archiving of Study Documentation ...........65 
13.3.1 
Study Documents .......................................................................................65 
14 REFERENCES ..................................................................................................................66 
APPENDIX 1 SUB-STUDY PROTOCOL: FOR OPT-IN SITES ONLY .............................69 
SUB-STUDY PROTOCOL SYNOPSIS .................................................................................70 
TABLE OF CONTENTS .........................................................................................................72 
LIST OF IN-TEXT FIGURES .................................................................................................73 
LIST OF IN-TEXT TABLES ..................................................................................................73 
LIST OF ABBREVIATIONS NOT USED IN THE MAIN PROTOCOL .............................74 
1 INTRODUCTION .............................................................................................................75 
1.1 
Rationale for the Sub-Study ...................................................................................75 
1.1.1 
Background ................................................................................................75 
1.1.2 
Considerations in the Selection of Cardiovascular Endpoints ...................77 
2 SUB-STUDY OBJECTIVES ............................................................................................82 
2.1 
Primary Objective ..................................................................................................82 
2.2 
Secondary Objectives .............................................................................................82 
2.3 
Exploratory Objectives ..........................................................................................82 
3 STUDY DESIGN...............................................................................................................83 
3.1 
Study Design Overview .........................................................................................83 

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3.2 
Study Endpoints .....................................................................................................83 
3.2.1 
Primary Endpoint .......................................................................................83 
3.2.2 
Secondary Endpoints .................................................................................83 
3.2.3 
Exploratory Endpoints ...............................................................................83 
4 SELECTION OF PATIENTS ............................................................................................83 
4.1 
Inclusion Criteria ...................................................................................................84 
4.2 
Exclusion Criteria ..................................................................................................84 
5 STUDY PROCEDURES AND SCHEDULE ....................................................................84 
5.1 
Schedule of Assessments .......................................................................................84 
5.2 
Description of Study Days .....................................................................................86 
5.2.1 
Screening (up to Week 4) ..........................................................................86 
5.2.2 
Treatment Period ........................................................................................86 
5.2.2.1 
Sub-Study Entry (up to 4 weeks after first dose) ...............................86 
5.2.2.2 
Week 28 (±2 weeks) ..........................................................................86 
5.2.2.3 
Week 52/ET (±2 weeks) ....................................................................86 
5.3 
Methods of Evaluation ...........................................................................................86 
5.3.1 
Efficacy Assessments .................................................................................86 
5.3.1.1 
Echocardiographic Assessments ........................................................86 
6 STATISTICAL METHODS ..............................................................................................87 
6.1 
General Statistical Considerations .........................................................................87 
6.1.1 
Analysis Sets ..............................................................................................87 
6.2 
Demographics and Background Characteristics ....................................................87 
6.2.1 
Demographics ............................................................................................87 
6.2.2 
Disease Characteristics ..............................................................................87 
6.3 
Efficacy Analyses ..................................................................................................87 
6.3.1 
Primary Efficacy Analysis .........................................................................87 
6.3.2 
Missing Data ..............................................................................................88 
6.3.3 
Multiple Comparisons / Multiplicity .........................................................88 
6.3.4 
Secondary and Exploratory Efficacy Analyses ..........................................88 
6.3.5 
Sensitivity Analyses ...................................................................................88 
6.4 
Determination of Sample Size ...............................................................................88 
7 SUB-STUDY REFERENCES ...........................................................................................89 
APPENDIX 2. PROTOCOL AMENDMENT 1: SUMMARY OF CHANGES .....................95 
APPENDIX 3. PROTOCOL AMENDMENT 1.1 UNITED STATES ONLY .......................97 
APPENDIX 4. PROTOCOL AMENDMENT 1.1 UNITED STATES ONLY: 
SUMMARY OF CHANGES .............................................................................................98 

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APPENDIX 5. PROTOCOL AMENDMENT 2 SUMMARY OF CHANGES ......................99 
APPENDIX 6. PROTOCOL AMENDMENT 3 SUMMARY OF CHANGES ....................102 
APPENDIX 7. PROTOCOL AMENDMENT 4 SUMMARY OF CHANGES ....................103 
 
LIST OF IN-TEXT FIGURES 
Figure 3.1 
Study Flowchart ............................................................................................31 
Figure 5.1 
Method of Administration ............................................................................38 
 
LIST OF IN-TEXT TABLES 
Table 1.1 
Schedule of Assessments and Study Activities at Key Visits ........................9 
Table 5.1 
Identity of the Investigational Medical Products ..........................................34 
Table 6.1 
Safety Laboratory Assessments ....................................................................47 
Table 7.1 
Definitions of Adverse Events Severity ........................................................50 
Table 7.2 
Guidelines for Determining the Relationship (if any) Between Adverse 
Event and the Study Drug .............................................................................50 
 
 
 

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LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
AE 
adverse event 
ALP 
alkaline phosphatase 
ALT 
alanine transaminase (SGPT) 
ANCOVA 
analysis of covariance 
AST 
aspartate transaminase (SGOT) 
ATC 
Anatomical Therapeutic Chemical 
AU 
Agatston units 
AUC 
area under curve 
BP 
blood pressure 
BMD 
bone mineral density 
BUN 
blood urea nitrogen 
BW 
body weight 
CAC 
coronary artery calcium 
CDC 
Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CHF 
congestive heart failure 
CKD 
chronic kidney disease 
Cmax 
observed maximum concentration 
Cmin 
minimum observed concentration 
CRA 
clinical research associates 
CRO 
contract research organisation 
CRP 
C-reactive protein 
CSP 
clinical study protocol 
CSR 
clinical study report 
CT 
computed tomography 
CTCAE 
common terminology criteria for adverse events 
CV 
cardiovascular 
CVC 
cardiovascular calcification 
DBP 
diastolic blood pressure 
DEXA 
dual-energy x-ray absorptiometry 
DSMB 
Data and Safety Monitoring Board 
EBCT 
electron beam computed tomography 
ECG 
electrocardiogram 

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Abbreviation 
Definition 
eCRF 
electronic case report form 
EDC 
electronic data capture 
eDMP 
electronic data management plan 
ESRD 
end-stage renal disease 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
gamma-glutamyl transpeptidase 
GRAS 
generally recognised as safe 
h 
hour 
HAP 
hydroxyapatite 
HD 
haemodialysis 
HIPAA 
Health Insurance Portability and Accountability Act 
HNR 
Heinz Nixdorf Recall 
HR 
heart rate 
IC50 
half maximal inhibitory concentration 
ICF 
informed consent form 
ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IEC 
Independent Ethics Committee 
IMP 
investigational medicinal product 
INR 
international normalised ratio 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
IV 
intravenous 
KDOQI 
Kidney Disease Outcomes Quality Initiative 
LDH 
lactic acid dehydrogenase 
LLOQ 
lowest level of quantification 
LOCF 
last observation carried forward 
MBD 
mineral and bone disease 
MDCT 
multi-detector CT scanners 
MedDRA 
Medical Dictionary for Regulatory Activities 
MESA 
Multi-Ethnic Study of Atherosclerosis 
mg 
milligram 
mg/kg 
milligram/kilogram 
MI 
myocardial infarction 

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Abbreviation 
Definition 
MMRM 
mixed model repeated measures 
mITT 
Modified intent-to-treat 
NOAEL 
no-observed adverse effect level 
PD 
pharmacodynamics 
PK 
pharmacokinetics 
pmp 
per million population 
PP 
per protocol 
PT 
prothrombin time 
PTH 
parathyroid hormone 
PTT 
partial thromboplastin time 
QTcB 
QTc corrected by Bazett’s formula 
RR 
respiratory rate 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SBP 
systolic blood pressure 
SOC 
system organ class 
SSR 
sample size re-estimation 
SUSAR 
suspected unexpected serious adverse reactions 
TEAE 
treatment-emergent adverse events 
TSAT 
transferrin saturation 
WBC 
white blood cell 
WHO 
World Health Organisation 
 

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1 
INTRODUCTION 
1.1 
INDICATION/BACKGROUND TO THE DISEASE 
1.1.1 
Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) 
Chronic kidney disease (CKD) is a serious condition associated with significant morbidity, 
premature mortality, decreased quality of life, and increased health-care expenditures. Risk 
factors for CKD include cardiovascular (CV) disease, diabetes mellitus, hypertension, and 
obesity. As the kidneys progressively fail, a variety of metabolic and hormonal abnormalities 
accumulate, eventually leading to a chronic state of inflammation, malnutrition, disordered 
mineral metabolism, anemia, and electrolyte disturbances. These conditions contribute 
further to the burden of CV disease in the CKD population; increasingly it has been 
recognized that extra-osseous soft tissue calcification, particularly cardiovascular 
calcification (CVC), plays an important role in the clinical manifestation of CV disease in 
these patients. 
Patients who reach the most severe stage of CKD, end-stage renal disease (ESRD), require 
replacement of renal function either through dialysis treatment or renal transplantation. 
ESRD patients receiving dialysis therapy have all-cause and CV mortality rates that are at 
least 15-20 times higher than the general age- and gender-matched population (USRDS 2015, 
Baigent 2000). This burden of CV disease is evident upon the initiation of renal replacement 
therapy. Forty percent of patients starting dialysis already have evidence of coronary heart 
disease and only 15% are considered to have normal left ventricular structure and function by 
echocardiographic criteria (USRDS 2015, Bansal 2013). As described below, the 
development of CVC during CKD leads to this reduction in cardiac function by the time 
patients reach ESRD and predisposes to arrhythmia and sudden cardiac death, the most 
prevalent form of CV mortality in this patient population.  
The occurrence of ESRD, as reflected by 2013 incidence rates for renal replacement therapy, 
varies by region, with countries in Europe generally ranging between 90-170 per million 
population (pmp) and a much higher incidence in the United States (363 pmp) driven by a 
greater U.S. incidence of diabetic ESRD (ERA-EDTA 2015, USRDS 2015). 
The economic burden of ESRD is far greater than its proportionate incidence. U.S. Medicare 
costs for ESRD exceed $32B annually, representing over 7% of total Medicare expenditures 
for a population that represents only 1.5% of Medicare patients (USRDS 2015). Similarly, in 
European countries like Italy, 2% of the annual healthcare budget is utilized for ESRD, 
which totals only approximately 0.1% of the general population (Pontoriero 2007). 
It is evident that for the ESRD population, investigation of a novel therapy to reduce the 
progression of CVC is an appropriate endeavor to lower the burden of morbidity and 
mortality in these disproportionately affected patients. Similarly, a reduction in the clinical 
consequences of CVC and CV disease would be expected to result in significant healthcare 
savings globally. 

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1.1.2 
Vascular Calcification 
Bone serves as the storage unit for 99% of total body calcium, predominantly in the form of a 
calcium-phosphate moiety called hydroxyapatite (HAP). Calcium deposition outside of bone 
is broadly termed extraskeletal calcification and is induced in the setting of cellular necrosis, 
damaged proteins, or transformation of cells to an osteoblastic phenotype. An important 
example of the latter occurs with vascular smooth muscle cell transformation resulting in 
mineralization of collagen and non-collagenous proteins within the arterial wall and other CV 
structures. Pathologic calcification of these CV structures is known as vascular calcification. 
In blood vessels, calcified deposits are found in distinct layers of the blood vessel and are 
related to underlying pathology. Intimal calcification occurs in atherosclerotic lesions, 
whereas medial calcification (also known as Monckeberg’s medial sclerosis) is associated 
with vascular stiffening and arteriosclerosis observed with age and metabolic disorders 
including diabetes and end-stage renal disease (ESRD). While intimal and medial 
calcification may each occur independently, patients with ESRD exhibit a mixture of both 
intimal and medial calcification. 
Vascular calcification is considered an actively regulated process that may arise via multiple 
cellular mechanisms, including the loss of inhibitors of mineralization that are typically 
expressed by vascular cells and osteogenic mechanisms operating within vascular lesions. 
Ultimately, no matter the initiating mechanism for vascular calcification, CKD and ESRD 
patients have additional exacerbating ‘passive’ mechanisms of elevated calcium and 
phosphorous, which combine to promote HAP nucleation and calcification crystal growth. 
Furthermore, evidence suggests that calcium and phosphorus may additionally have direct 
effects on vascular cells that predispose to mineralization.  
Computed tomography (CT) scanning using electron beam, spiral, or multi-detector scanners 
is the most common method for quantifying CVC. Common methods for calcium 
quantitation in the coronary arteries include the Agatston CAC score (in Agatston units or 
AU) and the newer calcium volume and mass (mineral) scores. The coronary artery calcium 
(CAC) score is an independent risk factor for adverse CV clinical outcomes in the general 
population (Madhavan 2014) and has been shown to be more predictive of CV disease events 
than carotid intima-media thickness measurement (Folsom 2008). In contrast to the CAC 
score, the calcium volume score represents an actual measured volume of CAC and has been 
reported to exhibit reduced variability between scans. A previous clinical trial evaluating the 
impact of an unrelated therapy on CVC progression in HD patients demonstrated a more 
significant impact on calcium volume score than on the CAC score (Raggi 2011). 
1.1.3 
Cardiovascular Calcification in CKD and ESRD  
As described above, the metabolic and hormonal disorders resulting from the progression of 
CKD to ESRD result in an environment within the circulatory system that is ripe for the 
development of CVC. It has been long recognized that patients with CKD exhibit more 
vascular calcification than arteries from age-matched healthy individuals. Seminal findings 
by Goodman (2000) and additional work by other groups demonstrates that coronary artery 
calcification occurs in young patients with ESRD decades before this pathology is observed 
in the normal population. Moreover, adult patients on receiving HD therapy are reported to 

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have calcification scores over 5-fold higher than age- and sex-matched individuals with 
established coronary artery disease, but normal kidney function. These HD patients displayed 
a disturbing tendency for progression of calcification over one year. Risk factors for greater 
progression of CVC in HD patients include age, diabetes mellitus, time since initiation of 
renal replacement therapy, and elevated levels of serum phosphorous and inflammatory 
markers. In addition to the magnitude of the CVC score, the rate of progression of vascular 
calcification also appears to be an important risk factor for CV events including mortality. 
The major clinical consequences of CVC in ESRD patients include medial artery 
calcification and cardiac valvular calcification. Medial calcification contributes to vascular 
stiffness, resulting in increased pulse-wave velocity, reduced diastolic blood pressure (DBP), 
and increased systolic blood pressure (SBP). These changes lead to increases in cardiac 
afterload and reductions in diastolic coronary artery perfusion pressures, both of which lead 
to left ventricular hypertrophy, diastolic dysfunction and, ultimately cardiac failure with a 
predisposition to arrhythmia and sudden cardiac death. Cardiac valve calcification is a major 
mechanism for valve failure and predisposes to stroke, atrial fibrillation, heart failure and 
sudden cardiac death. CVC is also found in locations of atherosclerotic vascular lesions, 
although the impact of calcification on plaque rupture or stabilization in the general 
population has been questioned recently. Regardless, increased density of calcium in 
atherosclerotic plaques was associated with increased all-cause mortality in a cohort of HD 
patients.  
Thus, the presence and progression of CVC in ESRD patients receiving HD therapy is 
increased compared the general population. Evidence suggests that this elevated CVC burden 
plays an important mechanistic role in the development of CV diseases, including heart 
failure, myocardial infarction (MI), stroke, and both CV-specific and all-cause death. The 
preponderance of data strongly suggests that CVC is an attractive target for an appropriate 
intervention to reduce the growth and propagation of calcification and potentially improve 
CV outcomes in the at-risk ESRD population treated with HD therapy. 
1.1.4 
Current Treatments 
There are no FDA approved therapies indicated for the treatment or reduction of CVC. A 
number of potential therapies putatively target the calcification process, but these are 
currently experimental, and there are few controlled studies on which to base therapeutic 
decisions. Compounds that have been investigated include pyrophosphate and 
bisphosphonates, thiosulfate, and vitamin K (O’Neill 2010). Each of these therapies has 
significant issues precluding either widespread use or specifically use in ESRD patients. 
Due to the lack of available therapy, treatment is currently focused on managing bone 
mineral metabolism (eg, normalizing calcium, phosphorus, and parathyroid hormone [PTH]), 
including either minimizing vitamin D use or considering cinacalcet therapy for secondary 
hyperparathyroidism in patients with known vascular calcification. Current treatment 
guidelines for the management of bone mineral metabolism disorders and related 
complications in CKD and ESRD patients are detailed in the Kidney Disease Outcomes 
Quality Initiative (KDOQI, National Kidney Foundation).  

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CV disease is the most common cause of mortality in patients with CKD and ESRD. CVC 
induced by calcium and phosphate excess and uraemia is a major risk factor and is 
independently associated with CV events and death (Toussaint 2007). 
Coronary artery calcification is a risk factor for adverse clinical outcomes in the general 
population (Madhavan 2014). Patients on dialysis exhibit more severe vascular calcification 
than age and sex-matched individuals without CKD. Moreover, patients on HD are reported 
to have CAC scores as evaluated by electron beam computed tomography (EBCT) over 5-
fold higher than age- and sex-matched individuals with established coronary artery disease, 
but normal kidney function. In addition to the magnitude of the CAC score, the rate of 
progression of vascular calcification also appears to be an important risk factor for CV events 
including mortality. 
In patients with CKD and diabetes mellitus, the risk of CVC increases compared to CKD 
patients without diabetes (Anand 2006). Prolonged exposure to hyperglycemia is a major 
factor in the pathogenesis of atherosclerosis in diabetes. It induces a large number of 
alterations at the cellular level of vascular tissue that potentially accelerate the atherosclerotic 
process including calcification (Aronson 2008). 
1.1.5 
Current Treatment Guidelines 
Current treatment guidelines for CKD and related complications are detailed in the KDOQI 
(National Kidney Foundation). There are a number of potential therapies that directly target 
the calcification process. These include pyrophosphate and bisphosphonates, thiosulfate, and 
vitamin K (O’Neill 2010). However, most of these therapies are considered experimental, 
and there are few controlled studies on which to base therapeutic decisions. There are no 
therapies indicated for treating vascular calcification and therapy is currently focused on 
managing bone mineral metabolism (eg, normalizing calcium, phosphorus, and PTH), 
including either minimizing vitamin D use or considering cinacalcet therapy for secondary 
hyperparathyroidism in patients with known vascular calcification. 
1.2 
INVESTIGATIONAL PRODUCT SNF472 
In an effort to address the significant medical challenges of CVC, SNF472 is being 
developed for the treatment of CVC and calciphylaxis in ESRD patients undergoing HD. 
SNF472 is an intravenous (IV) formulation of the hexasodium salt of myo-inositol 
hexaphosphate (IP6, phytate), a compound that inhibits calcification by binding to the growth 
sites of the HAP crystal. The molecular weight of SNF472 is 791.93 g/mol or daltons. 
IP6 is a naturally occurring substance found in beans, brown rice, corn, sesame seeds, wheat 
bran and other high-fibre foods. It is also present in mammalian cells and tissues at 
concentrations in the μM range (Shears 2001). The calcium salt of IP6 is listed by the US 
FDA as Generally Recognised as Safe (GRAS). It is highly polar and poorly absorbed when 
given orally. When high oral doses are administered, IP6 has chelating properties in the 
gastrointestinal lumen preventing the absorption of cations such as calcium, magnesium and 
iron (Davies 1979; Forbes 1984, Pallauf 1999). Due to this property, it has been regarded for 

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almost 50 years as an anti-nutrient, because it can reduce the gastrointestinal absorption of 
mineral oligoelements. 
The physicochemical properties of IP6 in biological systems make it undetectable with most 
conventional analytical techniques. Its presence in human tissues and body fluids was only 
shown at the end of the 1990s, after the development of sensitive assay methods (March 
1998, Grases 2004, Perelló 2004). Evidence of the potential health benefits of IP6 have 
emerged in parallel with advances in the development of analytical tools for its determination 
in biological fluids and tissues. These benefits include including antitumor, antioxidant, 
antiproliferative and antiplatelet properties. 
A new extracellular role for IP6 as an inhibitor of CVC is claimed by Sanifit, which is the 
rationale for the development of SNF472.  
SNF472 inhibits the final common pathway of CVC (Grases 2008) by inhibiting growth and 
formation of calcium crystals. This effect appears to be independent of the etiology of the 
CVC and is present at any plasma calcium and/or phosphate levels (Grases 1999). 
Based on current information, it is hypothesised that SNF472 is able to slow the process of 
CVC by: 
• blocking the formation and growth of HAP crystals in the blood vessels. SNF472 is a 
polyphosphate with a high affinity for solid calcium salts. It quickly binds to the surface 
of a forming nucleus or on the faces of a growing crystal. It acts as an inhibitor of 
crystallisation at substoichiometric levels, since it specifically binds to the growth sites 
(not the entire crystal surface required) blocking the calcification process. An effect on 
the circulating colloidal calciprotein particles in the blood stream is also likely. SNF472 
might be adsorbed on the surface of these nanoparticles, giving them negative charge and 
avoiding its aggregation to form the solid HAP crystal. 
• avoiding bone mass loss (a source of circulating calcium). As treatment, it could be used 
at serum concentrations far below free calcium concentrations. The target is not the free 
calcium in solution, but solid calcium being deposited on the vessels walls. From 
preclinical data, calcium chelation does not occur at therapeutic concentrations, 
suggesting that there will be no risk of producing hypocalcaemia with therapeutic doses. 
1.2.1 
Nonclinical Data 
SNF472 has been extensively studied in nonclinical models for efficacy, safety, 
pharmacokinetics (PK) and toxicity, and showed a promising profile that supported 
progression to studies in humans. The results of nonclinical studies are summarised in the 
Investigator’s Brochure. 
In vitro and in vivo studies show that SNF472 inhibits the formation of HAP through binding 
to the growing sites of the HAP, thus preventing the progression of crystallisation in vessels 
and soft tissues in IC50 in the range of 2-3 µM. 

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A vitamin D model was also used to evaluate the progression of already established 
calcification. SNF472 was able to stop the progression of calcification when it was 
administered in the presence of an established calcification. 
In a uremic model in rats (adenine model), SNF472 showed an efficacy of 80% when given 
intravenously infused for 4h with a plasma concentration of 6.5 µM in free concentration. 
SNF472 prevented peripheral (skin) calcification in rats in 3 models of calcinosis cutis. 
A pharmacodynamic (PD) assay to measure the crystallisation potential of blood has been set 
up to use as a biomarker to predict SNF472 activity. The first validation was performed in 
rats where the addition of SNF472 to plasma samples, in vitro or in vivo, reduced the HAP 
crystallisation rate. Subcutaneous administration of SNF472 in rats reduced the HAP 
crystallisation potential of plasma by up to 70%. The ex vivo HAP crystallisation rate is being 
used as a PD measurement of the CVC reduction of SNF472 in clinical trials. 
Pre-clinical safety and toxicology work has been completed, including up to 6 months in rats 
and 9 months repeated toxicology in dogs. No-observed adverse effect levels (NOAELs) 
obtained establish a wide safety margin that provides appropriate toxicology support to 
proceed with exposure in long-term clinical trials. 
1.2.2 
Pharmacology 
In vitro and in vivo pharmacological characterisation has been carried out for SNF472. 
Phase 1 clinical trial results of the key studies are summarised in the Investigator’s Brochure. 
1.2.3 
Clinical Experience 
Two Phase 1 studies designed to characterise the pharmacology, efficacy, and safety of 
SNF472 have been carried out, as listed below: 
• SNFCT2012-03 Part A was a double-blind, randomised, phase I, single-dose, tolerability 
and PK study of SNF472 in healthy volunteers. 
• SNFCT2012-03 Part C was a double-blind, randomised, phase I, single-dose, tolerability 
and PK study of SNF472 in HD patients. 
• SNFCT2014-03 was a double-blind, randomised, phase 1b/2a, tolerability and PK study 
of repeated doses up to 1 month of SNF472 in HD patients. 
 
In Part A, 20 healthy male volunteers received single ascending doses of SNF472 ranging 
from 0.5 mg/kg up to 12.5 mg/kg (19 volunteers) and/or placebo (8 volunteers) via IV 
infusion, under fasting conditions. Due to the cross-over design of the study, some of the 
subjects received both SNF472 and/or placebo.  
In Part C, 8 male HD patients were enrolled in the study and received SNF472 (9 mg/kg) or 
placebo during the dialysis session over a 4-h period under fasting conditions.  

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In total, 18 HD patients were enrolled in the Phase 1b/2a study (SNFCT2014-03). In 
Cohort 1, 10 patients were enrolled. Each patient received 5 different doses of SNF472 
ranging from 1 to 20 mg/kg, or placebo. Each dose was infused 3 times a week during HD 
sessions, in treatment periods of 1 week each. In Cohort 2, 8 HD patients were enrolled and 
received 10 mg/kg of SNF472 or placebo, infused 3 times a week, for 4 weeks during HD 
sessions. 
The details of these studies are provided in their respective clinical study reports (CSRs) and 
summarised in the Investigator’s Brochure. 
The Sponsor has also conducted SNFCT2015_04 (EudraCT 2014-004313-25), a Phase 2 
open-label, single arm, repeat dose study to assess the effect of SNF472 on wound healing in 
uraemic calciphylaxis patients. Follow-up of subjects has been completed with full results 
pending. 
1.2.4 
Potential Risks 
As of 13-Feb-2016, a total of 39 healthy volunteers and patients have been exposed to 
SNF472. 
No serious adverse reactions or suspected unexpected serious adverse reactions (SUSARs) 
were reported and no clinically relevant safety concerns were identified. One serious adverse 
event (SAE) of “polycystic kidney infection” was reported in the Phase 1b/2a study. The 
event was not considered to be related to SNF472 and resolved without sequelae. 
SNF472 has been shown to be safe and well tolerated in clinical trials to date, with the 
exception of non-serious mild to moderate local infusion site irritations in healthy volunteers. 
Infusion site irritations are not expected to be an issue in HD patients as SNF472 is infused 
into the dialysis catheter and passed through a volume of blood of at least 200 mL before 
reaching the patient’s blood vessels. 
Treatment-emergent adverse events (TEAEs), assessed as probably related to the SNF472, 
were infusion site pain, infusion site erythema, infusion site hypoesthesia, and infusion site 
swelling in healthy volunteers. TEAEs assessed as possibly related to the SNF472 were 
injection site bruising, headache, dizziness, pain in extremity, eyelid injury, and myalgia in 
healthy volunteers.  
No clinically significant effects of SNF472 were observed for vital signs or laboratory 
values. Electrocardiogram (ECG) analysis revealed no clinically significant effects of 
SNF472. Mild QTcB (QTc corrected by Bazett’s formula) prolongation was observed in 
healthy volunteers, although all QTcB values were under the upper limit of normal values. A 
limited number of ionised calcium values were available for analysis in this study; however, 
the available data suggested that mild hypocalcemia was the causative factor for modest 
prolongation in QTcB. In HD patients exposed to SNF472, no impact on QTcB was 
observed, potentially related to the lack of observable hypocalcemia among these patients 
receiving dialysis therapy. Coincident with SNF472 administration, the continuous systemic 

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exposure to dialysate calcium levels during the dialysis procedure is anticipated to negate any 
potential for mild reductions in serum calcium related to SNF472. 
Based on the totality of preclinical and clinical data generated to date, no clinically relevant 
safety concerns have been identified that preclude continued human investigation.  
1.3 
CORONARY ARTERY CALCIFICATION SCORES 
Coronary artery calcium level is a well-documented marker for coronary atherosclerosis 
(Budoff 2008). There are several methods used in the quantification of the amount of calcium 
in the coronary arteries. CT is the only noninvasive test with high sensitivity and specificity 
for calcium detection and is capable of quantifying calcification. Because of the strong 
correlation between the presence of coronary calcification and underlying coronary 
atherosclerosis, CT imaging of coronary calcium has been determined to be a good predictor 
of cardiac events (Madhavan 2014).  
A variety of imaging results can be produced with a CT scanner, including calcium area, 
volume and mass. Two widely used scoring methods include the calcium volume (or 
volumetric) score and the CAC/Agatston score. The original work (Agatston 1990) was 
based on EBCT which has now evolved in today’s imaging arena to high-speed, multi-
detector CT scanners.  
The CAC score in Agatston units (AU) is calculated using a weighted value assigned to the 
highest density calcification within the coronary artery being measured. The measurement is 
obtained in Hounsfield units and a score assigned based on area in square millimeters and a 
weighted score. The sum of these measurements is then calculated to give the CAC score. It 
is well established that patients with CAC score > 400 AU have an increased occurrence of 
coronary events (Budoff 2006, Greenland 2007). Several cohort studies, including the Multi-
Ethnic Study of Atherosclerosis ([MESA]; McClelland 2006, 2015), the Heinz Nixdorf 
Recall ([HNR]; Budoff 2013, Erbel 2014) study and the ADVANCE study (Floege 2010, 
Raggi 2011) have used calcium scoring, specifically CAC score as primary outcome 
measures. 
The calcium volume score is another measure of CVC using CT scans. This measure has 
been used in several studies and has the advantage over the CAC/Agatston score in reducing 
variability between scans, thus improving reproducibility (Detrano 2005, McEvoy 2010, 
Criqui 2014). For this reason, the calcium volume score may be a more sensitive and 
accurate measure of CVC progression over time. Similar to the CAC score, clinical 
investigations demonstrate that calcium volume is positively and independently associated 
with the occurrence of clinically significant CV events (Criqui 2014).  
1.4 
RATIONALE FOR THE STUDY 
Reducing the progression of CVC in HD patients may improve the severe burden of CV 
disease related to the underlying ESRD. As no therapy is currently indicated to target CVC, 
there is a need to investigate the ability of SNF472 to reduce CVC progression and, 
ultimately, to improve CV outcomes in HD patients. This phase 2b double-blind, 

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randomised, placebo-controlled study is designed as a proof-of-concept trial to assess the 
effect of SNF472 on the progression of CVC as measured by calcium volume and 
CAC/Agatston scores in ESRD patients receiving HD. The study hypothesis is that 
administration of SNF472 over 52 weeks can slow the progression of CVC in this patient 
population compared to placebo. 
2 
STUDY OBJECTIVES 
2.1 
PRIMARY OBJECTIVE 
The primary objective is to assess the effect of 2 dose levels of SNF472 (300 mg and 
600 mg) compared to placebo on the progression of coronary artery calcium volume score 
over a 12-month (52 weeks) period in ESRD patients on HD. 
2.2 
SECONDARY OBJECTIVES 
The secondary objectives of the study are to: 
• assess change from baseline (Week 1, Day 1) in coronary artery calcium (CAC)/Agatston 
score 
• assess the number of patients with <15% progression in CAC/Agatston score 
• assess the change from baseline in thoracic aorta calcification score 
• assess the change from baseline in aortic valve calcification score 
• assess the occurrence of the composite safety endpoint: death from cardiovascular causes, 
myocardial infarction (MI), stroke, or heart failure 
• assess changes in biomarkers as signals for treatment efficacy/response 
• assess changes in bone mineral density (BMD) 
• describe the long-term safety profile of SNF472 in this target population 
2.3 
EXPLORATORY OBJECTIVE 
The exploratory objective is to assess changes from baseline in pulse pressure, systolic blood 
pressure (SBP), and diastolic blood pressure (DBP). 
 
 

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3 
STUDY DESIGN 
3.1 
STUDY DESIGN OVERVIEW 
This study is designed as multicentre, double-blind, randomised, placebo-controlled, phase 
2b study. Approximately 75 sites in 3 countries will enroll approximately 270 patients. The 
study will consist of a screening period, a 52-week double-blind treatment period, and a 
follow-up visit. A study flow chart is provided in Figure 3.1. 
Figure 3.1 
Study Flowchart 
 
 
The study treatment duration of 52 weeks has been selected as an appropriate duration likely 
to provide clinically meaningful changes in the primary outcome. 
3.2 
STUDY ENDPOINTS 
3.2.1 
Primary Endpoint 
The primary endpoint is the change in log coronary artery calcium volume scores between 
baseline (Week 1, Day 1) and Week 52 measured by CT scan. 
3.2.2 
Secondary Endpoints 
The secondary endpoints are 
• change from baseline in CAC/Agatston score at Week 52 
Randomisation
SNF472 
300 mg
SNF472
600 mg
Placebo    
Step 1
Week 1                                                        
Week 52
End of Stdy
Double Blind Treatment Period
F/UP
Week 56
±3 days
Screening
21 ± 3 days
Day1
Day358
Step 2
Trt 
end
calcium
scores
Trt 
start
Treatment 3x Weekly
calcium
scores
See Table of Assessments

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• number of patients with <15% progression in CAC/Agatston score at Week 52 
• change from baseline in thoracic aorta calcification score at Week 52 
• change from baseline in aortic valve calcification score at Week 52 
• incidence of composite safety endpoint that include death from cardiovascular causes, 
MI, stroke, or heart failure 
• mortality rate (all-cause and CV) 
• change from baseline in levels of selected biomarkers, including C-reactive protein 
(CRP) 
 
The endpoints above will be analysed as efficacy as well as safety endpoints. 
The following secondary safety endpoints will be analysed: 
• changes in BMD levels between baseline and Week 52 
• safety of SNF472 in terms of incidences of adverse events (AE) and serious adverse 
events (SAE) and clinically relevant changes from baseline in laboratory and ECG 
parameters  
3.2.3 
Exploratory Endpoints 
The exploratory endpoints are changes from baseline in pulse pressure, SBP, and DBP at 
Week 28 and Week 52 in all patients and in the subgroup of patients with hypertension at 
baseline. 
4 
SELECTION OF PATIENTS 
Approximately 270 patients from approximately 75 sites in 3 countries are planned to be 
enrolled.  
Patients will be required to meet all the inclusion and none of the exclusion criteria detailed 
in subsequent sections to be enrolled in the study. Screening is scheduled 28 + 3 days prior to 
randomisation. 
4.1 
INCLUSION CRITERIA 
Patients meeting all of the following criteria will be considered for enrollment in the study: 
1. female or male patients, 18 to 80 years (inclusive) of age at randomisation 
2. CAC score of 100 to 3500 AU inclusive within a 4-week period prior to randomisation, 
as measured by a multi-detector CT scanner 
3. patients who are EITHER ≥ 55 years OR have a history of diabetes mellitus at 
randomisation 
4. patients on HD for ≥ 6 months prior to randomisation 

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5. willing and able to understand and sign the informed consent 
4.2 
EXCLUSION CRITERIA 
Patients presenting with any of the following will not be included in the study: 
1. scheduled date for kidney transplant from a known living donor 
2. weight above 300 lbs (136 kg) 
3. hospitalisation in the previous 3 months prior to randomisation for unstable angina, MI, 
stroke, transient ischaemic attack, amputation or peripheral or coronary bypass surgery 
4. history of unstable heart failure in the previous 3 months, defined as an unplanned 
presentation to a hospital or dialysis treatment facility with signs/symptoms of acute 
pulmonary edema and requiring ultrafiltration therapy 
5. history of cancer that has been in remission for < 5 years prior to randomisation. A 
history of basal cell carcinoma or Stage 1 squamous cell carcinoma of the skin is allowed  
6. pregnant or trying to become pregnant, currently breast-feeding, or of child-bearing 
potential (including peri-menopausal women who have had a menstrual period within one 
year) and not willing to practice birth control using a double barrier method (criteria 
apply to women only) at least 30 days post last dose of study medication 
7. hypocalcaemia defined as a serum calcium below 8.0 mg/dL (or 2.0 mmol/L) for the 
serum calcium most proximal to screening per patient’s medical records 
8. extreme elevation in serum phosphorous, defined as a phosphorous above 10 mg/dL (or 
3.23 mmol/L) within the last 2 months proximal to screening per patient’s medical 
records 
9. uncontrolled hypertension defined as any 2 or more consecutive post-dialysis DBP 
> 100 mmHg within the last 2 months proximal to screening 
10. expected survival < 2 years in the Investigator’s medical opinion 
11. known active drug or alcohol abuse within 1 year of randomisation  
12. use of other investigational drugs within 30 days of randomisation 
13. non-compliance with dialysis treatment which, in the opinion of the Investigator, 
evidenced by either repeated missed dialysis treatments or significant non-compliance 
with the patient’s medication regimen 
14. Inability to comply with all required study procedures and schedule, inability to speak 
and read in the protocol-derived language of that patient's clinical site, or unwillingness 
or inability to give written informed consent 
4.3 
RE-SCREENING AND SCREEN FAILURES 
Rescreening will be performed on a case-by-case basis after discussion with the Medical 
Monitor. 

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5 
STUDY TREATMENTS 
5.1 
INVESTIGATIONAL DRUGS 
Description of the investigational medicinal product (IMP) is provided below in Table 5.1. 
Table 5.1 
Identity of the Investigational Medical Products 
 
Active Treatment 
Matching Placebo 
Code name 
SNF472 
Not applicable 
Description 
Clear, colourless solution free from 
visible particles 
Clear, colourless solution free from 
visible particles 
Composition 
SNF472, 30 mg per 1 mL of 
physiological saline (0.9% sodium 
chloride) 
Physiological saline (0.9% sodium 
chloride) 
Dosage form 
Solution for IV infusion 
Solution for IV infusion 
Strength 
30 mg/mL 
Identical vials containing physiological 
saline  
Dose based on 85 kg 
body weight (BW) 
300 mg (3.5 mg/kg) 
600 mg (7.0 mg/kg) 
Identical vials are used containing only 
physiological saline 
 
SNF472 is prepared in 10 mL sterile vials of one strength, 30 mg/mL (300 mg/vial). The 
placebo will be supplied to be identical in appearance to SNF472. The full volume of the 
IMP will be administered as a constant rate IV infusion using one 100 mL bag of saline 
connected to an infusion pump, which will be connected directly to the dialysis machine via 
an IV giving set and an accessory heparin line. The infusion should be initiated 
approximately 30 min after the start of the dialysis treatment procedure and should take 
2.5 hrs. 
NOTE FOR UNITED STATES SITES ONLY: The preferred physiological saline bag size 
for dilution of the IMP is 100 mL. However, if 100 ml bags of physiological saline are not 
available, 150 mL or 250 mL bags may be used as described in Appendix 3. 
All patients will receive 2 identical vials of 10 mL: 
• Placebo arm: 2 vials of physiological saline  
• Dose 1 arm (300 mg): 1 vial of physiological saline and 1 vial of active (10 mL SNF472 
at 30 mg/mL)  
• Dose 2 arm (600 mg): 2 vials of active (10 mL SNF472 at 30 mg/mL) 
5.2 
DOSE RATIONALE 
The planned doses for this study are 300 mg (2.5-4 mg/kg for 75-120 kg bodyweight) and 
600 mg (5-8 mg/kg for 75-120 kg bodyweight) to be administered at every dialysis session 
during the treatment period. Administration is detailed in Section 5.5. 

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The dose response relationship with respect to vascular calcification in HD patients has been 
estimated using preclinical models of calcification along with a biomarker assay designed to 
provide an estimate of the PD activity of SNF472. These separate lines of evidence suggest a 
very steep dose response relationship with a narrow range between initial evidence of 
efficacy and asymptotic maximal efficacy.  
The biomarker assay results using both rat and human HD patient plasma samples suggest 
that SNF472 is able to inhibit systemic blood calcification when plasma levels are above the 
calculated IC50, estimated at plasma concentrations of ~5000 ng/mL (achieved with dosing of 
~ 2 mg/kg in humans). The PK-PD relationship estimated by the biomarker assay 
demonstrates a very steep dose-response curve, with ~ 70% inhibitory activity of SNF472 at 
3 mg/kg and a plateau of just over 80% inhibitory activity at 5 mg/kg and higher. 
Multiple preclinical models of accelerated cardiac and aorta calcification in rats demonstrate 
that doses below 1 mg/kg produce no effect; doses of 1 mg/kg can produce ~60% inhibition 
of calcification; and the maximal effect of 80% inhibition is seen at doses of 3 mg/kg and 
higher. Thus, a steep dose response curve is also demonstrated in these in vivo models. 
Pre-clinical safety and toxicology studies suggest an appropriate margin of safety for the 
doses tested in this clinical trial. Repeated dose administration of SNF472 was studied in rats 
for up to 6 months and up to 9 months in dogs. Hypocalcaemia, accompanied by QTc 
change, is the main adverse effect noted in rats and dogs when treatment is administered by 
bolus injection. This effect, thought to be due to chelation of plasma calcium in the presence 
of SNF472, is not seen when treatment is administered by infusion. Local injection site 
reaction, and associated thrombus formation, was observed in the 28 day and 6 month studies 
in rats but not in dogs when dosed up to 9 months. This event is believed to be related to 
local irritation when SNF472 is injected into a small caliber vein. Injection site reactions 
were observed in the healthy volunteer study, where treatment was given into a peripheral 
vein, but not in HD patients who received the treatment as part of the dialysis procedure. 
In this clinical trial, SNF472 is being administered via slow infusion and diluted within 
dialyses tubing by at least 200 mL volume of blood, thus ensuring lower Cmax concentration. 
Additionally, avoidance of hypocalcaemia is expected based on the constant exposure to a 
standard calcium concentration gradient across the dialysis membrane, which allows free 
exchange of calcium from dialysate to plasma compartments. SNF472 has been dosed for up 
to 1 month at 10 mg/kg in HD patients with no evidence of hypocalcaemia, local injection 
site irritation or other drug related toxicity. 
Taking into consideration the steep pharmacological activity observed with SNF472, doses of 
300 mg (2.5-4 mg/kg for 75-120 kg bodyweight) and 600 mg (5-8 mg/kg for 75-120 kg 
bodyweight) are considered appropriate options to evaluate clinical efficacy and are well 
within the anticipated safety and toxicity margins for the drug.  
5.3 
TREATMENT ASSIGNMENT 
Patients will be randomised to either one of two active drug dose levels or placebo (1:1:1). 

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Each patient’s treatment will be given a unique code number, traceable to the batch number 
of the IMP. The SNF472 and matched placebo treatments will be identical in appearance. To 
maintain the blinded nature of the clinical trial, the same volume of solution will be 
administered to each patient in a treatment group. 
5.3.1 
Randomisation 
Randomisation will be used to avoid bias and to enhance the validity of statistical 
comparisons. Blinded treatment (active and matched placebo) will be used to reduce 
potential bias during data collection and evaluation of clinical endpoints. 
Randomisation should occur on Day 1 after all pre-dose procedures have been performed and 
eligibility for the clinical trial has been confirmed. However, it is acceptable for first dose to 
occur on a later day than randomisation to accommodate for pharmacy/IMP preparation 
needs. For clarity, Day 1 Week 1 is the first dose date. Randomisation will be performed 
using a centralised electronic randomisation system.  
Due to the strong association of baseline CAC score on subsequent calcification progression, 
baseline CAC score will be used as a randomization stratification factor by breaking into 
three categories (100-399, 400-1000 and >1000). In keeping with the ICH E9 guidance, 
baseline CAC score will be included in the primary efficacy analysis. 
5.3.2 
Patient Identification 
At screening, each patient will be assigned a unique 4-digit screening number which will be 
used as the patient identification (ID) number all throughout the study. The numbers will be 
sequential. The patient ID should be used on all study documents relating to the patient from 
screening and throughout the study. No recognisable personal patient data (names, initials, 
etc.) will be collected. 
5.4 
BLINDING, PACKAGING, AND LABELING 
5.4.1 
Blinding 
The clinical trial will be performed in a double-blind manner, i.e., the Investigator, all 
clinical staff, the volunteers, and the Clinical Monitor involved in the trial will remain 
blinded throughout the clinical trial, unless safety concerns or a regulatory requirement make 
unblinding necessary. 
5.4.2 
Unblinding 
The clinical trial blind should not be broken except in a medical emergency (where 
knowledge of the IMP administered would affect the treatment of the emergency) or 
regulatory requirement (e.g., for SAEs).  
The decision to break the blind can only be made by the Investigator or other persons duly 
registered in the clinical trial file as sub-Investigator after consulting with the Medical 
Monitor. Unblinded staff members will not convey information regarding treatment 

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assignments in the clinical trial, whether informally or formally, to any other person, unless 
required for medical reasons. If the blind is broken, the date, time, and reason must be 
recorded and included in any associated AE report. 
If an emergency unblinding becomes necessary, the Investigator should notify the 
Sponsor/Medical Monitor prior to unblinding, if possible, unless identification of the IMP is 
required for emergency therapeutic measures.  
If either an Investigator or a patient is unblinded, the patient must be withdrawn from the 
clinical trial and procedures accompanying early termination visit will have to be performed. 
5.4.3 
Packaging 
SNF472 will be packaged, labeled, and supplied to study sites by: 
CSM Europe SA 
Watson & Crick Hill 
Rue Granbonpré 11 
1435 Mont-Saint-Guibert, Belgium  
Phone: +32 10 237 439 
Fax: +32 (0)10 470 860 
Email: mdenis@csmondemand.com  
The IMP at CSM Group will be stored in accordance with the manufacturer’s instructions 
(-20ºC). The IMP will be labelled according to the applicable local health authority, FDA and 
EMA requirements. CSM Group will send the IMP to the local depots and these will then 
send the IMP to the Clinical Unit. All IMP shipments will be carried out on dry ice. 
All supplies of SNF472 must be stored on site at 5±3ºC. The preparation of the patient doses 
will be described in the Pharmacy Manual.  
5.5 
ADMINISTRATION OF INVESTIGATIONAL MEDICINAL PRODUCTS 
The IMP will be administered 3 times weekly in conjunction with the patient’s dialysis 
sessions. The IMP administration will consist of one of 2 doses of SNF472 or placebo 
administered intravenously during HD. The infusion should be initiated approximately 
30 min after the start of the HD procedure and should take 2.5 hrs.  
The Principal Investigator or designees will administer/oversee the administration of all 
IMPs. The exact infusion starting and stopping times will be recorded in the electronic case 
report form (eCRF). 
The appropriate volume of the IMP will be administered as a constant rate IV infusion over 
2.5 hrs using a 100 mL bag of saline connected to an infusion pump, which will be connected 
directly to the dialysis circuit before the dialyzer via an IV giving set. 

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Figure 5.1 
Method of Administration 
 
 
 
5.6 
SUPPLIES AND ACCOUNTABILITY 
IMP will be sent to the sites from CSM Europe SA where it will be stored prior to the 
initiation of the study. The Investigators are responsible for maintaining accurate 
accountability records of the IMP throughout the clinical trial. 
Pharmaceutical services at the sites will keep cumulative inventory and dispensing records as 
appropriate throughout the clinical trial. Each administration of the IMP will be documented 
in the eCRF. 
Unused IMP will be destroyed following each site’s Drug Destruction Policy. The IMP 
destruction will only occur after drug accountability has been performed, after any 
discrepancies have been resolved, and after receiving approval of destruction by the Sponsor 
or designee. 
5.7 
COMPLIANCE 
The Principal Investigator or designees will administer/oversee the administration of all 
IMPs. In addition, the following measures will be taken to ensure treatment compliance: 

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• The Investigator will attempt to enroll patients that are able to understand and comply 
with the clinical trial requirements. 
• The exact day and the starting and stopping times of the IMP infusion will be recorded in 
the eCRF. 
• The Investigator will maintain accountability records showing the quantities of IMPs 
received at the site and dispensed to each patient. 
Any empty or partially used containers will be accounted for and destroyed according to each 
site’s drug destruction policy. Any unused IMP, will be accounted for and destroyed 
according to each site’s drug destruction policy after obtaining written Sponsor approval. 
6 
STUDY PROCEDURES AND SCHEDULE 
The timing of assessments required during the study is outlined in Table 1.1. Data will be 
collected using eCRF and an appropriate Electronic Data Capture (EDC) system, as 
described in Section 12. 
6.1 
DESCRIPTION OF STUDY DAYS 
Table 1.1 Schedule of Assessments and Study Activities describes the different activities 
per study visit, the assessments on intensive data collection visits. If also participating in 
Sub-Study, please see additional Schedule of Sub-Study Assessments in Appendix 1. 
6.1.1 
Screening (28 + 3 days) 
Screening will be conducted in two steps.  
6.1.1.1 
Step 1 
• Obtain written informed consent. 
• Determine patient eligibility according to the inclusion and exclusion criteria defined in 
Section 4. 
• Obtain a CT scan of the coronary artery using a multi-detector CT with at least 64 slices 
to measure calcium volume and CAC scores. The CAC score will be used for eligibility 
determination (only patients with CAC score of 100 to 3500 AU are eligible for the 
study), the volume and CAC scores for the endpoints. Refer to the Imaging Manual for 
detailed procedure. 
• In conjunction with the CT scan, BMD will be measured by dual-energy x-ray 
absorptiometry (DEXA). Refer to the Imaging Manual for detailed procedure. 
• Ensure that the patient meets the CAC score eligibility criterion of 100 – 3500 AU before 
proceeding to Step 2. 
6.1.1.2 
Step 2 
• Once the CAC score inclusion criterion is met, continue with the evaluation of patient 
eligibility according to the inclusion and exclusion criteria defined in Section 4. 

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• Record medical history and demographics. 
• Perform physical examination, including height and weight. 
• Record treatment history and current and prior medications (prescription drugs only taken 
30 days prior to Screening), therapies and surgical procedures. 
• Draw blood samples via the dialysis port for serum pregnancy test for female patients of 
childbearing potential. Blood volumes are defined in the laboratory manual. 
• Measure 12-lead ECG, including QTc interval (post-dialysis if done during a dialysis 
session). 
• Measure and record vital signs (heart rate [HR], respiratory rate [RR], blood pressure 
[BP], and body temperature [degree C]) (post-dialysis if done during a dialysis session). 
6.1.2 
Treatment Period 
6.1.2.1 
Week 1 
• Review and confirm patient eligibility according to the inclusion and exclusion criteria 
pre-dose as defined in Section 4. 
• Complete the randomisation process. 
• Draw blood samples via the dialysis port pre-dose for safety laboratory assessments 
(Table 6.1), including serum pregnancy testing for female patients of childbearing 
potential. Blood volumes are defined in the laboratory manual. 
• Draw blood samples via the dialysis port pre-dose for PTH, ferritin, transferrin saturation 
(TSAT). Blood volumes are defined in the laboratory manual. 
• For participating sites, draw blood samples for PK and biomarkers via the dialysis port 
pre-dose and at 3 hrs (~10 minutes before end of infusion). Blood volumes are defined 
in the bioanalytical manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis. 
• Measure post-dialysis weight. 
• Record change in concomitant medications (only prescription drugs), relative to previous 
visit.  
• Assess and record AEs. 
6.1.2.2 
Weeks 1 to 52 (3x weekly) 
• Administer study treatment 3x week during each HD session in the dialysis unit as 
described in Section 5.5. 
• Perform all standard of care assessments. 

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6.1.2.3 
Week 2 (preferably at mid-week HD session) 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.4 
Week 4 (preferably at mid-week HD session) 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Record change in concomitant medications (only prescription drugs), relative to previous 
visit. For administration of iron preparations, see Section 6.2.6. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.5 
Week 6 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for serum pregnancy test for female 
patients of childbearing potential. Blood volumes are defined in the laboratory manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.6 
Week 10 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for safety laboratory assessments 
(Table 6.1), including serum pregnancy test for female patients of childbearing potential. 
Blood volumes are defined in the laboratory manual. 
• For participating sites, draw blood samples for PK and biomarkers via the dialysis port 
pre-dose and at 3 hrs (~10 minutes before end of infusion). Blood volumes are defined 
in the bioanalytical manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure 12-lead ECG, including QTc interval post-dialysis. 
• Measure post-dialysis weight. 
• Record change in concomitant medications (only prescription drugs), relative to previous 
visit. For administration of iron preparations, see Section 6.2.6. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.7 
Week 16 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for serum pregnancy test for female 
patients of childbearing potential. Blood volumes are defined in the laboratory manual. 

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• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.8 
Week 22 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for serum pregnancy test for female 
patients of childbearing potential. Blood volumes are defined in the laboratory manual. 
• For participating sites, draw blood samples for PK and biomarkers via the dialysis port 
pre-dose and at 3 hrs  (~10 minutes before end of infusion). Blood volumes are defined 
in the bioanalytical manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.9 
Week 28 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for safety laboratory assessments 
(Table 6.1), including serum pregnancy test for female patients of childbearing potential. 
Blood volumes are defined in the laboratory manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure 12-lead ECG, including QTc interval post-dialysis. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis.  
• Measure post-dialysis weight. 
• Record change in concomitant medications (only prescription drugs), relative to previous 
visit. For administration of iron preparations, see Section 6.2.6. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.10 
Week 34 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for serum pregnancy test for female 
patients of childbearing potential. Blood volumes are defined in the laboratory manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.11 
Week 40 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for safety laboratory assessments 
(Table 6.1), including serum pregnancy test for female patients of childbearing potential. 
Blood volumes are defined in the laboratory manual. 

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• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure 12-lead ECG, including QTc interval post-dialysis. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis. 
• Measure post-dialysis weight. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.12 
Week 46 (preferably at mid-week HD session) 
• Draw blood samples pre-dose via the dialysis port for serum pregnancy test for female 
patients of childbearing potential. Blood volumes are defined in the laboratory manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Assess and record any new AEs relative to previous visit. 
6.1.2.13 
Week 52 (preferably at mid-week HD session) / Early Termination 
• Obtain a CT scan of the coronary artery using a multi-detector CT with at least 64 slices 
to measure calcium volume and CAC scores. Refer to the Imaging Manual for detailed 
procedure. 
• In conjunction with the CT scan, BMD will be measured by DEXA. Refer to the Imaging 
Manual for detailed procedure. 
• Perform physical examination, including weight. 
• Draw blood samples pre-dose via the dialysis port for safety laboratory assessments 
(Table 6.1), including serum pregnancy test for female patients of childbearing potential. 
Blood volumes are defined in the laboratory manual. 
• Draw blood samples pre-dose via the dialysis port for PTH, ferritin and TSAT. Blood 
volumes are defined in the laboratory manual. 
• For participating sites, draw blood samples for PK and biomarkers via the dialysis port 
pre-dose and at 3 hrs (~10 minutes before end of infusion). Blood volumes are defined 
in the bioanalytical manual. 
• Administer study treatment in the dialysis unit as described in Section 5.5. 
• Measure 12-lead ECG, including QTc interval post-dialysis. 
• Measure and record vital signs (HR, RR, BP and body temperature [degree C]) post-
dialysis.  
• Measure post-dialysis weight. 
• Record change in concomitant medications (only prescription drugs), relative to previous 
visit. For administration of iron preparations, see Section 6.2.6. 
• Assess and record any new AEs relative to previous visit. 

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6.1.2.14 
Early Termination 
Assessments are identical to those scheduled for Week 52. PK and biomarker samples will be 
collected during this visit if the post-baseline samples have not been collected prior to early 
termination. A CT scan for calcium quantification and DEXA for BMD should be done. If 
this is not possible for this visit, the site must make all efforts to set an appointment for a CT 
scan and DEXA. In addition, sites must encourage patients to report for a follow-up visit (see 
Section 6.1.3). 
6.1.3 
Follow-up Visit (Week 56 or 1 month after last dose) 
• Assess and record SAEs only. 
6.2 
METHODS OF EVALUATION 
6.2.1 
Efficacy Assessments 
6.2.1.1 
CT Scan 
A CT scan of the thoracic area will be performed using a multi-detector CT scanner with at 
least 64 slices at Screening (Step 1) and at Week 52 as shown in Table 1.1. The scan should 
be performed onsite or in a nearby facility. The methodology is described in detail in the 
Imaging Manual. 
6.2.1.2 
Calcium Scores 
From the CT scans, the following scores will be calculated: 
• calcium volume score 
• CAC/Agatston score in AUs 
• thoracic aorta calcification score 
• aortic valve calcification score 
The calculations are described in detail in the Imaging Manual. 
6.2.1.3 
Cardiovascular Events and Mortality 
Composite safety outcomes that include death from cardiovascular causes, MI, stroke, or 
heart failure will be assessed. Heart failure is defined as an unplanned presentation to a 
hospital or dialysis treatment facility with signs/symptoms of acute pulmonary edema and 
requiring ultrafiltration therapy.  
In addition, all-cause and CV mortality will also be assessed and recorded. 
6.2.2 
Pharmacokinetics 
Samples for PK analyses will be collected from subjects at participating sites which have 
a -70°C freezer for sample storage or, if requested by Sponsor, samples may be shipped on 

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dry ice on the same day as collection. Samples will be collected via the dialysis port at pre-
dose and at 3 hrs (~10 minutes before end of infusion) on the assessment day. 
The schedule of PK sampling is detailed in Table 1.1. The actual date and time of each blood 
sample collected will be recorded. PK analyses will be performed in central laboratories 
using a bioanalytical laboratory manual. 
For sites, PK samples (see also Section 6.2.3) will be stored at -70°C freezer and/or be 
packed on dry ice and shipped by courier as requested by the Sponsor to a qualified specimen 
storage depot/laboratory to hold until analysis is performed. 
When requested by Sponsor, all EU samples will be shipped by courier to Envigo for 
analysis. ALL PK samples will be analysed at:  
Department of Bioanalytics, Metabolism and Screening  
Envigo S.A.  
Ctra. de Castellar a Sentmenat C-1415, km 29,300 
08211-Castellar del Vallès, Barcelona, Spain  
Phone: +34 937 190 361  
Fax: +34 937 299 731  
6.2.3 
Biomarkers 
Samples for biomarker analyses will be collected from a subset of patients from participating 
sites which have a -70°C freezer for sample storage or as requested by Sponsor for same day 
dry ice shipment.. The samples will be collected via the dialysis port at pre-dose and at 3 hrs 
(~10 minutes before end of infusion) on the assessment day. The schedule of biomarker 
sampling is detailed in Table 1.1. The actual date and time of each blood sample collected will 
be recorded. 
CRP will be measured with the high sensitivity CRP test (hs-CRP). Additional biomarkers 
may include but are not limited to fetuin A, FGF23, MGP, sclerostin, phosphorus 
(phosphate), PD, and GDF15. No genetic testing will be conducted. 
For sites, serum samples for biomarkers analysis will be stored at -70°C freezer (see also 
Section 6.2.2), and/or will be packed on dry ice and shipped by courier as requested by the 
Sponsor to a qualified specimen storage depot/laboratory to hold until analysis is performed. 
Biomarker analyses will be performed in central laboratories using a laboratory manual. 
6.2.4 
Safety Assessments 
6.2.4.1 
Adverse Events 
The Investigator will carefully monitor each patient for AEs at each key evaluation visit as 
shown in Table 1.1. In addition, the information on AEs will be obtained by regular 
questioning of each patient by the clinical trial staff. No leading questions should be asked. 
When an AE occurs, the Investigator will decide whether to withdraw the patient from the 
clinical trial and/or initiate appropriate treatment. Generally, withdrawal is not warranted 

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unless there is clinical reason why this would benefit the patient. However, if the withdrawal 
does occur, the investigator will ensure that the patient is given appropriate medical care.  
In the case of any event requiring medical intervention occurring during the Treatment 
Period, the Investigator will institute general supportive measures including, where 
necessary, respiratory assistance and cardiopulmonary resuscitation. 
AEs are discussed in detail in Section 7. HD-related AEs, as listed in Section 7.2, should be 
recorded and indicated as such in the eCRF. 
6.2.4.2 
Bone Mineral Density 
BMD will be measured by DEXA at Screening (Step 1) and Week 52/ET visit. The 
methodology is described in detail in the Imaging Manual.  
6.2.4.3 
Medical History 
At Screening (Step 2), the patient’s medical history will be recorded in the eCRF under the 
medical history section. The medical history will comprise of previous illnesses and history 
of drug and alcohol abuse. 
6.2.4.4 
Physical Examination 
A physical examination (including weight and height) will include an examination of general 
appearance, skin, head and neck, chest, lungs, heart, abdomen, extremities and basic nervous 
system evaluation. If any physical findings are abnormal, the Investigator must document the 
abnormality as non-clinically significant or clinically significant. Any abnormality assessed 
as ‘CS’ must be recorded as an AE if not explained by a coexisting condition (documented in 
the medical history). Weight will be measured post-dialysis as part of the physical 
examination. 
Information about the physical examination must be present in the source documentation at 
the study site. Significant findings must be reported on the eCRF. 
6.2.4.5 
Vital Signs 
Vital signs (SBP and DBP, HR, RR, and body temperature) will be assessed post-dialysis at 
each assessment visit after the patient has been sitting for 5 min. The data are recorded for 
the study at key visits only. Standard of care vital signs assessments are not being recorded 
into study database at each HD visit. 
6.2.4.6 
Electrocardiograms 
Standard 12-lead ECGs (including QTc) will be performed at Screening and post-dialysis 
assessment visits as scheduled in Table 1.1. 
6.2.4.7 
Laboratory Evaluations 
The list of safety laboratory evaluations is provided in Table 6.1. Blood samples will be 
collected pre-dose via the dialysis port for haematology, coagulation, and chemistry tests. 

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Table 6.1 
Safety Laboratory Assessments 
Haematology 
haematocrit 
haemoglobin 
platelet count 
white blood cell (WBC) count (total and 
differential) 
Coagulation 
international normalised ratio (INR) 
partial thromboplastin time (PTT) 
prothrombin time (PT) 
Biochemistry 
alanine transaminase (ALT) 
albumin 
alkaline phosphatase (ALP) 
amylase 
aspartate transaminase (AST) 
bicarbonate 
blood urea nitrogen (BUN) 
calcium 
chloride 
creatinine 
gamma-glutamyl transpeptidase (GGT) 
glucose 
lactic acid dehydrogenase (LDH) 
magnesium 
phosphorus (phosphate) 
potassium 
sodium 
total bilirubin 
total protein 
uric acid 
 
The following safety parameters will also be analysed: 
• PTH level is an indicator of mineral metabolism status and will be monitored as safety 
laboratory. 
• Ferritin and TSAT are indicators of iron level status and will be monitored as safety 
laboratory. 
6.2.4.8 
Pregnancy 
All female patients of childbearing potential must use 2 reliable methods of contraception 
(see Section 6.3.2) until study completion and for at least 30 days following their final dose 
of study medication.  
For female patients of childbearing potential, serum pregnancy tests will be performed at the 
visits indicated in Table 1.1.  
Female subjects who become pregnant during the trial or within 1 month after the last dose of 
IMP will be followed for safety during the pregnancy through 1 month after delivery or 
termination of the pregnancy.  
6.2.5 
Collection Schedule for Biological Samples 
6.2.5.1 
Blood 
All blood samples will be drawn via the dialysis port following the schedule in Table 1.1. 
The volumes of the blood draws will be specified in the respective laboratory manual. 

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6.2.5.2 
Sample Handling, Shipment and Retention 
Collection, storage and handling of biological samples are described in the laboratory 
manual. See Sections 6.2.2 and 6.2.3 for storage and handling of PK and biomarkers samples, 
respectively. 
6.2.6 
Prior and Concomitant Treatments 
Only prescription drugs other than the IMP will be considered as prior and concomitant 
medications. At Screening, the patient’s treatment history of the past 30 days will be 
recorded in the eCRF under the prior concomitant medications section. Changes in prior 
medications relative to Screening will be documented prior to the first dose of IMP. 
Medications taken with or after the first dose of IMP will be considered concomitant 
medication. Changes in concomitant medications relative to the previous visit will be 
documented following the schedule in Table 1.1; only prescription concomitant medications 
are to be recorded.  
The use of iron preparations as part of standard of care is allowed. The timing of iron 
preparation administration relative to the IMP treatment is at the discretion of the site but 
should be documented in the eCRF. 
6.3 
RESTRICTIONS AND PRECAUTIONS 
6.3.1 
Dietary and Fluid Restrictions 
Food and fluids allowed will be in accordance with the dietary requirements for the HD 
patients. 
6.3.2 
Contraception Requirements 
To prevent pregnancy in a female patient or partner of a patient, or to prevent fertilisation of 
female participants in the study, they should be non-fertile, ie, post-menopausal females, 
surgically sterilised, or must practice an effective contraceptive method to prevent 
pregnancies.  
Effective contraceptive methods include: 
• Sexual abstinence starting before the first administration of the IMP until 30 days after 
final administration of the IMP. 
- 
Note: Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation 
methods) and withdrawal are not acceptable methods of contraception. 
• Female patients of child bearing potential should use an oral or injectable hormonal 
contraceptives, contraceptive patch, intrauterine devices, vaginal hormonal rings, vaginal 
diaphragm or cervical caps from before the first administration of the IMP until 30 days 
after final administration of the IMP. 
• Male patients should use a condom in addition to having their female partner use another 
acceptable method (see bullet point above). 

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- 
Note: Male patients must not have unprotected sexual intercourse with a female who 
is pregnant or breastfeeding during the clinical trial. 
• Male patient’s female sexual partner is of non-childbearing potential, ie, post-menopausal 
or surgically sterilised (eg, tubal ligation, hysterectomy in medical history). 
7 
ADVERSE EVENTS 
7.1 
DEFINITIONS 
7.1.1 
Adverse Event 
An AE is defined by the International Council for Harmonization (ICH) Guideline for Good 
Clinical Practice (ICH E6 GCP) as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and that does not necessarily 
have a causal relationship with this treatment. 
A TEAE is defined as an AE that begins or that worsens in severity after at least one dose of 
the IMP has been administered. 
AEs fall into the categories “non serious” and “serious” (see Section 7.1.2). 
Surgical procedures or laboratory values themselves are not AEs; they are therapeutic 
measures for conditions that require surgery or diagnose a condition. The condition for which 
the surgery or laboratory value is indicative for is an AE if it occurs or is detected during the 
study period. Planned surgical measures and the condition(s) leading to these measures are 
not AEs if the condition(s) was (were) known before the period of observation (see 
Section 7.2). In the latter case the condition should be reported as medical history. 
7.1.2 
Serious Adverse Event 
A SAE is one that at any dose (including overdose): 
• results in death 
• is life-threatening1 
• requires inpatient hospitalisation or prolongation of existing hospitalisation2 
• results in persistent or significant disability or incapacity3 
• is a congenital anomaly or birth defect 
• is an important medical event4 
1. “Life-threatening” means that the patient was at immediate risk of death at the time of the 
SAE; it does not refer to a SAE that hypothetically might have caused death if it were more 
severe. 
2. This means that hospital inpatient admission or prolongation of hospital stay was required for 
the treatment of the AE, or that one or the other occurred as a consequence of the event. 
3.  “Persistent or significant disability or incapacity” means a permanent or significant and 
substantial disruption of a person’s ability to carry out normal life functions. 

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4. Medical and scientific judgment should be exercised in deciding whether expedited reporting 
is appropriate in situations where none of the outcomes listed above occurred. Important 
medical events that may not be immediately life-threatening or result in death or 
hospitalisation but may jeopardise the patient or may require intervention to prevent one of 
the other outcomes listed in the definition above should also usually be considered serious. 
7.1.3 
Adverse Event by Severity or Intensity 
Assessment of severity of an AE will be rated according to the criteria in Table 7.1. 
Table 7.1 
Definitions of Adverse Events Severity 
Grade 1 (Mild) 
Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated. The AE does not interfere with routine activities. The 
patient may experience slight discomfort. 
Grade 2 (Moderate) 
Moderate; minimal, local or noninvasive intervention indicated. The AE interferes 
with routine activities. The patient may experience significant discomfort. 
Grade 3 (Severe) 
Severe or medically significant but not immediately life-threatening; hospitalisation 
or prolongation of hospitalisation indicated. The patient is unable perform routine 
activities. The patient may experience intolerable discomfort or pain. 
Grade 4 (Life-
Threatening) 
Life-threatening consequences; urgent intervention indicated. 
Grade 5 (Fatal) 
Death related to AE 
Based on the Common Terminology Criteria for Adverse Events v4.0 (CTCAE) 
7.1.4 
Relationship between Adverse Events and Investigational Product 
Determination of the relationship (if any) between the AE and the study drug will be made 
using the guidelines below: 
Table 7.2 
Guidelines for Determining the Relationship (if any) Between Adverse 
Event and the Study Drug 
Definite: 
This causal relationship is assigned if the AE starts a reasonable time after the 
administration of study drug, stops/improves when the study drug is stopped, and 
could reasonably be explained by known characteristics of the study drug. 
Probable: 
This causal relationship is assigned when the AE starts a reasonable time after the 
administration of study drug, stops/improves when the study drug is stopped, and 
could not be reasonably explained by known characteristics of the patient’s clinical 
state. 
Possible: 
This causal relationship is assigned when the AE starts a reasonable time after the 
administration of study drug, but could be produced by the patient’s clinical state or 
other modes of therapy administered to the patient. 
Not Related: 
This causal relationship is assigned when the time association or the patient’s clinical 
state is such that the study drug was not likely to have had an association with the 
observed AE. 
 

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7.2 
HAEMODIALYSIS-RELATED EVENTS 
The following events are known to occur during HD treatments: 
• hypotension 
• muscle cramps 
• disequilibrium syndrome 
• nausea and vomiting 
• headache 
• chest pain 
• itching 
• fever and chills 
• pyrogen reaction 
• hypertension 
Occurrence of these events should be recorded in the eCRF and indicated as HD-related 
events. 
The cannula inserted in a forearm vein for the collection of blood samples can lead to 
superficial irritation of the vein, inflammation or clot formation. This will be appropriately 
treated by the clinical trial staff and not reported as an AE in the eCRF or the CSR. 
7.3 
PERIOD OF OBSERVATION 
The AEs assessment will be carried out by the Investigator throughout the study period, ie, 
from baseline (first dose of IMP) until Week 56 (Follow-up Visit). 
All AEs experienced by a patient, irrespective of the suspected causality, will be monitored 
until the event has resolved, any abnormal laboratory values have returned to baseline or 
stabilised at a level acceptable to the Investigator and Medical Monitor, until there is a 
satisfactory explanation for the changes observed, or until the patient is lost to follow-up. 
7.4 
DOCUMENTATION AND REPORTING OF ADVERSE EVENTS 
7.4.1 
Documentation and Reporting of Adverse Events by Investigator 
7.4.1.1 
Recording of Adverse Events 
AEs will be collected from the first time a patient receives IMP until Week 52/ET; during the 
1-month follow up after last dose of IMP (Week 56), only SAEs will be documented. All 
AEs after informed consent signature but before first IMP administration should be captured 
as medical history. 

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All AEs, regardless of the relationship to IMP, will be recorded in the eCRF and documents 
provided by the Sponsor. All AE reports should contain a brief description of the event, date, 
and time of onset, date and time of resolution, intensity, type of AE whether serious or non-
serious, treatment required, causal relationship to IMP, action taken with the IMP, and 
outcome. 
7.4.1.2 
Reporting of Adverse Events 
All SAEs that occur during the period of observation (from the first administration of the 
IMP until Week 56 [or 1 month after last dose]) whether considered to be associated with the 
IMP or not, must be entered into the EDC system for reporting within 24 h to the Safety 
Contact (see Section 9.1). An alternative method of reporting will be provided to sites should 
they not have access to the EDC system. 
The Investigator should not delay initial SAE report entry due to missing data. As soon as the 
minimum information is available, and no later than 24 h after becoming aware of the SAE 
event, the initial SAE report will be entered into eCRF. The eCRF will automatically 
generate a notification e-mail that will inform the Safety Associate at the Contract Research 
Organisation (CRO) and at the Sponsor that an SAE has been reported. 
Each initial SAE report should contain at least the following information: 
• sender of report (name, address of Investigator) 
• patient identification (screening/randomisation number, NO names, NO initials) 
• protocol number 
• details of the IMP 
• Investigator’s identification 
• AE (description, start date, outcome on the day of the report) 
• Investigator’s assessment of seriousness and intensity (severity) 
• Investigator’s assessment of causal relationship to study drug and study procedures 
If necessary, the Investigator will provide follow-up reports in a timely manner after 
knowledge of further relevant information. 
A 24h- emergency contact will be available during the conduct of the clinical trial. For 
medical emergencies, phone numbers will be available for contacting the Medical Monitor in 
each participating country. 
After receipt of the initial report, the Safety Centre will review the information and, if 
necessary, contact the Investigator to obtain further information for assessment of the event. 
The Investigator will be responsible for informing the Institutional Review Board (IRB) or 
Independent Ethics Committee (IEC), and the Sponsor will be responsible for informing the 
Regulatory Authority of the SAE as per local requirements. 

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If considered necessary, the Investigator may decide to withdraw patients from the study as a 
consequence of SAEs or AEs. 
If a patient is withdrawn from the study due to an AE at the end of the Treatment Period, the 
patient should be followed-up until an outcome of the event can be defined. If this is not 
possible due to clinical or organisational reasons, an outcome assessment has to be performed 
by the Investigator. A final examination should be performed. 
AEs will be coded by data management using the latest version of Medical Dictionary for 
Regulatory Activities (MedDRA) and displayed in tables and listings using MedDRA system 
organ class (SOC) and preferred term. 
7.4.2 
Reporting of Adverse Events by Sponsor 
The Sponsor or their designee will provide annual safety reports to the Regulatory 
Authorities and the Independent Ethics Committee (IEC) responsible for the clinical trial, as 
applicable. These updates will include information on SUSARs and other relevant safety 
findings. 
Any AE that is serious, unexpected, and has evidence suggesting a causal relationship to IMP 
(ie, a SUSAR) has additional reporting requirements. Reporting of SUSARs will follow all 
applicable local safety reporting requirements. 
The Sponsor or their designee will notify the Investigators of relevant information about 
SUSARs that could adversely affect the safety of patients in a timely fashion. Follow-up 
information may be submitted if necessary. 
7.5 
DATA AND SAFETY MONITORING BOARD 
A Data and Safety Monitoring Board (DSMB) will monitor patient safety and data integrity. 
The roles and responsibilities of the DSMB are defined in a DSMB Charter. 
8 
DISCONTINUATION AND WITHDRAWALS  
8.1 
REMOVAL OF PATIENTS FROM THE STUDY 
After discussion with the Medical Monitor a patient may be discontinued from study 
medication or withdrawn from the study for reasons including but not limited to 
• AE 
• patient request/withdrawn consent 
• Investigator’s decision 
• study termination by the Sponsor 
 
All patients who discontinued prematurely will continue with their standard of care dialysis 
sessions. They will report for an early termination visit, as described in Table 1.1 and 

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Section 6.1.2.14. The sites will make every effort to get post-baseline CT scans and DEXA 
and to have patients return for a follow-up visit. 
If considered necessary, the Investigator may decide to withdraw patients from the study for 
safety reasons. 
8.2 
REPLACEMENT OF PATIENTS 
Patients withdrawn from the study will not be replaced. 
8.3 
WITHDRAWAL OF SAMPLES 
Blood samples collected will be stored under the control of Laboratoris Sanifit for a 
maximum of 1 year after study end and then destroyed. In case of early discontinuation, no 
additional samples will be collected from the patient. The patient has the right to withdraw 
any remaining biological samples or have them destroyed. 
9 
EMERGENCY PROCEDURES 
9.1 
EMERGENCY SPONSOR CONTACT 
All SAEs that occur during the study must be reported immediately (within 24 hrs of 
awareness). Detailed SAE reporting instructions and training will be provided to study site 
personnel. 
9.2 
EMERGENCY IDENTIFICATION OF INVESTIGATIONAL PRODUCTS 
See unblinding procedures in Section 5.4.2. 
10 STATISTICAL METHODS  
The primary endpoint of coronary artery calcium volume score values will be log-
transformed prior to analysis. The primary analysis will use an ANCOVA model with the 
change in log score (log 52 week score – log week1/day1 score] as the dependent variable 
and with a fixed effect term for randomised treatment group and log coronary artery calcium 
volume score at baseline as a covariate; the model will also be stratified by the randomization 
stratification factor, i.e. baseline CAC/Agatston score.  
10.1 GENERAL STATISTICAL CONSIDERATIONS 
10.1.1 
Analysis Sets 
The following analysis populations will be defined: Safety, modified Intent-to-Treat (mITT), 
and Per Protocol (PP). 
The Safety population will consist of all randomised patients who receive at least one dose of 
IMP. Patients will be analysed according to the treatment they received. The Safety 
population will be used for analyses of AEs and safety endpoints. 

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The mITT population will consist of all enrolled patients who are randomised, receive at 
least one dose of IMP, and have at least one post-randomization efficacy evaluation. Patients 
will be analysed according to the treatment to which they were randomised. The mITT 
population will be handled as the primary efficacy analysis population. 
The PP population is the subset of the mITT population who do not have any major protocol 
violations or deviations (both of which will be determined prior to final data lock and 
unblinding). The PP population will be used for secondary/supportive efficacy analyses. 
10.1.2 
Subgroups and Subsets 
10.1.3 
Covariates and Strata 
The primary efficacy analysis will be adjusted for log coronary artery calcium volume score 
at baseline as a covariate. The analysis will be stratified for baseline CAC score (as this is a 
stratification variable in the randomization). 
As exploratory analysis, clinically relevant covariates will be included in the analysis model, 
including but not limited to: age, use of non-calcium containing phosphate binder at baseline, 
diabetes status at baseline, and dialysis vintage. If any covariates are considered to be 
imbalanced across the treatment arms, then those covariates will also be included in the 
covariate-adjusted model to determine if they have an impact on calcification progression. 
10.2 DEMOGRAPHICS AND BACKGROUND CHARACTERISTICS 
The treatment groups will be compared for baseline demographic and disease history 
variables. 
10.2.1 
Demographics  
Demographic and baseline characteristic data will be summarised with descriptive statistics 
across the 3 treatment arms. Demographic variables will include sex, race, ethnicity, age, and 
diabetes status. 
10.2.2 
Disease Characteristics 
Disease characteristics will be summarised with descriptive statistics across the 3 treatment 
arms. Disease characteristic variables will include diabetes status, baseline CAC score, 
baseline calcium volume score, years since primary ESRD diagnosis, use of non-calcium 
containing phosphate binder at baseline, and dialysis vintage. 
10.2.3 
Disposition 
Patient disposition over time will be presented overall as well as separately for each 
treatment arm, showing the number of patients screened, enrolled, randomised, treated, etc. 
Reasons for early discontinuation from study will be presented with frequencies and 
percentages for all categories.  

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10.2.4 
Exposure and Compliance 
Study treatment dosing compliance will be summarised with descriptive statistics by 
treatment group. 
10.2.5 
Concomitant Therapies 
Concomitant medications will be coded with the World Health Organisation (WHO) drug 
dictionary. Concomitant medications will be summarised with descriptive statistics by drug 
Anatomical Therapeutic Chemical (ATC) Classification System (level one), generic name, 
and treatment group. 
Dialysis calcium ion concentrations will be recorded as concomitant medications. 
10.3 EFFICACY ANALYSES 
The mITT analysis population will be considered primary for all primary and secondary 
efficacy analyses. Unless specified otherwise, all baseline assessments will be based upon the 
Week 1, Day 1 assessment. 
10.3.1 
Primary Efficacy Analysis 
The primary endpoint of coronary artery calcium volume score values will be log-
transformed prior to analysis. The primary analysis will use an ANCOVA model with the 
change in log score (log 52-week score – log week1/day1 score] as the dependent variable 
and with a fixed effect term for randomised treatment group and log coronary artery calcium 
volume score at baseline as a covariate; the model will also be stratified by the randomization 
stratification factor, i.e. baseline CAC/Agatston score. LS  means for each of the 3 treatment 
groups will be estimated and back transformed prior to presentation. The main contrasts of 
interest to assess treatment effect will be the difference in LS means between each dose and 
placebo and between the average of the two doses vs placebo. These contrasts and their 
estimated 95% CIs will be back transformed prior to presentation. P-value for each contrast 
will also be provided. 
To facilitate data interpretation, the preceding ANCOVA will be re-run but with the log of 
the 52-week coronary artery calcium volume score as the dependent variable (i.e., without 
subtracting log baseline score). This will allow estimation of the absolute 52-week score by 
back transformation as well as the common baseline score so that the degree of absolute 
change in coronary artery calcium volume score can be assessed in a fashion that is 
consistent with the preceding analysis of the change in log score. 
 
The secondary endpoint of change from baseline in CAC/Agatston score at Week 52 will be 
analyses in the same manner as the primary endpoint.  
Underlying details of the other secondary analyses will be specified in the Statistical 
Analysis Plan (SAP). 

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10.3.2 
Missing Data 
The primary efficacy analysis will impute missing Week 52 calcium volume score via last 
observation carried forward (LOCF) imputation; per Table 1.1, patients who discontinue 
early will have a calcium volume assessment at the time of discontinuation – for those 
patients, that last calcium volume value will be used for the missing Week 52. In addition to 
LOCF imputation, additional analyses using multiple imputation will be implemented to 
explore the impact of missing data. Firstly, missing data will be imputed within each arm 
using distribution implied by the non-missing patient data for that arm. Secondly, missing 
data will be imputed for all arms using distribution implied by the non-missing patient data 
within the placebo arm. Further, tipping point analyses may be performed to assess how 
extreme a departure in the distribution of data from patients with missing values would have 
to be to render the primary endpoint analysis non-significant. 
10.3.3 
Multiple Comparisons / Multiplicity 
The trial will not be adjusted for multiple comparisons. The primary efficacy analysis (high-
dose active to control) will be assessed at the 0.05 significance level. Secondary efficacy 
analyses will all be examined at the 0.05 significance level. 
10.3.4 
Secondary and Exploratory Analyses 
Secondary efficacy analyses will be implemented to assess the treatment effect on a variety 
of efficacy endpoints. Continuous variables will be analysed via ANCOVA; categorical 
variables will be analysed by chi-square. All-cause mortality will be displayed descriptively 
using the Kaplan-Meier curves, censoring subjects as of the last known contact.  
Secondary efficacy variables include: 
• change from baseline (Week 1, Day 1) in CAC/Agatston score at Week 52 
• number of patients with <15% progression in CAC/Agatston score at Week 52 
• change from baseline (Week 1, Day 1) in thoracic aorta calcification score at Week 52 
• change from baseline (Week 1, Day 1) in aortic valve calcification score at Week 52 
• incidence of composite safety endpoint that include death from cardiovascular causes, 
MI, stroke, or heart failure 
• mortality rate (all-cause and CV) 
• change from baseline (Week 1, Day 1) in levels of CRP and other selected biomarkers 
• changes in BMD between baseline (Week 1, Day 1) and Week 52 
• safety of SNF472 in terms of incidences of adverse events (AE) and serious adverse 
events (SAE) and clinically relevant changes from baseline in laboratory and ECG 
parameters  
 

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The exploratory efficacy variables are changes from baseline in pulse pressure, systolic blood 
pressure (SBP), and diastolic blood pressure (DBP) at Week 28 and Week 52. 
 
The final list of biomarkers will be defined prior to database lock. The underlying details of 
the secondary and exploratory analyses will be specified in the SAP. 
10.4 SAFETY ANALYSES 
Safety analyses will be performed on the Safety analysis population. 
10.4.1 
Adverse Events 
All reported terms (Investigator descriptions) for AEs will be coded using the most recent 
version of the MedDRA and summarised with frequencies and percentages by treatment 
group, SOC classification, and preferred term. 
Additionally, AE summaries will be broken out by all AEs occurring during treatment and 
follow-up periods, all TEAEs, Sponsor-identified AEs of special interest, AEs leading to 
discontinuation from the study, AEs possibly or probably related to study treatment, and AEs 
by Common Terminology Criteria for Adverse Events (CTCAE) severity. For all AE 
summaries, events will be counted only once for a given patient by primary SOC and 
preferred term. When an AE occurs more than once for a patient, the maximum severity and 
causality will be used. 
All AEs will be included in comprehensive data listings. A separate listing will be included 
for AEs leading to discontinuation from study. 
10.4.2 
Bone Mineral Density 
BMD is an indication of bone health and CKD patients may develop mineral and bone 
disease (CKD-MBD). To assess whether this occurs, BMD will be assessed at baseline 
(Week 1, Day 1) and Week 52. BMD will be analysed using the same analysis method as the 
primary efficacy model – an ANCOVA of Week 52 BMD T-score adjusted for baseline 
(Week 1, Day 1) score and treatment group. 
10.4.3 
Clinical Laboratory Evaluation 
Laboratory assessments and change from baseline will be summarised with descriptive 
statistics by panel, test, treatment group, and time point. Additionally, abnormal results will 
be summarised with frequencies and percentages by clinical significance, panel, test, 
treatment group, and time point. 
10.4.4 
Vital Signs 
The results of change from baseline of vital signs (including HR, RR, SBP and DBP, body 
temperature, and weight) will be summarised with descriptive statistics by treatment group 
and time point. 

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10.4.5 
ECG 
ECG findings will be summarised with frequencies and percentages by treatment group and 
time point. 
10.4.6 
Physical Findings and Other Observations Related to Safety 
The results of physical examinations will be summarised with frequencies and percentages 
by category, treatment group, and time point. 
10.5 OTHER STATISTICAL ANALYSES 
Additional statistical analyses and more detailed descriptions of the methods presented in this 
protocol will be included in a separate SAP. 

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10.6 DETERMINATION OF SAMPLE SIZE 
The hypothesized values for calcium volume score at baseline and Week 52 for placebo 
(standard of care) are provided in the table below. These data are derived from the 
ADVANCE trial (Raggi 2010).  The standard deviation of the change from baseline to Week 
52 in calcium volume scores is estimated to be 0.30 on the log scale (Raggi 2010). 
 
Hypothesized values for calcium volume score at baseline and Week 52 for placebo 
  
Placebo 
Assumed percentage change in calcium volume score progression from baseline to Week 52 
35% 
Expected raw calcium volume score at Week 52 assuming a raw calcium volume score of 
380 at baseline (Week 1, Day 1) 
513 
Expected change in log-transformed calcium volume score progression from baseline to 
Week 52  
0.30 
Estimated standard deviation of change in log-transformed calcium volume scores from 
baseline to Week 52 
0.30 
 
With N=270 subjects randomized (ie, 90 per group) and 200 patients expected to provide 
Week 52 data, and assuming a 35% progression in CAC score on placebo at Week 52, this 
trial has 80% power with a 1-sided alpha level of 2.5% to test the hypothesis that the true 
difference between SNF472 high dose vs placebo in log CAC progression scores is 0.146.  
This corresponds to a true ratio of CAC progression scores, SNF472 high dose vs placebo, of 
1.157 which, in turn, corresponds to a 16.7% progression score on SNF472 high dose vs 35% 
on placebo.     
The corresponding value for the average of the two SNF472 doses vs placebo to provide 80% 
power to test the hypothesis that the true difference between SNF472 average dose vs 
placebo alone in log CAC progression scores is 0.126.  This corresponds to a true ratio of 
CAC progression scores, SNF472 average dose vs placebo of 1.134 which, in turn, 
corresponds to a 19.0% progression score on SNF472 average dose vs 35% on placebo.   
10.7 INTERIM ANALYSIS 
Approximately 270 subjects were planned to be randomized with N=190 expected to provide 
Week 52 data on the primary endpoint in the final analysis. A non-binding interim futility 
analysis will be conducted when approximately N=120 subjects (63% of N=190) have 
provided Week 52 data. The purpose of this interim analysis is to ascertain if the conditional 
power for achieving a statistically significant result in the final analysis of the two SNF472 
doses combined would be low, ≤ 5%; if so the study may be declared futile and subject 
follow-up may consequently cease. There is no plan or intent to curtail follow-up at this 
interim for a positive efficacy finding. Conditional power is to be computed under the result 
observed at the interim as per Mehta and Pocock (2011).  
In the event of an equivocal result of the futility analysis indicating borderline conditional 
power of the study, additional analyses of the same dataset will be conducted to support 
forward decision making regarding clinical development of SNF472. Additional analyses 

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will include primary and secondary endpoints, demographic and background characteristics, 
key subgroups, and PK/PD correlations with efficacy. Further details will be provided in the 
SAP. 
In addition, PD and PK analyses will be performed at the time of the interim analysis. PD as 
the percent inhibition of HAP crystallization and PK as the EOI plasma levels (Cmax) may 
be analyzed by timepoint (Week 1, 10, 22, and 52) or by pooling all timepoints. The percent 
inhibition and Cmax may be then used to calculate a PK/PD correlation between both 
parameters by timepoint and by pooling all timepoints. Further details will be provided in the 
SAP. 
10.8 CHANGES IN THE CONDUCT OF THE STUDY OR PLANNED 
ANALYSIS 
Any changes to the protocol-specified analyses will be described and explained in the SAP 
and/or CSR. 
11 REGULATORY, ETHICAL AND LEGAL OBLIGATIONS 
11.1 GOOD CLINICAL PRACTICE 
The procedures set out in this Clinical Trial Protocol are designed to ensure that the Sponsor 
and the Investigator abide by the principles of the guidelines provided by the ICH E6 GCP 
and the Declaration of Helsinki and applicable amendments. The clinical trial will also be 
carried out according to the national and local legal requirements. 
11.2 INFORMED CONSENT 
All patients will be required to participate in the consent process. During the consent process, 
the person obtaining consent will inform the patient of all elements of informed consent. No 
protocol specific procedures, including screening procedures will be performed until the 
patient has signed and dated an IRB/IEC - approved informed consent form (ICF). Study 
participation will start with the signing and dating of the ICF. 
The Investigator must ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the clinical trial. Patients 
must also be notified that they are free to withdraw from the clinical trial at any time without 
prejudice to future care. The patient should be given the opportunity to ask questions and 
allowed time to consider the information provided. 
In case of protocol amendment, the Subject Information Sheet and ICF need to be revised to 
reflect the changes, if needed. Also, if the Subject Information Sheet and ICF are revised, 
they must be reviewed and approved by the responsible IRB/IEC, and signed by all patients 
subsequently enrolled in the clinical trial as well as those currently enrolled in the clinical 
trial. 

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11.3 PATIENT CONFIDENTIALITY AND DISCLOSURE 
All clinical trial findings and documents will be regarded as confidential. The Investigator 
and members of his research team must not disclose such information without prior written 
approval from the Sponsor. 
The anonymity of participating patients must be maintained. All patient data will be 
identified only by a patient identification number. Documents that identify the subject (e.g., 
the signed Subject Information Sheet and ICF) must be maintained in confidence by the 
Investigator. However, in compliance with federal guidelines regarding the monitoring of 
clinical studies and in fulfillment of his/her obligations to the Sponsor, the Investigator must 
permit the study monitor, Sponsor representative or auditor, and/or FDA representative or 
other regulatory authority to review the portion of the patient’s medical record that is directly 
related to the study. This shall include all study-relevant documentation including medical 
history to verify eligibility, admission/discharge summaries for hospital stays occurring while 
the patient is enrolled in the study and autopsy reports if a death occurs during the study. 
11.4 PROTOCOL AMENDMENTS 
To alter the Clinical Study Protocol (CSP), amendments must be written. Administrative 
changes may be made without the need for a formal CSP Amendment, but will also be 
mentioned in the integrated CSR. All CSP Amendments will be distributed to all CSP 
recipients, with appropriate instructions. 
11.5 APPROVAL OF THE CLINICAL STUDY PROTOCOL AND 
AMENDMENTS 
Before the start of the clinical study, the CSP and other relevant documents will be approved 
by the IRB/IEC/Regulatory Authorities in accordance with local legal requirements. The 
Sponsor must ensure that all ethical and legal requirements have been met before the first 
patient is enrolled in the clinical trial. This CSP should be followed exactly. 
The CSP Amendments must be released by the responsible staff and receive 
IRB/IEC/Regulatory Authority approval prior to implementation (as appropriate). The only 
circumstance in which an amendment may be initiated without prior IRB/IEC approval is to 
eliminate an apparent immediate hazard to a patient or patients. In such a case, however, the 
Investigator must notify the Sponsor immediately and the IRB/EC within 5 working days 
after implementation or according to the Investigator’s IRB/IEC requirements. 
11.6 ONGOING INFORMATION FOR INDEPENDENT ETHICS 
COMMITTEE/ INSTITUTIONAL REVIEW BOARD 
If a safety issue of clinical relevance is identified, from review of any data, then the Sponsor 
will issue prompt notification to all parties ‒ Investigator and IRB/IEC/Regulatory 
Authorities. 

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A safety issue of clinical relevance is one that has a relevant impact on the course of the 
clinical trial or program (including the potential for suspension of the clinical trial program or 
amendments to the CSP) or warrants immediate update of the Subject Information Sheet and 
ICF. 
11.7 CLOSURE OF THE STUDY 
The Investigator is required to submit eCRFs and all other relevant data and records to the 
Sponsor. The Investigator will complete and report (submission of eCRFs) his/her study in 
satisfactory compliance with the protocol as soon as possible after the completion of the 
study. 
The Investigator must submit a final report as required by their IRB/IEC of study completion 
or early termination. 
11.8 RECORD RETENTION 
According to ICH guidelines, essential documents should be retained for a minimum of 2 
years after the last approval of a marketing application in an ICH region and until there are 
no pending or contemplated marketing applications in an ICH region or at least 2 years have 
elapsed since the formal discontinuation of clinical development of the IMP. However, these 
documents should be retained for a longer period if required by the applicable legal 
requirements. 
12 DATA MANAGEMENT, MONITORING AND AUDITS 
12.1 STUDY MONITORING 
The CRO will be responsible for monitoring the trial according to GCP guidelines. 
Clinical Research Associates (CRAs) will conduct both central monitoring and monitoring 
on site. 
Central monitoring will include data review by the CRA via the EDC off-site, with a focus 
on incomplete fields and fields where potential errors could exist, based on the CRA’s 
understanding of the data specification. 
On site, the CRA will review the eCRF data entry against the source documents. Handling of 
queries and clarification/reconciliation of queries between the CRA and the site will be 
described in the eData Management Plan (eDMP). 
12.2 DATA CAPTURE AND VERIFICATION 
Data capture and management will be conducted using the CRO’s clinical management and 
EDC/eCRF system. The EDC/eCRF system will be compliant with the Health Insurance 
Portability and Accountability Act (HIPAA) and meet all requirements for 21 CFR Part 11. 
The processes and responsibilities of data collection, management and quality assurance will 
be specified in the eDMP. 

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All applicable study data collected on each subject will be entered by approved site personnel 
into the eCRF. Instructions for the completion and submission of eCRFs will be provided to 
the sites in a separate document. 
Authorised personnel will verify all data entered into eCRFs for completeness and accuracy 
with reference to the source documents and records and will issue data queries to correct 
missing data or discrepancies found against the source within the EDC system. Data 
validation will consist of automated and manual edit checks that are created directly in the 
EDC system. Edit checks will be executed on all data points defined and documented by the 
study team and data management will be able to issue manual queries as needed to the eCRF. 
Study metrics will be reported from the EDC system. 
Only authorised site personnel will be able to enter/modify/correct data in the eCRF. Once all 
data have been verified by approved staff at the CRO, an Investigator or sub-Investigator 
listed on the statement of Investigators (Form FDA 1572) must sign the eCRF. 
12.3 ON-SITE AUDITS 
During the course of the study and/or after it has been completed, 1 or more study sites may 
be audited by authorised representatives of the Sponsor. The purpose of the audit is to 
determine whether or not the study is being conducted and monitored in compliance with 
recognised GCP/ICH guidelines and regulations. 
Additionally, the study may be inspected by regulatory authorities. These inspections may 
take place at any time during or after completion of the study and are based on local 
regulations. 
13 DOCUMENTATION AND USE OF STUDY FINDINGS 
13.1 DOCUMENTATION OF STUDY FINDINGS 
An eCRF must be completed and submitted for each subject enrolled, including those 
discontinued from the study for any reason. For screen failures, only baseline demographics 
and the reason for discontinuation will be recorded. The eCRFs must be kept current to 
reflect the subject’s status at each phase during the course of the study. Subjects are not to be 
identified on eCRFs by name; appropriately coded by subject identification number. The 
Investigator must keep a separate log of the subjects’ names and addresses. 
Source documents such as the clinic chart are to be maintained separately from the eCRF to 
allow data verification. Because of the potential for errors, inaccuracies, and illegibility in 
transcribing data onto eCRFs, originals of laboratory and other test results must be kept on 
file at the site. Source documents and copies of test results must be available at all times for 
inspection by the CRA. 
13.2 USE OF STUDY FINDINGS 
By signing the CSP, the Investigator agrees with the use of results of the clinical trial for the 
purposes of national and international registration, publication, and information for medical 

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and pharmaceutical professionals. If necessary, the Regulatory Authorities will be notified of 
the Investigator’s name, address, qualifications, and extent of involvement. 
An Investigator shall not publish, or present for publication any articles or papers, or make 
any presentations, nor assist any other person in publishing any articles or papers, or making 
any presentations, or making any public declaration relating or referring to the clinical trial, 
the results of the clinical trial, in whole or in part, without the prior written consent of the 
Sponsor. 
13.3 STUDY REPORT, PUBLICATION POLICY AND ARCHIVING OF 
STUDY DOCUMENTATION 
13.3.1 
Study Documents 
The Investigator must maintain primary source documents supporting significant data for 
each subject’s medical notes. These documents, which are considered ‘source data’, should 
include documentation of: 
• demographic information 
• evidence supporting the diagnosis/condition for which the patient is being studied 
• general information supporting the subject’s participation in the study 
• general history and physical findings 
• CT scans 
• DEXA scans 
• ECG tracings 
• laboratory test results 
• Investigator’s prescriptions/concomitant medications for the respective subject related to 
this study 
• unscheduled laboratory test or other investigation, if done 
• hospitalisation or Emergency Room records (if applicable) 
• each study visit by date, including any relevant findings/notes by the Investigator(s), 
occurrence (or lack) of AEs, and changes in medication usage, including the date the IMP 
was started and stopped 
• any additional visits during the study 
• any relevant telephone conversations with the subject regarding the study or possible AEs 
The Investigator must also retain all subject-specific printouts/reports of tests and procedures 
performed as a requirement of the study. During monitoring visits the CRA will validate 
eCRF entries against these sources of data. 

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Toussaint ND, Kerr PG. Vascular calcification and arterial stiffness in chronic kidney disease: Implications and 
management. Nephrology. 2007; 12:500-509. 
USRDS (United States Renal Data System) 2015 annual data report. Epidemiology of kidney disease in the 
United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 
Bethesda, MD, 2015. 

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APPENDIX 1 Sub-Study Protocol: For Opt-In Sites Only 
SNFCT2015-05 Sub-Study 
Sub-Study to Assess the Effects of SNF472 on Arterial 
Stiffness and Cardiovascular Function in ESRD Patients 
on Hemodialysis 
 
Investigational Product: 
SNF472 
Indication: 
CVC in ESRD 
Sponsor: 
Laboratoris Sanifit 
Palma de Mallorca, Spain 
EudraCT Number 
2016-002834-59 
IND Number 
116437 
Conduct: In accordance with the ethical principles that originate from the Declaration of 
Helsinki and that are consistent with International Council for Harmonisation Guidelines 
on Good Clinical Practice (ICH E6 GCP) and regulatory requirements as applicable. 
CONFIDENTIAL INFORMATION 
This document is the sole property of Laboratoris Sanifit. This document and any and all 
information contained herein has to be considered and treated as strictly confidential. This 
document shall be used only for the purpose of the disclosure herein provided. No 
disclosure or publication shall be made without the prior written consent of Laboratoris 
Sanifit. 
 

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SUB-STUDY PROTOCOL SYNOPSIS 
Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
Title of Study:  Sub-Study to Assess the Effects of SNF472 on Arterial Stiffness and 
Cardiovascular Function in ESRD Patients on Hemodialysis 
Protocol Number:  SNFCT2015-05 Sub-Study 
EudraCT: 2016-002834-59 
IND Number: 116437 
Number of Patients and Study Centre(s): It is estimated that up to 50% of the sites 
participating in the main study may opt into participating in the Sub-Study in order to enroll 
up to 200 subjects. 
Indication:  Cardiovascular calcification (CVC) in ESRD 
Objectives: 
The primary objective of this Sub-Study is to assess the effect of 2 dose levels of SNF472 
(300 mg and 600 mg) compared to placebo on the progression of arterial stiffness as 
measured by an absolute change in pulse wave velocity (PWV) over a 52-week period in 
ESRD patients on HD. 
The secondary objectives of this Sub-Study are to assess: 
• Change from Sub-Study Entry in left ventricular mass index (LVMI) 
• Change from Sub-Study Entry in left ventricular (LV) function parameters 
 
The exploratory objectives of this Sub-Study are to assess: 
• Change from Sub-Study Entry in left atrial (LA) function and change in parameters over 
time 
• Change from Sub-Study Entry in aortic valve gradient 
 
Methodology: Patients enrolled in the main study will be eligible to participate in this Sub-
Study and will be requested to undergo additional assessments as outlined in the Sub-Study 
Schedule of Assessments. 
Endpoints: 
The primary endpoint is the absolute change in aortic PWV (m/s) from Sub-Study Entry to 
Week 52 by 2-dimensional (2D) echocardiography. 
The secondary endpoints will be assessed by 2-D echocardiography and are: 
• Absolute change in LVMI from Sub-Study Entry to Week 52.  
• Absolute change in LV function from Sub-Study Entry to Week 52:  
• Absolute change in the ratio of mitral inflow early diastolic to mitral annular velocity 
(E/e’ ratio) 

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Sponsor: 
Laboratoris Sanifit 
Investigational Product: 
SNF472 
Developmental 
Phase: Phase 2b 
• Absolute change in mitral annular early diastolic tissue velocity (e’) measured with tissue 
Doppler (average of septal and lateral values) 
• Absolute change in LV global longitudinal systolic strain (%) measured by speckle 
tracking echocardiography 
The exploratory endpoints are: 
• Absolute change in additional measures of LA volume (mL) and LA ejection fraction 
from Sub-Study Entry to Week 52: 
• Absolute change in PWV, LVMI and other parameters of LV and LA function over time 
(Weeks 28 and 52). 
• Absolute change in aortic valve gradient from Sub-Study Entry to Week 28 and 
Week 52) in all subjects and in the subgroup of subjects with evidence of aortic stenosis 
at Sub-Study Entry 
 
Criteria for Inclusion: 
1. Participant in the main study 
2. Willing and able to understand and sign the additional Sub-Study informed consent 
Criteria for Exclusion: 
1. Presence of current atrial fibrillation, atrial flutter with variable atrioventricular 
conduction, or very frequent premature beats (premature ventricular contractions 
[PVCs]) 
2. A diagnosis of primary hypertrophic obstructive cardiomyopathy, or cardiac infiltrative 
disease (such as cardiac amyloidosis). 
3. Severe cardiac valve disease 
Test Product, Dose and Mode of Administration:  Per main protocol 
Reference Therapy, Dose and Mode of Administration:  Per main protocol 
Study Duration: Per main protocol 
Statistical Methods: 
The primary Sub-Study endpoint will be summarized using descriptive statistics (by treatment 
arm) and analyzed using an ANCOVA model to compare the 2 active treatment groups 
(pooled) to the control group, with the Week 52 value as the response variable, and Sub-
Study Entry value and treatment group as explanatory variables. This comparison will be 
evaluated using a 95% 1-sided level of significance and will be conducted in the Sub-Study 
ITT and PP populations. Pairwise comparisons, relative to the control, will be presented as 
90% two-sided confidence intervals. 
The secondary and exploratory endpoints will be summarized using descriptive statistics by 
treatment arm and analyzed using methods similar to the primary Sub-Study endpoint. 
 

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TABLE OF CONTENTS 
 
SUB-STUDY PROTOCOL SYNOPSIS .................................................................................70 
TABLE OF CONTENTS .........................................................................................................72 
LIST OF IN-TEXT FIGURES .................................................................................................73 
LIST OF IN-TEXT TABLES ..................................................................................................73 
LIST OF ABBREVIATIONS NOT USED IN THE MAIN PROTOCOL .............................74 
1 INTRODUCTION .............................................................................................................75 
1.1 
Rationale for the Sub-Study ...................................................................................75 
1.1.1 
Background ................................................................................................75 
1.1.2 
Considerations in the Selection of Cardiovascular Endpoints ...................77 
2 SUB-STUDY OBJECTIVES ............................................................................................82 
2.1 
Primary Objective ..................................................................................................82 
2.2 
Secondary Objectives .............................................................................................82 
2.3 
Exploratory Objectives ..........................................................................................82 
3 STUDY DESIGN...............................................................................................................83 
3.1 
Study Design Overview .........................................................................................83 
3.2 
Study Endpoints .....................................................................................................83 
3.2.1 
Primary Endpoint .......................................................................................83 
3.2.2 
Secondary Endpoints .................................................................................83 
3.2.3 
Exploratory Endpoints ...............................................................................83 
4 SELECTION OF PATIENTS ............................................................................................83 
4.1 
Inclusion Criteria ...................................................................................................84 
4.2 
Exclusion Criteria ..................................................................................................84 
5 STUDY PROCEDURES AND SCHEDULE ....................................................................84 
5.1 
Schedule of Assessments .......................................................................................84 
5.2 
Description of Study Days .....................................................................................86 
5.2.1 
Screening (up to Week 4) ..........................................................................86 
5.2.2 
Treatment Period ........................................................................................86 
5.2.2.1 
Sub-Study Entry (up to Week 4 after First Dose) ..............................86 
5.2.2.2 
Week 28 (±2 weeks) ..........................................................................86 
5.2.2.3 
Week 52/ET (±2 weeks) ....................................................................86 
5.3 
Methods of Evaluation ...........................................................................................86 
5.3.1 
Efficacy Assessments .................................................................................86 
5.3.1.1 
Echocardiographic Assessments ........................................................86 

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6 STATISTICAL METHODS ..............................................................................................87 
6.1 
General Statistical Considerations .........................................................................87 
6.1.1 
Analysis Sets ..............................................................................................87 
6.2 
Demographics and Background Characteristics ....................................................87 
6.2.1 
Demographics ............................................................................................87 
6.2.2 
Disease Characteristics ..............................................................................87 
6.3 
Efficacy Analyses ..................................................................................................87 
6.3.1 
Primary Efficacy Analysis .........................................................................87 
6.3.2 
Missing Data ..............................................................................................88 
6.3.3 
Multiple Comparisons / Multiplicity .........................................................88 
6.3.4 
Secondary and Exploratory Efficacy Analyses ..........................................88 
6.3.5 
Sensitivity Analyses ...................................................................................88 
6.4 
Determination of Sample Size ...............................................................................88 
7 SUB-STUDY REFERENCES ...........................................................................................89 
APPENDIX 2. PROTOCOL AMENDMENT 1: SUMMARY OF CHANGES .....................95 
APPENDIX 3. PROTOCOL AMENDMENT 1.1 UNITED STATES ONLY .......................97 
APPENDIX 4. PROTOCOL AMENDMENT 1.1 UNITED STATES ONLY: 
SUMMARY OF CHANGES .............................................................................................98 
 
LIST OF IN-TEXT FIGURES 
Figure 3.1 
Study Flowchart ............................................................................................31 
Figure 5.1 
Method of Administration ............................................................................38 
Figure S.1.1 
Pathological Pathways through which Aortic Stiffness may Contribute to the 
Development of Diastolic Dysfunction ........................................................76 
 
LIST OF IN-TEXT TABLES 
Table S.5.1 
Schedule of Sub-Study Assessments and Visits ...........................................85 
 

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LIST OF ABBREVIATIONS NOT USED IN THE MAIN PROTOCOL 
Abbreviation 
Definition 
2D 
2-dimensional 
4D 
Deutsche Diabetes Dialyse studies 
AASK 
African-American Study of Kidney Disease 
CF 
carotid-femoral 
CRIC 
Chronic Renal Insufficiency Cohort 
DCOR 
Dialysis Clinical Outcomes Revisited study 
EACVI 
European Association of Cardiovascular Imaging 
e’ 
mitral annular early diastolic tissue velocity  
E/e’ 
ratio of mitral inflow early diastolic to mitral annular velocity 
EF 
ejection fraction 
eGFR 
estimated glomerular filtration rate 
Einc 
incremental elastic modulus 
ET 
early termination 
EVOLVE 
Evaluation of Cinacalcet Hydrochloride Therapy to Lower 
Cardiovascular Events trial 
GLS 
global longitudinal strain 
HEMO 
Hemodialysis Study 
LA 
left atrial 
LAVI 
left atrial volume index 
LIFE 
Losartan Intervention For Endpoint study 
LV 
left ventricular 
LVEF 
left ventricular ejection fraction 
LVH 
left ventricular hypertrophy 
LVM 
left ventricular mass 
LVMI 
left ventricular mass index 
MACE 
Major Cardiovascular Events 
PVC 
premature ventricular contraction 
PWV 
pulse wave velocity 
 
 
 
 
 

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1 
INTRODUCTION 
This exploratory Sub-Study is offered to only those sites and subjects participating in the 
main study, Study SNFC2015-05, A double-blind, randomised, placebo-controlled study to 
assess the effect of SNF472 on progression of cardiovascular calcification on top of standard 
of care in end-stage-renal-disease patients on haemodialysis. The Sub-Study is optional to 
main study sites. Assessments will be performed only in subjects consenting to participate in 
the Sub-Study at sites that opt-in to participate in the Sub-Study. The main study will 
continue as per protocol. The Sub-Study will require assessments to measure the functional 
consequence of a reduction in progression of CVC on arterial stiffness as well as cardiac 
structure and function as assessed by pulse wave velocity (PWV), left ventricular mass index 
(LVMI), diastolic function, myocardial strain, and other echocardiographic parameters. 
1.1 
RATIONALE FOR THE SUB-STUDY 
1.1.1 
Background 
Cardiovascular disease is a significant contributor to morbidity and mortality in patients with 
ESRD on dialysis (USRDS, 2015; Bansal et al, 2013; Baigent et al, 2000). No drugs have 
received regulatory approval for the reduction of CV events in ESRD patients on dialysis. 
Large CV trials designed to show benefit of a given therapeutic intervention in dialysis 
patients such as Deutsche Diabetes Dialyse Studies (4D), the Evaluation of Cinacalcet 
Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) trial, the Hemodialysis 
(HEMO) Study, and the Dialysis Clinical Outcomes Revisited (DCOR) have utilized 
traditional endpoints such as all-cause mortality and Major Cardiovascular Events (MACE) 
requiring large sample sizes and significant time to enroll and complete these studies 
(Wanner et al, 2005; EVOLVE Trial Investigators, 2012; St. Peter et al, 2008; Eknoyan et al, 
2002). These and other similar studies unfortunately have failed to show CV benefit with the 
studied intervention in the dialysis population and thus, a significant unmet need remains. 
Identifying and assessing surrogate CV functional endpoints that are reasonably likely to 
predict clinical benefit ahead of large CV outcomes trials may be important to hasten 
development of therapeutics in this area and increase the probability of success. 
The main objective of the Phase 2b study is to demonstrate that SNF472 can slow the 
progression of CVC. If SNF472 demonstrates a significant reduction in progression of CVC 
in dialysis patients, it is unknown whether this reduction will translate into improvement of 
CV outcomes in subsequent studies. The inclusion of additional cardiovascular surrogate 
endpoints should inform the likelihood that reducing CVC will translate to an improvement 
in CV outcomes prior to subsequent larger CV outcomes trials. The selection of these 
surrogate endpoints is guided by an understanding of the initial role that calcification may 
play in contributing to CV disease, particularly aortic stiffening as measured by PWV and the 
resultant pathophysiologic changes as illustrated in Figure S.1.1. 

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Figure S.1.1 
Pathological Pathways through which Aortic Stiffness may Contribute to 
the Development of Diastolic Dysfunction 
  
Adapted from Mottram et al, 2005. 
As shown, progressive aortic stiffening leads to a widening of pulse pressure, changes in 
coronary perfusion, and an increase in left ventricular (LV) afterload that results in structural 
and function changes in the heart and consequent diastolic dysfunction. A number of these 
surrogate clinical endpoints have been well studied in the dialysis population and have been 
demonstrated to be relevant predictors of CV morbidity and mortality including left 
ventricular mass (LVM), diastolic function, myocardial strain, left atrial (LA) size and 
function, and PWV, the latter as a measure of arterial wall stiffness.  
The hypothesis for this Sub-Study is that improving the burden and progression of CVC will 
slow the progressive aortic stiffening and also improve left ventricular hypertrophy (LVH) 
and diastolic dysfunction. To explore these hypotheses, additional surrogate endpoints are 
being evaluated in the Sub-Study, namely PWV, an indicator of aortic stiffness, LVMI, 
diastolic function, and LA structure and function. A scientific rationale and justification for 
inclusion of these endpoints is provided below. 

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1.1.2 
Considerations in the Selection of Cardiovascular Endpoints 
The use of surrogate structural and/or functional CV measures in this Sub-Study provides an 
opportunity to assess the effect of SNF472 on arterial and LV structure and function (Rubin 
et al, 2011). Whereas it is recognized that CV structural/functional surrogate markers are not 
equivalent to clinical outcomes, the evaluation of the impact of SNF472 on these surrogate 
endpoints should provide valuable information about potential CV effects of the drug and 
will guide the design of future trials. In general, we selected endpoints which are:  
1. Plausibly modified by SNF472 via the drug’s hypothesized effects on reducing vascular 
calcification, arterial stiffness, and secondary effects on LV afterload;  
2. Considered clinically relevant, and have been previously studied in patients with ESRD 
in particular. The clinical relevance was established based on the following 
considerations:  
a) Positive effects on these endpoints can reasonably be expected to mediate a potential 
clinical CV benefit of SNF472;  
b) Endpoints represent quantitative traits that can be obtained non-invasively, 
accurately, reproducibly, and with minimal risk to trial subjects;  
c) Endpoints are independently predictive of prospective CV risk in various populations, 
particularly among patients with ESRD;  
d) Whenever possible, available data demonstrates that modification of the endpoint by 
an intervention reflects the ultimate benefit of that intervention on CV outcomes.  
Aortic PWV 
Large artery stiffness is a highly relevant phenotype in CKD. Arterial stiffening impairs the 
ability of conduit arteries to accommodate the stroke volume intermittently ejected by the LV 
during systole, thus increasing the pulsatile hydraulic load to the LV (Chirinos and Segers, 
2010a; Chirinos and Segers, 2010b). In addition, given the effect of arterial stiffness on 
pulsatile hemodynamics, increased large artery stiffness can also promote excessive 
penetration of pressure and flow pulsatility into the kidney and the brain, leading or 
contributing to target organ damage (O’Rourke and Safar, 2005).  
PWV is a functional parameter affected by the stiffness of the arterial wall, which is 
intimately related to the incremental elastic modulus (Einc) of the wall material, as 
demonstrated by the Moens-Korteweg equation (Chirinos, 2012).  
Arterial stiffness increases with aging and various disease states, including kidney disease 
(Payne et al, 2010). Large artery stiffness increases with declining kidney function (Hermans 
et al, 2007; Mourad et al, 2001). In the Chronic Renal Insufficiency Cohort (CRIC) study 
unadjusted analysis indicated that each 10 mL/min/1.73m2 decrease in estimated glomerular 
filtration rate (eGFR) was associated cross-sectionally with a 0.5 m/s increase in aortic PWV 
(Kaminski et al, 2011; Townsend et al, 2010). 
Available studies demonstrate that carotid-femoral (CF) PWV, an index of large artery 
stiffness, independently predicts the risk of incident CV events across a number of patient 
populations, including high risk populations with hypertension, diabetes, and ESRD 
(Chirinos et al, 2014; Vlachopoulos et al, 2010; Mattace-Raso et al, 2006; Boutouyrie et al, 

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2002). In a recent meta-analysis of 17 longitudinal studies across a number of different 
patient populations, each 1 m/s increase in aortic PWV resulted in an age-, sex-, and risk 
factor adjusted increase of 14% in total CV events and 15% in CV mortality. Each 1 standard 
deviation increase in PWV, which averaged about 3 m/s, was associated with a 47% increase 
in total CV events and a 47% increase in CV mortality (Nakanishi et al, 2017). Importantly, 
among these 17 studies were four studies of ESRD populations, which showed increased risk 
for CV events and mortality consistent with the other populations from studies included in 
the meta-analyses. Available evidence also demonstrates the prognostic value of PWV across 
the spectrum of CKD severity (Sulemane et al, 2017). In subjects with CKD stages 4 and 5, 
aortic PWV is independently related to renal function decline (Chen et al, 2013a; Tripepi et 
al, 2007). CF-PWV is also an independent predictor of incident heart failure in CKD 
(Chirinos et al, 2014).  
Importantly, among patients on hemodialysis, longitudinal changes in measures of aortic 
PWV in response to an intervention were predictive of future risk for mortality. In a study of 
150 hemodialysis patients reported by Guerin et al, mean aortic PWV was higher at baseline 
(11 m/s compared with 9.5 m/s) and rose over time in those who died during follow up, 
despite antihypertensive treatment compared with those patients in the study who survived in 
which a fall in PWV and a parallel reduction in mean arterial pressure was observed over 
time (Guerin et al, 2001). 
A number of studies haves established an important link between arterial calcification and 
PWV across populations, including those with ESRD. Arterial calcification is an independent 
correlate of increased pulse pressure (a surrogate of aortic stiffness) in ESRD (Kraus et al, 
2015). Aortic and superficial femoral artery calcification is associated with increased aortic 
stiffness in healthy individuals (McEniery et al, 2009) and in patients with CKD (Toussaint 
et al, 2008; Sigrist et al, 2006). In a rodent model of CKD, aortic calcium content measured 
by atomic absorption spectrophotometry was related to an increase in PWV (Ng et al, 2011). 
Among 48 patients with CKD (GFR 17-55 mL/min), abdominal aortic and superficial 
femoral artery calcification, aortic vascular calcification correlated positively with PWV 
(Toussaint et al, 2008). Similarly, among 134 subjects with advanced CKD (60 hemodialysis 
patients, 28 peritoneal dialysis and 46 patients with CKD stage 4) increase in calcification of 
the superficial femoral artery as measured by CT was associated with increased CF-PWV 
and increased pulse pressure (Sigrist et al, 2006). Observational studies suggest that higher 
dialysate calcium is associated with a transient increase in PWV, probably from a smooth 
muscle effect (Mac-Way et al, 2011); however, one study suggested that a higher dialysate 
calcium was associated with an increased progression of PWV over a 6-month period (Mac-
Way et al, 2011; LeBeuf et al, 2011). 
Left ventricular mass 
LVH is associated with CKD (Hee et al, 2014). Approximately 3 out of 4 patients initiating 
dialysis have LVH. LVH is also highly prevalent in earlier stages of kidney disease and is 
more prevalent with worsening renal function. Levin et al reported prevalence rates of 27%, 
31% and 45% of LVH among CKD patients with a creatinine clearance >50 mL/min, 
25-50 mL/min and <25 mL/min, respectively. The major correlates of LVH in this study 
were systolic hypertension and anemia (Levin, 2003). LVH is a common cardiac abnormality 

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in patients with ESRD with varying incidence of 36% to >90% in incident and prevalent 
dialysis patient populations (Di Lullo et al, 2011; Foley et al, 2010; Foley et al, 1995; Takeda 
et al, 2008; Hayashi et al, 2013; Satyan et al, 2007; Madsen et al, 2007; Dimitrijevic et al, 
2009; Virga et al, 2006; Kutlay et al, 2006). 
LVH is a strong independent predictor of the risk of adverse CV events (such as coronary 
events, heart failure and death) in the general population and in patients with CKD (Dubin et 
al, 2017; Gardin et al, 2004; Gardin et al, 1997; Koren et al, 1991; Levy et al, 1990). The 
regression or worsening in LVH is strongly predictive of subsequent cardiac events among 
patients on dialysis (Paoletti et al, 2004; Zoccali et al, 2004). In addition, regression of LVH 
in response to therapy independently predicts a favorable prognosis (Lantelme et al, 2008; 
Levin et al, 1998), supporting the use of LVM as a useful surrogate endpoint of the clinical 
benefit of therapeutic interventions (Wachtell et al, 2007; Devereaux et al, 2004). In the 
Losartan Intervention For Endpoint (LIFE) study, a 11% reduction in LVMI with therapy 
was associated with a 15% reduction in relative risk of cardiovascular events, which was 
independent of the degree of blood pressure lowering (Wachtell et al, 2007; Devereaux et al, 
2004). Importantly for this particular trial, a 10% reduction in LVM achieved by multiple 
interventions was associated with a relative risk of 0.72 for CV death among patients with 
advanced hypertensive kidney disease (London et al, 2001).  
Although the pathophysiology of LVH in CKD is complex, hemodynamic load is a key 
factor contributing to LVH in this population. In the presence of a normal aortic valve, LV 
afterload is largely dependent on the properties of the arterial tree (Desai et al, 2011; 
Nicholas, 2011) including aortic stiffness. Among 49 patients on chronic hemodialysis, LVM 
has been shown to be associated with increased PWV, systolic blood pressure and abdominal 
aortic calcification quantified by CT (Nitta et al, 2004). Furthermore, longitudinal changes in 
LVM in 55 patients with stage 3/4 CKD were shown to be independently associated with 
aortic stiffness. Over 2 years, among patients with initial normal LV indices, 68% showed no 
appreciable change with time while 32% developed LVH, whereas among those with 
initial LVH, 50% maintained elevated LV indices and 22% regressed. Factors to maintaining 
or achieving normal LVM included age, a lower pulse pressure and a higher GFR (McMahon 
et al, 2004). Interestingly, PWV has been shown to be independently associated with LVH in 
ESRD even in the absence of hypertension, consistent with the fact that hemodynamic load, 
as opposed to blood pressure per se, is related to LVH in this population (Lin et al, 2002).  
LV diastolic function and filling pressures 
LV diastolic dysfunction is highly prevalent (~85%) in advanced CKD, with greater than 1/3 
of patients demonstrating grade 2 or higher diastolic dysfunction. Diastolic dysfunction is a 
strong predictor of mortality in patients with stage 4-5 CKD (Farshid et al, 2013). Among 
patients with ESRD, the ratio of mitral inflow early diastolic peak flow velocity (E) to mitral 
annular velocity (e’) is indicative of an increased LV filling pressure and predicted all-cause 
mortality and CV death independently of LVM and LV ejection fraction (LVEF) (Wang et 
al, 2008; Sharma et al, 2006).  
In other studies that included patients with stage 3-5 CKD, a high E/e’ was independently 
associated with CV events, mortality and progression to dialysis (Kim et al, 2013; Chen et al, 

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2013b). Similarly, among 578 patients enrolled in the African-American Study of Kidney 
Disease (AASK) cohort, LV hypertrophy and diastolic function parameters predicted 
cardiovascular events requiring hospitalization or causing death; a renal composite outcome 
of doubling of serum creatinine or ESRD; and heart failure. After adjustment for LVM and 
clinical variables, lower systolic tissue Doppler velocities were significantly associated with 
future heart failure events (Peterson et al, 2013). However, in the CRIC study, which 
included 3939 racially and ethnically diverse individuals between the ages of 21–74 years old 
with eGFR between 20 and 70 mL/min per 1.73 m2, diastolic dysfunction assessed by 
echocardiography was not significantly associated with heart failure or death (Dubin et al, 
2017). The differences between these 2 studies may be due to differences in the study 
cohorts. In the AASK trial, all subjects were African American, diabetes was an exclusion 
criterion and 50% of participants in the AASK had a history of prior CV disease. In contrast, 
the CRIC study included an ethnically diverse cohort with diabetes and excluded those who 
self-reported heart failure. 
Diastolic function is also correlated with aortic stiffness and PWV and calcification (Fujiu et 
al, 2008; Weber et al, 2008; Borlaug et al, 2007). In a study that included 142 hemodialysis 
patients, aortic arch calcification volume measured by CT and arterial stiffness estimated by 
brachial-ankle PWV were independently associated with the E/e' ratio (Fujiu et al, 2008).  
In summary, diastolic function is an independent predictor of outcomes in ESRD. Further, 
given the association with PWV and vascular calcification, improvement in these parameters 
may translate into improvements in diastolic function. 
LV longitudinal strain and strain rate 
Myocardial deformation (strain) is a highly sensitive measure of myocardial function, even in 
patients with preserved ejection fraction (EF). Strain is defined as the percent change in 
length, relative to a reference length, a given direction. For the LV, the end-diastolic length is 
used as the reference length. LV strain in the radial, circumferential and longitudinal 
directions can be measured with 2D-echocardiography, using speckle-tracking 
echocardiography. In speckle tracking echocardiography, small stable myocardial footprints 
(“speckles”) are tracked throughout the cardiac cycle using digital echocardiographic images. 
Strain in the longitudinal direction has been shown to be the most clinically significant 
parameter in a variety of clinical conditions (Collier et al, 2017).  
Longitudinal LV strain measured with speckle-tracking echocardiography has been shown to 
be reduced in CKD (Pressman et al, 2015; Chen et al, 2014; Wang et al, 2012) even in the 
absence of overt systolic dysfunction measured by LVEF. Reduced LV longitudinal strain 
demonstrates a progressive reduction with worsening stages of renal dysfunction (Panoulas et 
al, 2015; Krishnasamy et al, 2014; Liu et al, 2011). Reduced LV strain has also been 
associated with CKD even in patients with established heart failure with preserved EF 
(Unger et al, 2016).  
Multiple studies demonstrate the high clinical relevance of LV strain in CKD. Among 
108 patients with stage 3/4 CKD, reduced (i.e., less negative) global longitudinal strain 
(GLS) is associated with a reduced submaximal exercise capacity (6-minute walk distance) 

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and health-related quality of life (Krishnasamy et al, 2016). Among 106 patients with CKD, 
no history of CV disease, and normal LVEF, a reduced GLS was predictive of a composite 
endpoint of all-cause mortality, acute coronary syndrome, stable angina requiring 
revascularization, hospitalization for heart failure and stroke, over a median follow up period 
of 49 months, independently of other predictors and CF-PWV (Sulemane et al, 2017). 
Among 88 stable hemodialysis patients with preserved LVEF followed-up for 25.6±9.9 
months, a reduced GLS was an independent predictor of all-cause mortality (Liu et al, 2013). 
Across the spectrum of CKD severity (stages 1-5), GLS is also predictive of all-cause 
mortality (Krishnasamy et al, 2014) and CV events (Panoulas et al, 2015).  
Importantly, strain is a more sensitive marker of myocardial function in CKD than the LVEF, 
and predicts incident events independently of EF and measures of diastolic function. In a 
study including 48 African Americans with ESRD and preserved LVEF, GLS was 
independently predictive of all-cause mortality during a median follow-up of 1.9 years, 
whereas LVEF was not. The association between GLS and mortality persisted after 
adjustment for multiple potential confounders, including LVEF (Pressman et al, 2015). The 
prognostic value and clinical significance of GLS in patients with CKD above and beyond 
LV EF is further supported by a study among 183 patients with stage 4-5 CKD (63% on 
dialysis). During a median follow up of 7.8±4.4, GLS was a significant predictor of all-cause 
and CV mortality after adjustment for relevant clinical variables including LVMI and EF. 
GLS also had greater predictive power for both all-cause and CV mortality compared to EF. 
Furthermore, reduced GLS (less negative than -16%) was associated with a 5.6-fold 
increased unadjusted risk of CV mortality in patients with preserved EF (Krishnasamy et al, 
2015a). In another study that included 89 patients with advanced CKD (43 non-dialysis 
patients and 43 dialysis patients) followed for 70.2±35 months, reduced GLS was the only 
significant echocardiographic predictor of survival in non-dialysis CKD patients, whereas 
among dialysis patients, GLS and the E/e’ ratio were significant predictors of survival 
(Valocikova et al, 2016).  
Importantly, reduced longitudinal systolic function is associated with arterial stiffness in 
patients with CKD. Among 136 patients with moderate CKD (stages 3 and 4), GLS measured 
with speckle-tracking echocardiography was independently associated with CF-PWV 
(Krishnasamy et al, 2015b). This is consistent with the known effect of afterload on LV 
longitudinal function, even in patients with preserved EF (Chirinos, 2017; Chirinos and 
Segers, 2010a; Chirinos and Segers, 2010b; Weber et al, 2008). Therefore, it is highly 
plausible that an intervention that reduces aortic stiffness can have a positive impact on LV 
strain. 
Whereas one study suggests that GLS demonstrates little sensitivity to removal of volume 
during hemodialysis (Panoulas et al, 2015), another study demonstrated a ~1.5% absolute 
reduction in GLS with hemodialysis (Choi et al, 2008). These data have implications 
regarding the timing of the dialysis session and volume status of the dialysis patient. 
Therefore, to the extent possible we will standardize the time of the echocardiogram relative 
to dialysis session in the trial.  

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LA size and function 
LA size is a well-established marker of CV risk in general and among patients with CKD in 
particular. Among 200 patients with creatinine clearance <60 mL/min followed-up for 
3.7 (3.5-4.0) years, LA size was independently predictive of CV mortality (Chan et al, 2008). 
Among 289 unselected consecutive patients referred for transthoracic echocardiography, 
patients with stage 3 or 4 CKD (n=49) demonstrated a higher LA volume index (LAVI) than 
controls. Furthermore, CKD, hypertension and a larger LAVI were independent predictors of 
a composite endpoint of cardiac death, myocardial infarction, and congestive cardiac failure 
(Hee et al, 2014). LA size has also been shown to predict CKD progression (Chen et al, 
2013a). Importantly, longitudinal changes in LA size have been shown to predict subsequent 
fatal and nonfatal CV events in patients on hemodialysis, independently of baseline LA 
volume and LVM (Tripepi et al, 2007).  
LA size is independently associated with PWV (Lantelme et al, 2008), consistent with the 
effects of aortic stiffness on LV afterload and diastolic function. Given that methods for the 
assessment of LA strain are relatively novel, data regarding the correlates of reduced LA 
strain in ESRD are not yet available. However, given the importance of diastolic dysfunction 
on LA function, it is likely that aortic stiffness can influence LA strain through effects on LV 
load. 
2 
SUB-STUDY OBJECTIVES 
2.1 
PRIMARY OBJECTIVE 
The primary objective of this Sub-Study is to assess the effect of 2 dose levels of SNF472 
(300 mg and 600 mg) compared to placebo on the progression of arterial stiffness as 
measured by an absolute change in PWV over a 52-week period in ESRD patients on HD. 
2.2 
SECONDARY OBJECTIVES 
The secondary objectives of this Sub-Study are to assess: 
• Change from Sub-Study Entry in LVMI  
• Change from Sub-Study Entry in LV function parameters 
2.3 
EXPLORATORY OBJECTIVES 
The exploratory objectives of this Sub-Study are to assess: 
• Change from Sub-Study Entry in LA function and change in parameters over time 
• Change from Sub-Study Entry in aortic valve gradient 
 

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3 
STUDY DESIGN 
3.1 
STUDY DESIGN OVERVIEW 
Patients enrolled in the main study will be eligible to participate in this Sub-Study and will be 
requested to undergo additional assessments as outlined in the Sub-Study Schedule of 
Assessments (Table S.5.1).  
3.2 
STUDY ENDPOINTS 
3.2.1 
Primary Endpoint 
The primary endpoint is the absolute change in aortic PWV (m/s) from Sub-Study Entry to 
Week 52 by 2-dimensional (2D) echocardiography.  
3.2.2 
Secondary Endpoints 
The secondary endpoints will be assessed by 2D echocardiography and are: 
• Absolute change in LVMI from Sub-Study Entry to Week 52 
• Absolute change in LV function from Sub-Study Entry to Week 52:  
o Absolute change in the E/e’ ratio 
o Absolute change in mitral annular early diastolic tissue velocity (e’) measured 
with tissue Doppler (average of septal and lateral values) 
o Absolute change in LV global longitudinal systolic strain (%) measured by 
speckle tracking echocardiography 
3.2.3 
Exploratory Endpoints 
The exploratory endpoints are: 
• Absolute change in additional measures of LA volume and LA ejection fraction from 
Sub-Study Entry to Week 52: 
• Absolute change in PWV, LVMI and other parameters of LV and LA function over 
time (Weeks 28 and 52). 
• Absolute change in aortic valve gradient from Sub-Study Entry to Week 28 and Week 
52 in all subjects and in the subgroup of subjects with evidence of aortic stenosis at 
Sub-Study Entry 
4 
SELECTION OF PATIENTS 
It is estimated that up to 50% of the sites will participate in order to enroll up to 200 subjects.  

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4.1 
INCLUSION CRITERIA 
Patients meeting all of the following criteria will be considered for enrollment in this Sub-
Study: 
1. Participant in the main study 
2. Willing and able to understand and sign the additional Sub-Study informed consent 
4.2 
EXCLUSION CRITERIA 
Patients presenting with any of the following based on medical history will not be included in 
this Sub-Study: 
1. Presence of current atrial fibrillation, atrial flutter with variable atrioventricular 
conduction, or very frequent premature beats (premature ventricular contractions [PVCs]) 
2. A diagnosis of primary hypertrophic obstructive cardiomyopathy, or cardiac infiltrative 
disease (such as cardiac amyloidosis). 
3. Severe cardiac valvular disease 
5 
STUDY PROCEDURES AND SCHEDULE 
5.1 
SCHEDULE OF ASSESSMENTS 
For subjects participating in the Sub-Study, echocardiographic measures will be done at Sub-
Study Entry, Week 28, and Week 52 or early termination (ET), whichever comes first. 
Table S.5.1 shows key visits as well as timing for echocardiographic assessments for the 
Sub-Study. Refer to the Echocardiography Manual for detailed procedures. 
 

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Table S.5.1 
Schedule of Sub-Study Assessments and Visits 
Procedures 
Screeninga  
Double-Blind Treatment Period 
Wk 56 or 1 
month after 
last dose 
 
 
156 VISITS: Study Drug Infusion Administered at Each HD Session (3x Weekly) 
 
Key Evaluation Visits (On Day After Dialysis) 
Week 
Step 1a Step 2a 
Sub-Study Entry 
Wk 1 – Wk 4b 
Wk 6 Wk 10 Wk 16 Wk 22 Wk 28 Wk 34 Wk 40 Wk 46 
Wk 
52/ETc 
 
Day 
 
 
1 – 28b 
36 
(±3 d) 
64 
(±3 d) 
106 
(±3 d) 
148 
(±3 d) 
190  
(±2 wks) 
232 
(±3 d) 
274 
(±3 d) 
316 
(±3 d) 
358 
(±2 wks) 
 
Sub-Study informed 
consentd 
 
X 
 
 
 
 
 
 
 
 
 
 
Sub-Study Eligibility, 
inclusion/exclusion 
criteriae 
 
X 
 
 
 
 
 
 
 
 
 
 
Sub-Study-Specific Assessmentsf 
Echocardiographic 
assessmentsf 
 
Xb 
 
 
 
 
Xg 
 
 
 
Xg 
 
d: day; ET: early termination; HD: hemodialysis; Wk: week 
a 
Screening for the main study as described in the main study protocol will proceed in 2 steps: Step 1 will involve informed consent followed by the CT scan for coronary artery 
calcium score and bone mineral density by Dexa for Screening. Only those patients who are eligible in Step 1 can proceed to Step 2. 
b 
Sub-Study Entry echocardiographic assessments can be completed from Screening Step 2 up to 4 weeks after initiation (first dose) of study drug. 
c 
The ET visit will replace the Week 52 visit if the patient terminates the study earlier than planned. 
d 
Sub-Study informed consent can be obtained from Step 2 of Screening and up to Week 4 post first dose. Patients will provide written informed consent before any clinical 
Sub-Study-specific procedures are performed. 
e 
The Sub-Study inclusion/exclusion criteria can be assessed from Step 2 of Screening and up to Week 4. 
f 
It is recommended that the echocardiographic assessments be performed on the day after dialysis (see Study Echocardiographic Manual for further details). 
g 
For the echocardiographic assessments at Weeks 28 and 52/ET, a window of ±2 weeks is allowed to complete the assessments. 

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5.2 
DESCRIPTION OF STUDY DAYS 
5.2.1 
Screening (up to Week 4) 
Following completion of Step 1 of the Screening activities for the main study:  
• Obtain written informed consent for the Sub-Study. 
• Determine patient eligibility for the Sub-Study according to the inclusion and exclusion 
criteria defined in Section 4. 
5.2.2 
Treatment Period 
Day 1 is the first day of study treatment per the main protocol. 
5.2.2.1 
Sub-Study Entry (up to 4 weeks after first dose) 
• Review and confirm patient eligibility for the Sub-Study according to the inclusion and 
exclusion criteria pre-dose as defined in Section 4 
• Perform echocardiographic assessments up to 4 weeks after the first dose 
5.2.2.2 
Week 28 (±2 weeks) 
• Perform echocardiographic assessments (a window of ±2 weeks is allowed to complete 
the assessments) 
5.2.2.3 
Week 52/ET (±2 weeks) 
• Perform echocardiographic assessments (a window of ±2 weeks is allowed to complete 
the assessments) 
5.3 
METHODS OF EVALUATION 
5.3.1 
Efficacy Assessments 
5.3.1.1 
Echocardiographic Assessments 
Two-dimensional echocardiography will be performed at Sub-Study Entry, Week 28, and 
Week 52 by dedicated technicians. It is recommended that the echocardiographic 
assessments be performed on non-dialysis days (see Echocardiography Manual) since this 
period permits better control of hydration status and is associated with the least intravascular 
volume.  
The echocardiographic assessment for Sub-Study Entry can be performed up to 4 weeks after 
initiation of study drug. While performing the initial echocardiographic assessments after 
randomization and up to the first 4 weeks of treatment may not be characterized as a true 
“baseline” assessment, it is not expected that clinically significant changes in the progression 
of vascular calcification will occur in treatment arms during this short time period. Therefore, 
the overall assessment of change in PWV and other echocardiographic measures from the 
time period of the initial intervention at study entry to end of study should not be affected by 
this approach. Therefore, to increase subject participation and the feasibility of performing 
the Sub-Study, a window of time from weeks 1-4 will be allowed to consent subjects for 
Sub-Study participation and to complete the initial echocardiographic assessments. Refer to 

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the Echocardiography Manual for detailed procedures and description of assessments of 
PWV, LVMI, LV function, LA function, and other parameters. 
6 
STATISTICAL METHODS 
6.1 
GENERAL STATISTICAL CONSIDERATIONS 
6.1.1 
Analysis Sets 
The Sub-Study analysis sets will be derived from the primary modified ITT (mITT) and PP 
sets for the main study. The Sub-Study mITT will be made of subjects in the overall mITT 
set who consented to participate in the Sub-Study. Similarly, the Sub-Study PP set will be 
made of subjects in the overall PP set who consented to participate in the Sub-Study. 
6.2 
DEMOGRAPHICS AND BACKGROUND CHARACTERISTICS 
The treatment groups in the Sub-Study will be descriptively summarized for baseline (main 
study) demographic and disease history variables using the Sub-Study mITT set. The baseline 
characteristics and diagnostic factors of those subjects included in the Sub-Study will be 
informally compared to the baseline characteristics and diagnostic factors of those subjects 
not included to ensure there are no major differences of clinical relevance. 
6.2.1 
Demographics 
Demographic and baseline characteristic data for the Sub-Study will be summarized with 
descriptive statistics across the 3 treatment arms. Demographic variables will include sex, 
race, ethnicity, age, and diabetes status. 
6.2.2 
Disease Characteristics 
Disease characteristics for the Sub-Study will be summarized with descriptive statistics 
across the 3 treatment arms. Disease characteristic variables will include diabetes status and 
baseline CAC score, baseline calcium volume score, years since primary ESRD diagnosis, 
use of non-calcium containing phosphate binder at baseline, and dialysis vintage. 
6.3 
EFFICACY ANALYSES 
6.3.1 
Primary Efficacy Analysis 
The primary Sub-Study endpoint, absolute change in PWV (m/s) from Sub-Study Entry to 
Week 52 measured by 2D echocardiography, will be summarized using descriptive statistics 
(by treatment arm) and analyzed using an ANCOVA model with the Week 52 value as the 
dependent variable and randomized treatment group as an explanatory fixed effect and the 
Sub-Study Entry value as a covariate. The analysis will be stratified by baseline CAC score 
category and conducted in the Sub-Study mITT and PP populations. The main contrasts of 
interest to assess treatment effect will be the difference in LS means between each dose 
and placebo and between the average of the two doses vs placebo. These contrasts and their 
estimated 2-sided 90% CIs will be back transformed prior to presentation. The 1-sided P-
value for each contrast will also be provided. 
 As recommended by current guidelines (Townsend et al, 2015), additional analyses will be 
performed after adjustment for mean arterial pressure and heart rate. 

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6.3.2 
Missing Data 
The efficacy analyses for the Sub-Study will impute missing Week 52 values with the latest 
post-Sub-Study Entry value. If no such value is available multiple imputation will be 
implemented. by imputing missing data within each arm using distribution implied by the 
non-missing patient data for that arm. As an additional analysis, missing data will be imputed 
for all arms using distribution implied by the non-missing patient data within the placebo 
arm. 
6.3.3 
Multiple Comparisons / Multiplicity 
The analyses for the Sub-Study are viewed as exploratory and no adjustments for multiple 
comparisons/multiplicity are planned. 
6.3.4 
Secondary and Exploratory Efficacy Analyses 
The secondary endpoints of this Sub-Study are provided in Section 3.2.2. 
The secondary and exploratory endpoints will be summarized using descriptive statistics by 
treatment arm and analyzed using methods similar to the primary Sub-Study endpoint; 
ANCOVA with the value at Sub-Study Entry and treatment as the explanatory variables. The 
results will be summarized both in tabular form and graphically as forest plots (2-sided 90% 
confidence intervals for the pairwise treatment comparisons to control). As these analyses are 
viewed as supportive, no adjustment for multiple testing is planned. 
For the endpoint related to aortic valve gradient, evidence of aortic stenosis at Sub-Study 
Entry will be defined as subjects with a mean aortic valve gradient >20 mm Hg at Sub-Study 
Entry. 
6.3.5 
Sensitivity Analyses 
Given the potential effect of co-existing valvular disease on LV strain, LV diastolic function 
parameters and LA strain, we will perform a sensitivity analysis excluding subjects who 
demonstrate more than moderate left sided regurgitant valvular disease (aortic regurgitation, 
mitral regurgitation) and/or more than mild mitral or aortic stenosis at baseline. These criteria 
for sensitivity analyses will not apply for assessment of aortic PWV.  
6.4 
DETERMINATION OF SAMPLE SIZE 
The sample size (up to approximately 65/placebo and 130/active) is considered adequate to 
provide preliminary estimates of the change from Sub-Study Entry for the treatment arms 
and the treatment effect (placebo vs. the pooled active arms) of the primary endpoint for the 
Sub-Study. Assuming a standard deviation in the change from Sub-Study Entry of 1.75 m/s 
in PWV, the test of the difference between the placebo and active arms (pooled) would have 
approximately 85% power to detect a true difference of 0.75 m/s (1-sided alpha level of 0.05 
for the proof-of-concept objective) for these sample sizes. This threshold is considered 
clinically significant based on results of previous studies discussed in Section 1.1.2.  

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KM, Cockcroft JR, Dixon AK, Wilkinson IB and Anglo-Cardiff Collaboration Trial I. Aortic calcification is 
associated with aortic stiffness and isolated systolic hypertension in healthy individuals. Hypertension. 
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Mitchell GF. Clinical achievements of impedance analysis. Med Biol Eng Comput. 2009;47:153-63. 
Mottram PM, Haluska BA, Leano R et al. Relation of arterial stiffness to diastolic dysfunction in hypertensive 
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Wanner C, Krane V, März W, et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing 
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APPENDIX 2. PROTOCOL AMENDMENT 1: SUMMARY OF 
CHANGES 
This section describes the changes in reference to the Protocol Incorporating Amendment 1. 
The primary purpose of this amendment is to add the Sub-Study, an opt-in Investigator 
addition of echocardiographic assessments, to measure reduction in progression of CVC on 
arterial stiffness for exploratory analyses on subjects participating in the main study and 
willing to provide additional informed consent. Additionally, this protocol was amended for 
administrative updates and to clarify procedural details. The justification for the each of the 
changes to the protocol is listed below. 
1. Addition of opt-in Sub-Study echocardiographic assessments at 3 time points: Sub-
Study Entry, Week 28, and Week 52/Early Termination. See addition of Appendix 1 
for complete details and endpoints.  
Justification: The main objective of the Phase 2b study is to demonstrate that SNF472 
can slow the progression of CVC. If SNF472 demonstrates a significant reduction in 
progression of CVC in dialysis patients, it is unknown whether this reduction will 
translate into improvement of CV outcomes in subsequent studies. The inclusion of 
additional cardiovascular surrogate endpoints should inform the likelihood that 
reducing CVC will translate to an improvement in CV outcomes prior to subsequent 
larger CV outcomes trials. The selection of these surrogate endpoints via 
echocardiographic assessments is guided by an understanding of the initial role that 
calcification may play in contributing to CV disease. 
2. Increase the Screening Period duration from 21 days +/- 3 days to 28 days +3 days. 
Justification: To allow sites more time to schedule subjects for required screening CT 
and Dexa scans with radiology facility/personnel for inclusion into the study. 
3. Changed number of participating countries from 5 to 3. 
Justification:  Updated to reflect actual number of countries participating:  USA, UK, 
Spain 
4. Changed “Indication” being studied from ESRD to Cardiovascular Calcification 
(CVC) in ESRD. 
Justification:  More accurately reflects patient population under study. 
5. Clarified PK and Biomarker sample collection information. Should be done ~10 
minutes before end of infusion and participating sites do NOT need to have a -70 
freezer. 
Justification:  Clarification to time of collection from previous “end of infusion” was 
not specific enough. Sites now can be provided dry ice for same day sample 
shipments, as needed. 
6. Updated section 5.3.1 Randomisation to allow the act of randomisation to treatment 
assignment in the study system and first day of dosing to be on different days, if 
needed. 
Justification:  To accommodate for pharmacy/IMP preparation time needs. For 
clarity, Day 1 Week 1 is the first dose date. 
7. Updated 5.4.3 Packaging supplier name. 
Justification:  Former “B&C” supplier was acquired by CSM Europe SA. 

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8. Deleted B&C Group to ship and store of biomarker samples. 
Justification:  Central laboratory being used for the study is providing storage. 
9. Section 9.1 Emergency Sponsor Contact updated. 
Justification:  Provided more specific safety contact information for EU and USA 
sites. 
 
 

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APPENDIX 3. PROTOCOL AMENDMENT 1.1 UNITED STATES ONLY 
 
Section 5 specifies that the study drug is to be added to a 100 mL bag of physiological saline 
(0.9% sodium chloride) and administered via an infusion pump which is connected directly 
to the dialysis machine via an IV giving set and an accessory heparin line. The infusion 
should be given at a constant rate over 2.5 hours.  
 
Due to the shortage of 100 mL saline bags, sites that are unable to obtain 100 mL saline bags 
can use saline bags with a volume of 150 mL or 250 mL. The preparation and administration 
of the study drug will be the same, however, the infusion rate will be adjusted to allow the 
infusion to be completed in 2.5 hours (see table below). 
 
Additional fluid should be removed as necessary according to the site’s standards of care. 
 
 
Bag Volume 
(mL) 
IMP Volume (mL) 
Total Volume (mL) 
Infusion Rate 
(mL/hr) 
100 mL 
20 mL 
120 mL 
48 mL/hr 
150 mL 
20 mL 
170 mL 
68 mL/hr  
250 mL 
20 mL 
270 mL 
108 mL/hr  
 
 
 

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APPENDIX 4. PROTOCOL AMENDMENT 1.1 UNITED STATES 
ONLY: Summary of Changes 
 
The purpose of this US only amendment is to allow sites who are unable to obtain 100 ml 
bags of physiological saline to use larger bags. The amendment also specifies the flow 
volume to be used with each bag size. The locations of changes in this amendment are 
detailed in the table below. 
 
SECTION 
AMENDMENT 1  
AMENDMENT 1.1  
APPENDIX 2. 
Protocol 
Amendment 1: 
Summary of 
Changes 
none 
Protocol Amendment 1  Summary of 
Changes 
APPENDIX 3. 
Protocol 
Amendment 1.1 
United States 
Only 
none 
Protocol Amendment 1.1 US Only 
Allows use of bags larger than 100 mL 
and specifies adjusted flow rate 
 
 
 

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APPENDIX 5. PROTOCOL AMENDMENT 2 SUMMARY OF 
CHANGES  
The main goals of this amendment are to increase the upper limit of the CAC score allowed 
for enrollment from 2000 AU to 3500 AU, to clarify the planned sample size re-estimation, 
to clarify the endpoint descriptions, and provide additional details on planned statistical 
analyses, including those in the substudy. Additional description and rationale for the 
changes is provided below. 
1) Minor revision to primary objective and primary endpoint to remove “absolute 
change”.  
Rationale: Results will be analyzed on a log scale to give results that can be presented as 
absolute change or percent change. 
Sections: Synopsis, Section 2.1, Section 10.3 
2) The secondary endpoint “percent change from baseline in calcium volume score at 
Week 52” was deleted.  
Rationale:  This information will be provided as part of the primary endpoint. 
Sections: Synopsis, Section 10.3.4. 
3) The secondary endpoints “absolute change from baseline in CAC/Agatston score at 
Week 52” and “percent change from baseline in CAC/Agatston score at Week 52” 
were consolidated to “change from baseline in CAC/Agatston score at Week 52”. 
Rationale: Results will be analyzed on a log scale to give results that can be presented as 
absolute change or percent change. 
Sections: Synopsis, Section 10.3.4. 
4) Description of the composite safety endpoint “death from cardiovascular causes, MI, 
stroke, or heart failure” was standardized throughout the protocol to clarify and 
specify that it included deaths only from cardiovascular causes and not all-cause 
mortality.  
Sections: Synopsis, Sections 3.2.2, 6.2.1.3, 10.3.4 
5) It is now specified that C-reactive protein (CRP) is one of the biomarkers that will be 
assessed. 
Sections: Synopsis, Section 6.2.3 
6) The safety endpoint was revised to add “clinically relevant changes from baseline in 
laboratory and ECG parameters.”  
Sections: Synopsis, Section 10.3.4. 

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7) A blood pressure exploratory objective and endpoint were added.  
Sections: Synopsis, Sections 2.3, 3.2.3, and 10.3.4  
8) Inclusion Criterion 2:  The maximum allowable CAC score has been increased from 
2000 AU to 3500 AU: “CAC score of 100 to 2000 3500 AU”.  
Rationale: After additional literature review and consultation with medical experts the 
Sponsor believes that subjects with higher CAC scores are at risk of cardiovascular 
events and may benefit from therapeutic intervention. Raising the CAC limit to 3500 AU 
will allow recruitment of a more representative sample of ESRD patients. 
Sections: Synopsis, Sections 4.1 and 6.1.1.1 
9) Revision of the primary endpoint analysis method to, “The dependent variable will be 
the difference between log 52-week and log baseline calcium volume scores, with log 
baseline calcium volume score and treatment group as explanatory variables. This 
analysis will be stratified for the randomization stratification factor, i.e. baseline 
CAC/Agatston score.”  
Rationale: Clarification of methods and stratification factor 
Section: Synopsis and Section 10.3.1 
10) Figure 5.1 was revised to more accurately show the location of study drug infusion. 
11) Correction of the definition of concomitant medications in Section 6.2.6 to 
“Medications taken with or after the first dose of IMP will be considered concomitant 
medication.” 
12) Conditions for removal of patients from the study (Section 8.1) has been revised so 
that patients will not be withdrawn from the study for missed doses. The following 
sentence was deleted, “Patients who missed 12 consecutive doses (4 weeks) of the 
IMP or 24 aggregate doses will be considered as non-compliant and will be 
withdrawn from the study.” In addition, Investigators are asked to contact the Medical 
Monitor prior to discontinuing a patient from study medication or withdrawing a 
subject from the study. 
13) Statistical Methods: Clarified that the primary efficacy analysis population is a 
modified ITT (Section 10.1.1 and Appendix 1 Section 6.1.1). Methods for imputation 
of missing data were added (Section 10.3.2). Details and clarifications on blinded 
sample size re-estimation procedure were provided and a nonbinding futility analysis 
was added (Section 10.6). Additional methods and clarifications were provided 
throughout Section 10. 
14) The objective “Change from Sub-Study Entry in aortic valve gradient” and 
corresponding endpoint of “Absolute change in aortic valve gradient from Sub-Study 
Entry to Week 28 and Week 52 in all subjects and in subjects with evidence of aortic 
stenosis at Sub-Study Entry” were added. 
Sections: Appendix 1, Substudy Sections 2.3, 3.2.3, 6.3.4  

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15) Clarification was provided that the first echocardiogram can occur within 4 weeks of 
the first dose of study drug (Section 5.2.2.1). 
16) Investigational Drugs. Notation was added that US SITES ONLY may use 150 mL or 
250 mL bags of physiological saline for dilution of the IMP if 100 mL bags are not 
available. The preferred bag size for dilution of the IMP remains 100 mL. This 
allowance was previously communicated to US Sites as Protocol Amendment 1.1 as 
described in Appendices 3 and 4. 
17) Additional minor administrative changes and changes to version numbering and dates 
were made throughout. 
 
 

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APPENDIX 6. Protocol Amendment 3 Summary of Changes  
The amendment provides a revised sample size calculation which led to a reduction in 
planned enrollment from approximately 450 to approximately 270. There are no changes in 
study visits or procedures. Additional details are provided below. 
1) Changed planned sample size from approximately 450 to approximately 270. 
Sections: Synopsis, Sections 3.1, 4, 10.6 
Rationale: To expose the minimum number of subjects needed to achieve 80% power 
based on the revised sample size calculation. 
2) Removed details of planned sample size re-estimation (SSRE, Section 10.6). 
Rationale: Because of the revised sample size, the previous considerations regarding 
SSRE are no longer germane.  
3) Revised sample size calculation (Section 10.6). 
Rationale: The previous versions of the protocol based sample size on the anticipated Per 
Protocol Population, however, the primary efficacy analysis will be carried out on the 
modified ITT Population (Section 10.1.1) with last observation carried forward (LOCF) 
imputation for missing data (Section 10.3.2). To establish consistency the sample size 
calculation has been revised to more appropriately use the modified ITT Population. In 
addition, the Sponsor has determined that 80% power with 2-sided significance level of 
0.05 is acceptable for a Phase 2 study, in contrast to the previously planned 85% power. 
4) Clarified the definition of the Per Protocol population (Section 10.1.1). The PP 
population is the subset of the mITT population who do not have any major protocol 
violations or deviations. 
5) New Appendix 5 containing the summary of changes for Amendment 2 
6) Revisions of amendment number and date throughout. 
 
 
 

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APPENDIX 7. Protocol Amendment 4 Summary of Changes  
 
1) Added phosphorus (phosphate) to the list of analytes in the safety laboratory 
assessments (Table 6.1) and the list of biomarkers Section 6.2.3. 
Rationale: Corrects omission of a standard analyte and clarifies list of biomarkers. 
2) Clarification that IMP must be added to the dialysis circuit before the dialyzer 
(Section 5.5). 
Rationale: Clarification 
3) Addition of a non-binding interim futility analysis to be conducted when 
approximately N=120 subjects (63% of N=190) have provided Week 52 data on the 
primary endpoint. PK and PD analyses will also be conducted at the time of the 
interim analysis (Synopsis, Section 10.7, Section 14).  
Rationale: To allow the Sponsor to assess whether there is a low probability of success of 
the trial and to determine that the PK and PD characteristics of SNF472 are as expected. 
4) New Appendix 6 containing the summary of changes for Amendment 3 
5) Revisions of amendment number and date throughout.