A Safety and Efficacy Study of N-acetylcysteine in Patients With Transplant-Associated Thrombotic Microangiopathy
Phase: PHASE3
Conditions: Thrombotic Microangiopathies, Hematologic Diseases
Sponsor: The First Affiliated Hospital of Soochow University

Study Protocol 
 
 
A Safety and Efficacy Study of NAC in Patients 
With TA-TMA 
 
 
Vision 1.0 Nov. 01, 2017 
 
ClinicalTrials.gov Identifier: NCT03252925 
Principal Investigator Yue Han, MD, PhD, 
hanyue@suda.edu.cn;  
Jiangsu Institute of Hematology, The First Affiliated Hospital 
of Soochow University, Suzhou 215006, China.  
 
 

Protocol version  
Vision 1.0  
Issue date  
Nov. 01, 2017 
Study center  
The First Affiliated Hospital 
of Soochow University 
Protocol Summary  
Study center  
The First Affiliated Hospital of Soochow University 
Principal Investigator  
Yue Han, MD, PhD  
Methodology  
A phase III, open-label, single-center, randomized placebo-
controlled trial 
Primary objective  
The primary outcome was the incidence of transplant-
associated thrombotic microangiopathy  (TA-TMA). 
Inclusion criteria  
Patients with malignancies between the ages of 12 and 70 
who are scheduled to undergo allogeneic hematopoietic 
stem cell transplantation are eligible to enter the study. 
Eligible patients met the following criteria. (i) planned to 
receive allo-HSCT; (ii) established stable donor 
hematopoiesis; (iii) Eastern Cooperative Oncology Group 
(ECOG) performance status of 0-2.  
Exclusion criteria  

Exclusion criteria were allergy to any component of NAC, 
bronchial asthma, peptic ulcer, pregnancy and lactation, 
absence of uncontrolled infection or severe liver, kidney, 
lung, or heart disease. 
Intervention  
Patients were randomized 1:1 by interactive response 
technique to receive either oral NAC (50 mg/kg/day 
continuously from 9 days before HSCT to 30 days after 
HSCT) or a placebo. A placebo (identical-looking tablets) 
was administered similarly to NAC for patients randomized 
to the placebo group. 
Total number of patients: 300 
Total duration of the study: 3 years 
 
Background  
Transplant-associated thrombotic microangiopathy (TA-
TMA) is a severe complication in patients following 
hematopoietic stem cell transplantation (HSCT). Previous 
investigations suggest that multiple factors resulting in 
endothelial cell injury lead to the occurrence of TA-TMA. 
Specifically, the abnormity of complement system 
contributes to the development of TA-TMA. TA-TMA shares 
a similar clinical manifestation with thrombotic 
thrombocytopenic purpura (TTP) and atypical hemolytic 
uremic syndrome (aHUS), which is characteristic with 
microangiopathic hemolytic anemia, platelet consumption, 
fibrin deposition in the microcirculation, and, ultimately, end-
organ injury [1]. However, the diagnostic criteria of TA-TMA 
are far from accurate. Although several diagnostic criteria 

had been proposed, no criterion has been rigorously 
evaluated clinically due to lack of pathological diagnosis. 
Moreover, the pathogenesis of TA-TMA is still unclear. 
Conventional treatment management is less efficient [2]. 
Plasma infusions or therapeutic plasma exchange is 
considered as limited efficacy, with relatively low response 
rates (20–50%) in comparison to idiopathic TTP (75%) 
generally reported [3].  
N-acetylcysteine (NAC) is an antioxidant synthesized from 
cysteine that increases glutathione biosynthesis and 
scavenges reactive oxygen species directly or indirectly [4]. 
NAC was recently suggested as a potential treatment for 
patients with thrombotic thrombocytopenic purpura (TTP) [5-
7]. Li and colleagues provide a case report of a TTP patient 
relieved with NAC, providing the first clinical evidence for the 
efficacy of NAC in treating TTP [5]. In our study, we explored 
whether TA-TMA patients might benefit from NAC via 
targeting complement.  
Reference  
1. Jodele S, Licht C, Goebel J, et al. Abnormalities in the 
alternative pathway of complement in children with 
hematopoietic stem cell transplant-associated thrombotic 
microangiopathy. Blood. 2013;122:2003-2007. 
2. Gavriilaki E, Sakellari I, Anagnostopoulos A, et al. 
Transplant-associated thrombotic microangiopathy: opening 
Pandora's box. Bone marrow transplantation. 2017;52:1355-
1360. 
3. Kennedy GA, Kearey N, Bleakley S, et al. 
Transplantation-associated thrombotic microangiopathy: 
effect of concomitant GVHD on efficacy of therapeutic 

plasma exchange. Bone marrow transplantation. 
2010;45:699–704. 
4. G. F. Rushworth and I. L. Megson. Existing and potential 
therapeutic uses for N-acetylcysteine: the need for 
conversion to intracellular glutathione for antioxidant 
benefits. Pharmacol Ther. 2014;141:150-9. 
5. G. W. Li, S. Rambally, J. Kamboj, S. Reilly, J. L. Moake, 
et al. Treatment of refractory thrombotic thrombocytopenic 
purpura with N-acetylcysteine: a case report. Transfusion. 
2014;54:1221-4. 
6. A. Rottenstreich, S. Hochberg-Klein, D. Rund and Y. 
Kalish. The role of N-acetylcysteine in the treatment of 
thrombotic thrombocytopenic purpura. J Thromb 
Thrombolysis. 2016;41:678-83. 
7. G. Cabanillas and A. Popescu-Martinez. N-Acetylcysteine 
for Relapsing Thrombotic Thrombocytopenic Purpura: More 
Evidence of a Promising Drug. Am J Ther. 2016;23:e1277-9. 
 
Study Outcomes   
Primary Outcome:   
The primary outcome was the incidence of TA-TMA. 
Secondary Outcome Measures:   
1. The level of VWF multimers in patients post HSCT.  
2. The level of endothelial micro particle in patients post 
HSCT.  
3. The level of TNF-α in patients post HSCT.  
4. The level of ROS in patients post HSCT.  

 
Dosage and administration  
Patients were randomized 1:1 by interactive response 
technique to receive either oral NAC (50 mg/kg/day 
continuously from 9 days before HSCT to 30 days after 
HSCT) or a placebo. A placebo (identical-looking tablets) 
was administered similarly to NAC for patients randomized 
to the placebo group. 
• Drug: N-Acetylcysteine 
50mg/Kg.d, oral 
Other Name: NAC 
• Drug: Placebo Oral Tablet 
50mg/Kg.d, oral 
Other Name: Placebo 
 
Statistical methods  
Kaplan-Meier survival analysis was used to estimate 
cumulative incidence of TA-TMA, the cumulative predicted 
overall survival (OS) rate and event-free survival (EFS) rate, 
cumulative recurrence rate of malignant hematologic 
disease, cumulative mortality associated with 
transplantation, and log-rank test was performed. The 
statistical process and graph were all run on SPSS 13.0 
software. All tests were bilateral, and P≤0.05 was considered 
to be significant. OS and EFS are estimated by Kaplan-
Meier method.   
 

 
Ethical statement Ethical principles  
The study should be carried out in accordance with Helsinki 
declaration proposed by World Medical Association and 
subsequent amendments and approved by the Independent 
Ethics Committee (IEC) before implementation.  
Information and informed consent  
ØAll the patients who agree to participate should be asked to 
sign the informed consent form to prove their approval for 
participation in this study. The informed consent form must 
be signed and dated personally by the patients and 
investigators.  
ØBefore obtaining the informed consent, the investigators 
must provide sufficient information to the patients who are 
potential participants in this study:  
·  The investigators should orally inform the patients of all 
the relevant circumstances of this study;   
·  The information provided to patients must be fully and 
easily understood by non-professionals, so that they can 
make a decision according to their own willingness based on 
their full understanding of this study;   
·  Additionally, the patients voluntarily participate in the 
study, and are free to quit from the study at any time, without 
any reasons. The subsequent treatment of patients is not 
under the influence of unwilling to participate or quitting from 
the study.   
ØAll the patients who agree to participate should be asked to 
sign the Informed Consent Form (ICF) to prove their 
approval for participation in this study. The ICF must be 

signed and dated personally by the patients and the 
investigators;  
ØThe signed ICF will be kept in the Data Center and must 
be safely kept for future review at any time throughout the 
study.  
Withdrawal from the study  
The main withdrawal criteria are as following:  
ØChanges in the patient’s condition after inclusion, which 
suggests that the  study protocol is unsuitable for the patient; 
  
ØSevere complications affecting the implementation of the 
study treatment;   
ØPatients who are confirmed to require emergency 
treatment due to other  diseases after inclusion;  
ØTreatment unmated with the study protocol;   
ØPatients who voluntarily quit or discontinue any 
examination, treatment and monitoring required by the study 
for personal reasons at any stage after inclusion in this 
study. The PI also has the right to withdraw patients from the 
study if he/she feels that the withdrawal is in the best 
interests of the patients.  
 
Identity and privacy of patients  
ØAfter obtaining an ICF, each enrolled patient is assigned a 
subject number (allocation number). This number will 
represent the identity of the patient during the study and for 
the retrieving of dedicated clinical research database;  

ØThroughout the study, several measures will be taken to 
minimize any breaches of personal information, including:  
·  Only the PI and co-investigators will be able to link to the 
research data of the patients to themselves through the 
identifiable table after authorization;   
·  Collection, transmission, handling and storage of the 
study data must comply with the data protection and privacy 
regulations.   
Responsibility of independent ethics committee  
The responsibilities of independent ethics committee include: 
ØReview of this study;  
ØEvaluate this study to determine if risks to which patients 
are exposed have  been duly minimized and whether these 
risks are reasonable compared to  expected benefits;   
ØCheck the study protocol and relevant documents (patient 
information  sheet, ICF, CRF, etc.) submitted by the 
Research Committee before  beginning of the study;  
ØProvide the written proof of ethical review opinions, the 
written proof of the  date of the review meeting, the written 
proof of the members presenting at the meeting and voting 
members, the written proof of recording of the reviewed 
versions of study protocol, ICF and other related documents, 
and if possible, a copy of the minutes, to the Research 
Committee. The study can begin only after obtaining the 
written proof of favorable opinions/approval of the IEC;   
ØSupervise the legitimacy of the process of informed 
consent;   
ØEnsure the safety of patients during the research process 
by examining the  reported safety information. The 

investigators should report to the IEC on any therapeutic 
complications which may affect the safety of patients. When 
complications that affect the patient safety occur, the IEC 
should inform PI to withdraw patients from the study and use 
any possible treatment to cure patients. If the PI decides not 
to withdraw patients from the study, he should provide a 
written proof of explanation to the IEC;  ØReview the 
reasonableness of the costs incurred by patients in the 
course of the study through a selective check for 
hospitalization expenses. When the patient has indications 
for off-label use of drugs, the IEC will receive the notice and 
the description of relevant situation from the investigators. 
The IEC should record the relevant records;   
ØReview the revisions of the study protocol, and any 
changes must be approved by the IEC before they are 
adopted. Unless the change is necessary to eliminate an 
immediate hazard to the patients, in which case the IEC 
should be informed as soon as possible;  
ØReview the progress of the study annually and the close-
out report submitted by the Research Committee at the end 
of the trial.  
Responsibility of investigator  
The responsibilities of investigators are as follows:  
ØInvestigators, participated in the clinical trial, should be 
obtained certificate for assistant practicing doctor, resigned 
and attended the training of the GCP guidelines and the 
correlation of laws and regulations, possessed specialty, 
qualification and ability in clinical trial.  
ØSubjects are adequately recruited by the investigator 
during required time according to the clinical trial，and 

operation capacity and possibility to be qualified the item 
should be evaluated by the previous working experience.  
ØInvestigators are familiar with clinical trial protocols and 
execute instruction strictly according to the protocols and 
case report form.  
ØIn all adverse events, subjects must be taken appropriate 
therapies and made a contact with the investigator as soon 
as possible. Investigators will take responsibilities of relevant 
medical decision of clinical trial to ensure subjects that is 
taken adequate medical treatment.   
ØAny information on the case report form possesses original 
data, to ensure the case history and case report form filled in 
truly, accurately, completely， timely, regularly and legally.   
ØSubjects will be illustrated the relevant situation where the 
clinical trial is fully consent by Ethics Committee. The 
informed consent will be acquired and, during the process, it 
must meet the specification.   
ØSupervision and inspection will be received by supervisor 
and inspector assigned by sponsor to ensure the quality of 
clinical trial.  
ØAny advices and suggestions focused on the study 
protocols might be submit to the principal institution of 
clinical research, and made a discussion with sponsors to 
decide whether adopting the above advice or suggestions, 
during the clinical trial.  
Publications  
ØAll the data collected during this study are the property of 
the study sponsor and cannot be communicated in any case 

to a third party without the written agreement of the 
investigator.  
ØAny publication or communication (oral or written) will be 
decided from a common agreement between the 
investigators and will respect the international 
recommendations: "Uniforms Requirements for Manuscripts 
Submitted to Biomedical Journals" 
(http://www.cma.ca/publications/mwc/uniform.htm): notably, 
an authorship will be proposed to each clinical center 
participating in the study and to each member of the steering 
committee according to his/her actual participation.  
Organization and responsibility  
The Research Committee is responsible for developing 
study protocol, auditing patient eligibility and guiding 
interpretation of informed consent. It is also responsible for 
collection of complication reports, guiding diagnosis and 
treatment of complications and emergency intervention for 
serious complications, as well as approving the content and 
distribution of all publications related to the study.  
 
 
Patient consent form for study participation  
Title：A safety and efficacy study of NAC in patients with 
TA-TMA 
Patient Name 
 
Please tick each box below o if you have known the 
corresponding statement.  
oWhat you should know about a research study  

Someone will explain this research study to you.  
Ø A research study is something you volunteer for.  
Ø Presence or absence of participation in the research study is 
up to you.  
Ø You can choose not to take part in the research study.  
Ø You can agree to take part now and later change your mind.  
Ø Whatever you decide it will not be held against you.  
Ø You can feel free to ask all the questions that you want 
before you decide.  
o What is the purpose of this study?  
Transplant-associated thrombotic microangiopathy (TA-
TMA) is a severe complication in patients following 
hematopoietic stem cell transplantation (HSCT). Previous 
investigations suggest that multiple factors resulting in 
endothelial cell injury lead to the occurrence of TA-TMA. 
Specifically, the abnormity of complement system 
contributes to the development of TA-TMA. TA-TMA 
shares a similar clinical manifestation with thrombotic 
thrombocytopenic purpura (TTP) and atypical hemolytic 
uremic syndrome (aHUS), which is characteristic with 
microangiopathic hemolytic anemia, platelet consumption, 
fibrin deposition in the microcirculation, and, ultimately, 
end-organ injury. However, the diagnostic criteria of TA-
TMA are far from accurate. Although several diagnostic 
criteria had been proposed, no criterion has been 
rigorously evaluated clinically due to lack of pathological 
diagnosis. Moreover, the pathogenesis of TA-TMA is still 
unclear. Conventional treatment management is less 
efficient. Plasma infusions or therapeutic plasma exchange 
is considered as limited efficacy, with relatively low 

response rates (20–50%) in comparison to idiopathic TTP 
(75%) generally reported.  
N-acetylcysteine (NAC) is an antioxidant synthesized from 
cysteine that increases glutathione biosynthesis and 
scavenges reactive oxygen species directly or indirectly. 
NAC was recently suggested as a potential treatment for 
patients with thrombotic thrombocytopenic purpura (TTP). 
Li and colleagues provide a case report of a TTP patient 
relieved with NAC, providing the first clinical evidence for 
the efficacy of NAC in treating TTP. In our study, we 
explored whether TA-TMA patients might benefit from NAC 
via targeting complement. 
 
o Do I have to take part?  
·  Participation in the study is entirely voluntary.   
·  You will be given sufficient time to consider whether you 
want to  participate in the study.   
·  Non-participation in the study will not affect your future 
care that you will receive from your medical and nursing 
team in our hospital.  
·  If you decide to join the study, you will be asked to sign 
an informed  consent form.   
·  You are free to withdraw from this research at any time 
and without  giving a reason. Any of your current medical 
care and future treatment in our hospital will not be 
affected.   
o What will happen to me if I take part?   
·  All patients who agree to take part and provide a written 
informed consent form will be included into this study.   

·  You will be  randomized 1:1 by interactive response 
technique to receive either oral NAC (50 mg/kg/day 
continuously from 9 days before HSCT to 30 days after 
HSCT) or a placebo. 
·  Your doctors will introduce the detailed treatment 
procedures to you. You are free to ask any question about 
the treatments you may have.   
o What are the risks of the study?   
Potential adverse event of NAC includes:   bronchial 
asthma, peptic ulcer, pregnancy and lactation, absence of 
uncontrolled infection or severe liver, kidney, lung, or heart 
disease. 
o What are my responsibilities in this study?  If you 
choose to take part in this study, you will need to:  
· Keep your study appointments.  
· Tell your doctor about:  All medications and supplements 
you are taking; Any discomforts or complications you 
suspect; Any doctors’ visits or hospital stays outside of this 
study; Whether you have been or are currently in another 
research study.  
o How will my privacy be protected?   
· Your health information, such as your response to drug, 
results of study tests, and medicines you took, will be kept 
by the data center of this research. This information is 
strictly confidential. However, your name and contact 
information will not be put in the database. If information 
from this study is published or presented at scientific 
meetings, there will be no personally identifiable 
information.  

o What happens if I change my mind during the 
study?   
· We would certainly recommend that you continue the 
study, however, participation in the study is voluntary and 
you may stop the participation at any time that you wish 
without losing any of your rights as a patient here. Your 
treatment at our hospital will not be affected in any way. 
The PI of this study also has the right to withdraw patients 
from the study if he feels that the withdrawal is in your best 
interests. Your follow-up information will still be kept by 
doctor after you have stopped participating in the research. 
o Who is organizing the research?   
· The study is organized by the The First Affiliated Hospital 
of Soochow University, Suzhou 215006, China.  
 
 
 
 

Signature page  
I have read all the above, asked questions, and received 
answers concerning areas I did not understand. I have had 
the opportunity to take this consent form home for review or 
discussion.  
I willingly give my consent to participate in this program. 
Upon signing this form, I will receive a copy. I may also 
request a copy of the protocol (full study plan).  
                     Patient signature  
                     Date signed  
                     Investigator signature  
                     Date signed