Early Intervention With Eculizumab to Treat Thrombotic Microangiopathy/Atypical Hemolytic Uremic Syndrome (TMA/aHUS)-Associated Multiple Organ Dysfunction Syndrome (MODS) in Hematopoietic Stem Cell Transplant (HCT) Recipients
Phase: PHASE2
Conditions: Thrombotic Microangiopathies, Atypical Hemolytic Uremic Syndrome, Multiple Organ Dysfunction Syndrome
Sponsor: Children's Hospital Medical Center, Cincinnati

 
 
COVER PAGE FOR CLINICALTRIALS.GOV 
 
 
Protocol Title: Early Intervention with Eculizumab to Treat Thrombotic 
Microangiopathy/atypical Hemolytic Uremic Syndrome (TMA/aHUS)-
associated Multiple Organ Dysfunction Syndrome (MODS) in 
Hematopoietic Stem Cell Transplant (HCT) Recipients 
 
 
NCT Number: NCT03518203 
 
 
/Document Version Date: 07/02/2020 

CCHMC IRB#: 2018-7119C
      
Page 1 of 43
Early Intervention with Eculizumab to Treat Thrombotic 
Microangiopathy/atypical Hemolytic Uremic Syndrome (TMA/aHUS)-
associated Multiple Organ Dysfunction Syndrome (MODS) in Hematopoietic 
Stem Cell Transplant (HCT) Recipients
IND 136738
Sponsor: Stella M Davies, MBBS, PhD, MRCP
CINCINNATI CHILDRENS HOSPITAL MEDICAL CENTER (CCHMC)
Lead Principal Investigator: 
Sonata Jodele, MD 
          
Investigators:                                          Stella M Davies, MBBS, PhD, MRCP                                
                                                                 Jacob Bleesing, MD, PhD
Sharat Chandra, MD
Christopher Dandoy, MD, MSc
Rebecca Marsh, MD
Parinda Mehta, MD
Kasiani Myers, MD
Michael Grimley, MD
Pooja Khandelwal, MD
Ashish Kumar, MD, PhD
   
Michael Jordan, MD
Adam Nelson, MBBS, FRACP
Gregory Wallace, DO
Mary Christa Krupski, DO, MPH
Ruby Khoury, MD
Statistician:
Adam Lane, PhD
Pharmacist: 
Ashley Teusink-Cross, PharmD, MBA, BCPS
Pharmacologist: 
Kana Mizuno, BPharm, MS, PhD
CHILDRENS HOSPITAL LOS ANGELES (CHLA)
Co-Investigator: 
             Paibel Aguayo-Hiraldo, MD
CHILDREN’S HOSPITAL OF PHILADELPHIA (CHOP)
Co-Investigator:
Jason Freedman, MD, MSCE
DANA-FARBER CANCER INSTITUTE (DFCI)/BOSTON CHILDREN’S HOSPITAL (BCH)
Co-Investigator:
Leslie Lehmann, MD

CCHMC IRB#: 2018-7119C
      
Page 2 of 43
TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE
ABBREVIATIONS
PROTOCOL SYNOPSIS
1. INTRODUCTION
1.1 Purpose and rationale of the study
1.2 Significance of the study in relation to human health
1.3 Background
1.4 Previous work done in this area
2. STUDY PLAN
2.1 Study synopsis
2.2 Hypotheses
2.3 Number of Subjects
2.4 Selection
2.5 Recruitment
2.6 Expected duration of the study
3. STUDY ENDPOINTS
3.1 Primary study endpoint
3.2 Secondary study endpoints
4. ELIGIBILITY
4.1 Inclusion criteria
4.2 Exclusion criteria
5. STUDY DRUG
5.1 Eculizumab availability for study
5.2 Eculizumab mechanism of action
5.3 Study drug management
5.4 Eculizumab safety profile
6. TREATMENT PLAN
6.1 Eculizumab dosing and administration for HCT recipients with TMA
6.2 Eculizumab dosing schedule for HCT recipients
6.2.1 Eculizumab dosing schedule modification from listed in Table 1
6.2.2 Supplemental eculizumab dosing for patients receiving FFP and TPE
6.2.3 Patient monitoring during eculizumab therapy
6.2.4 Patient monitoring after eculizumab therapy completion
6.3 Concomitant HCT medication and supportive care guidelines

CCHMC IRB#: 2018-7119C
      
Page 3 of 43
6.4 Post-transplant follow-up
7. TOXICITY MONITORING
7.1 Eculizumab safety
7.2 Risk for meningococcal infections during eculizumab therapy
7.3 Prevention of meningococcal infections in HCT recipients receiving eculizumab therapy
7.4 Risk to unborn fetus
8. ASSESSMENT OF SAFETY
8.1 Study monitoring and auditing
8.2 Data safety monitoring plan
8.3 Adverse events (AE)
8.3.1 Adverse event definitions
8.3.2 Adverse event reporting
9. RISK/BENEFIT ANALYSIS
9.1 Potential benefits
9.2 Potential risks, discomforts, and inconveniences
10. STATISTICAL ANALYSIS
11. PATIENT ENROLLMENT
12. COMMUNICATION BETWEEN PARTICIPATING CENTERS
13. DATA MANAGEMENT 
14. ETHICS/PROTECTION OF HUMAN SUBJECTS
14.1 Regulatory
14.2 Confidentiality
14.3 Future Use
15. STUDY FUNDING AND COMPENSATION
16. REFERENCES
17. APPENDIX I: TMA DIAGNOSIS IN HCT RECIPIENTS 
18. APPENDIX II: DEFINITIONS OF TMA-ASSOCIATED MODS IN HCT RECIPIENTS 
19. APPENDIX III: TMA TEST REQUISITION INFORMATION 
20. APPENDIX IV: STUDY SAMPLE COLLECTION FOR REPOSITORY 
21. APPENDIX V: ADVERSE EVENT REPORTING OF TMA ASSOCIATED CONDITIONS

CCHMC IRB#: 2018-7119C
      
Page 4 of 43
STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with Good Clinical Practice (GCP) as required by the 
applicable laws and regulations. 
All key personnel (all individuals responsible for the design and conduct of this trial) have completed 
Human Subjects Protection Training. 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitments. 
I agree to conduct this trial in accordance with the ethical principles outlined in the Declaration of 
Helsinki. 
Site Name (type/print): ______________________________________________________________
Site Principal Investigator Name (type/print): ____________________________________________
Site Principal Investigator Signature: _____________________________ Date: _________________

CCHMC IRB#: 2018-7119C
      
Page 5 of 43
ABBREVIATIONS 
CCHMC
Cincinnati Children’s Hospital Medical Center
CHLA
Children’s Hospital Los Angeles
HCT
Hematopoietic cell transplant 
aHUS
atypical hemolytic uremic syndrome
TMA
thrombotic microangiopathy in hematopoietic cell transplant recipients
MODS
Multi-organ dysfunction syndrome
Ur pr/cr ratio
Random urine protein/random urine creatinine ratio
PK/PD
pharmacokinetic/pharmacodynamics testing
PRES 
Posterior reversible encephalopathy syndrome
NRM
Non-relapse mortality
autoHCT
Autologous hematopoietic cell transplant
alloHCT
Allogeneic hematopoietic cell transplant
sC5b-9
Soluble membrane attack complex 
TTP 
Thrombotic thrombocytopenic purpura
ADAMTS13
a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13
CH50
Total hemolytic complement activity
DSMB
data and safety monitoring board
IND
Investigational new drug
Cyst C GFR
Cystatin C based glomerular filtration rate
AKI
Acute kidney injury
CKD
Chronic kidney injury
PH
Pulmonary hypertension
GI
Gastrointestinal 
BSI
Blood stream infection
PICU
Pediatric intensive care unit
REMS
Risk Evaluation and Mitigation Strategy
FDA
Food and Drug administration
C5
Complement Factor 5
LDH
Lactate dehydrogenase
PNH
Paroxysmal nocturnal hemoglobinuria
ID
Identification
FFP
Fresh frozen plasma
TPE
Therapeutic plasma exchange
IVIG
Intravenous immunoglobulin
PI
Principal investigator
AE
Adverse event
SAE
Severe adverse event
CRC
Clinical research coordinator

CCHMC IRB#: 2018-7119C
      
Page 6 of 43
PROTOCOL SYNOPSIS
Title
Early intervention with eculizumab to treat thrombotic microangiopathy/atypical 
hemolytic uremic syndrome (TMA/aHUS)-associated multiple organ dysfunction 
syndrome (MODS) in hematopoietic stem cell transplant (HCT) recipients
Abbreviation 
TMA/aHUS in HCT recipients will be abbreviated as “TMA”. 
Study type
Single arm multi-institutional prospective study
Population
HCT recipients with clinical diagnosis of high risk TMA
Enrollment
21 patients (plus replacements if needed for early death or relapse)
Participating 
Institutions
Cincinnati Children’s Hospital Medical Center (CCHMC)
Children’s Hospital Los Angeles (CHLA)
Children’s Hospital of Philadelphia (CHOP)
Dana-Farber Cancer Institute (DFCI)/Boston Children’s Hospital (BCH)
Expected 
study duration 
4 years: anticipate enrollment of 7-10 patients annually for 2-3 years with 1 year post-
transplant follow-up. 
Purpose and 
rationale
The large majority of the published clinical experience with treatment of TMA with 
complement blockade has been performed in a single center (Cincinnati), where the 
biology and treatment of TMA is a key research focus. In this protocol we seek to 
establish a treatment regimen that can be generalizable to multiple sites and does not 
require time-intensive individual PK and PD monitoring. In preparation for this study, 
we established prospective screening for TMA, determined high-risk disease markers, 
and performed eculizumab detailed pharmacokinetic/pharmacodynamics (PK/PD) 
studies in children receiving HCT. We will perform the current study at multiple centers 
to establish exportability; the regimen is expected to provide satisfactory outcomes for 
a large majority of children without highly specialized monitoring.
Hypotheses
1.  Early intervention with complement blocker eculizumab will double survival in 
HCT recipients with high risk TMA, as compared to historical untreated controls.  
2.  An optimal eculizumab dosing schedule can be determined for this population 
through eculizumab pharmacokinetic and pharmacodynamics (PK/PD) testing. 
Primary 
endpoint 
Survival at 6 months from TMA diagnosis.  
Statistical 
considerations 
for primary 
endpoint
This prospective single arm study will test the null hypothesis of 18% survival versus 
a projected increase in survival to 45% at 24 weeks from TMA diagnosis in this high 
risk population by using early therapy with eculizumab. The primary endpoint will be 
assessed using a 1-sided exact binomial distribution test. The sample size of 21 has a 
greater than 80% power of yielding a significant p-value. The primary analysis will be 
intent-to-treat. A secondary “successfully treated patient analysis” (defined as >4 doses 
of eculizumab administered) will also be performed using a non-relapse mortality 
endpoint. Children who receive 4 or fewer doses of therapy, or who relapse with 
malignancy prior to 24 weeks on the study will be replaced.
Secondary 
endpoints

Cumulative incidence of organ dysfunction at 6 months after TMA diagnosis 
and 1 year after HCT, compared with historical controls with high risk TMA 
using MODS definition is shown in APPENDIX II. Organ systems evaluated 
will be:
o
Renal 

Includes hypertension evaluation
o
Cardiac
o
Pulmonary 
o
Gastrointestinal 
o
CNS function
o
Pericardial Effusion

CCHMC IRB#: 2018-7119C
      
Page 7 of 43

Timing and extent of resolution of organ dysfunction in the first year after 
therapy.

1 year non-relapse mortality (NRM) compared with historical controls. 

Characterization of eculizumab PK/PD. 
Study design
This is prospective single arm multi-institution study in patients undergoing allogeneic 
(alloHCT) or autologous hematopoietic stem cell transplantation (autoHCT). We will 
enroll 21 consecutive HCT recipients (plus replacements if needed for early death due 
to inability to receive a minimal level of therapy, or relapse; see statistical section for 
details) diagnosed with high risk TMA using our published criteria (Jodele et al, Blood 
2014). The eculizumab dosing regimen for this study was derived from our clinical and 
PK/PD data in 50 eculizumab treated HCT recipients with a goal to identify drug 
administration schedule that would be effective in the majority of HCT recipients with 
high risk TMA due to high mortality seen in untreated and undertreated disease. All 
patients will receive eculizumab loading doses at the beginning of therapy followed by 
induction dosing due to high drug clearance that occurs during the first five weeks of 
therapy. This allows rapid disease control, which is essential to avoid organ injury. 
Maintenance dosing will continue until all patients complete a total of 24 weeks of 
therapy (Table 1). Survival will be assessed at 6 months from TMA diagnosis as the 
primary study endpoint. With high mortality associated with TMA after HCT, it is 
important to avoid undertreatment of these patients in order to improve chances of 
preventing MODS and death. This dosing regimen should be feasible at institutions that 
don’t have the availability to monitor drug PK/PD in real time. PK/PD testing obtained 
during this study will allow us further optimize the eculizumab dosing schedule and to 
determine patients in whom shorter therapy might be possible. All study patients will 
receive antimicrobial prophylaxis adequate to cover N. Meningitides for the duration 
of the eculizumab therapy plus until the CH50 and eculizumab serum level is 
unmeasurable (<25 µg/ml), when complement should no longer be blocked. 
Eculizumab PK/PD studies will be performed on all study patients and will be used for 
secondary endpoints. After the primary study endpoint is met, patients will be treated 
and monitored as clinically indicated, with final follow-up at 1 year after HCT.
Inclusion 
criteria
Patients of any age undergoing allogeneic or autologous HCT with:

Histologic TMA diagnosis 

OR clinical TMA diagnosis and presenting with high risk disease features 
including:

elevated plasma sC5b-9 above laboratory normal value (≥244ng/ml). 
AND

proteinuria: measured as ≥30mg/dL of protein on random urinalysis 
x2 or protein/creatinine ratio ≥1mg/mg or patient receiving renal 
replacement therapy.
             TMA diagnostic criteria are shown in APPENDIX I

Minimum weight of ≥ 5kg.

ADAMTS13 Activity lab sample must be drawn during or prior to screening 
(results can be pending and are not required for initial eligibility).  
Development of TMA can be a medical emergency and thus if patient meets 
all other eligibility criteria, patient may proceed with enrollment and study 
treatment even if ADAMTS13 results are not available. If test results confirm 
diagnosis of TTP defined by ADAMTS13 activity test <10%, then study 
treatment will be immediately halted and patient will be removed from study.
Exclusion 
criteria

Known hypersensitivity to any constituent of the study medication.

Subjects with unresolved serious Neisseria meningitides infection or 

Progressive severe infection.

CCHMC IRB#: 2018-7119C
      
Page 8 of 43

Patients previously treated with eculizumab or other complement blockers 
within the 60 days prior to first dose of study treatment.
Laboratory 
monitoring
TMA activity markers and PK/PD studies are listed in Table 3. PK/PD data will be 
used to evaluate the efficacy of complement blockade with the eculizumab regimen 
administered. 
Eculizumab 
dosing 
See Table 1
Study drug 
availability
Eculizumab (Soliris) will be provided by Alexion Pharmaceuticals at no cost to study 
subjects. 
1.
INTRODUCTION
1.1 Purpose and rationale of the study
Thrombotic microangiopathy or transplant associated atypical hemolytic uremic syndrome (aHUS) is an 
important cause of multi-organ dysfunction syndrome (MODS) and death after HCT (further in the protocol 
referred as “TMA”). The large majority of the published clinical experience with treatment of TMA with 
complement blocking agent eculizumab has been performed at a single center (Cincinnati), where the 
biology and treatment of TMA is a key research focus. In this protocol we seek to establish a treatment 
regimen that can be generalizable to multiple sites and does not require time-intensive individual 
pharmacokinetic and pharmacodynamics (PK/PD) monitoring.  In preparation for this study, we established 
prospective screening for TMA, determined high-risk disease markers, and performed detailed eculizumab 
PK/PD studies in children receiving HCT. We will perform the current study at multiple centers to establish 
exportability; with that established, the approach should be able to be adopted more broadly. The regimen 
is expected to provide satisfactory outcomes for a large majority of children without highly specialized 
monitoring. Due to the high mortality observed among patients with high-risk TMA who don’t receive 
targeted anti-complement therapy, a randomized study including untreated control arm is not considered to 
be ethically feasible.
1.2 Significance of the study in relation to human health
Hematopoietic stem cell transplantation (HCT)-associated thrombotic microangiopathy (TMA) is an 
understudied complication of HCT that significantly affects transplant related morbidity and mortality. 
Over the past several decades, the cause of TMA was unknown, limiting treatment options to non-specific 
therapies adapted from other diseases. Our recent prospective studies dedicated to the study of TMA have 
provided new insights into the pathogenesis of, and genetic susceptibility to TMA, raising awareness of this 
important transplant complication and allowing for the identification of novel therapeutic targets. 
Specifically, many patients with TMA develop multiple organ dysfunction syndrome (MODS) due to tissue 
injury through endothelial damage mediated by activation of the complement pathway. This knowledge has 
led to complement blockade using eculizumab as a therapy directly targeting the cause of the disease. This 
new strategy has the potential to favorably influence clinical practice and change the standard of care for 
how HCT recipients with TMA are managed. Preliminary data and experience to date suggest that early 
TMA therapy will reduce incidence of MODS after HCT and improve long-term outcomes in transplant 
survivors. The data this study will generate will have importance beyond the field of stem cell 
transplantation in helping to understand mechanisms of TMA induced endothelial injury that are relevant 
to other microangiopathies in whom populations are smaller and prospective systematic study is not 
possible.
1.3 Background
TMA occurs in 30% of children undergoing HCT, and about half of these children develop MODS that is 
generally lethal if not treated early. TMA affects the endothelium of small vessels, leading to MODS 

CCHMC IRB#: 2018-7119C
      
Page 9 of 43
presenting as renal failure, pulmonary hypertension with cardiac failure, polyserositis, and bowel ischemia 
and necrosis. Retrospective literature consistently reports over 80% mortality with TMA/MODS, with the 
large majority of patients dying within 6 months of TMA diagnosis.1-3 To date there is no effective, 
generally adopted standard of care therapy for TMA in HCT recipients. In our earlier study, we showed 9% 
overall survival in patients with high risk TMA and MODS who did not receive TMA targeted therapy with 
82% of patients dying by week 24 after TMA diagnosis (Jodele et al, Blood 2014).4
Laboratory investigations we performed demonstrated that patients with TMA develop MODS through 
endothelial damage mediated by complement system activation, allowing us to propose a novel therapeutic 
strategy using the complement blocker eculizumab. We identified that activated terminal complement and 
proteinuria are early prognostic markers of poor survival in TMA and complement blockade with 
eculizumab can significantly improve survival in these patients who historically have dismal outcomes. In 
contrast to this, in a single center prospective study we showed that eculizumab therapy given for TMA and 
MODS improved survival to 62% compared to 9% (p=0.0007) in patients with same risk TMA not receiving 
eculizumab (Jodele et al, BBMT 20135 and 20156 ). We have extended this experience using complement 
blockade for TMA/MODS, having treated more than 50 patients, optimizing therapy through 
pharmacokinetic and pharmacodynamic (PK/PD) testing. Our experience and publications indicate that the 
main reason for failure in treating TMA after HCT is late initiation of eculizumab intervention. Once 
TMA/MODS is advanced, severely impaired organ function can’t be salvaged. In our clinical cohort, 
patients were started on eculizumab therapy on average 43 days from TMA diagnosis; those at end stages 
of their disease more often having poor outcome. Our data to date also indicate that eculizumab 
pharmacokinetics in HCT recipients differ significantly from patients reported with atypical hemolytic 
uremic syndrome (aHUS)(Jodele et al, BBMT 2015).6 HCT recipients with TMA have much higher disease 
activity and much faster eculizumab clearance indicating the need to determine an optimal eculizumab 
dosing schedule that will be effective in HCT patients through PK/PD based eculizumab dosing.  
There is a significant need for a prospective, multicenter study that examines eculizumab efficacy in TMA 
after HCT in consistent manner, initiating therapy early in patients at high risk for TMA associated MODS. 
Because of the high mortality observed among patients with high-risk disease who did not receive targeted 
anti-complement therapy, a randomized study with untreated control group is not considered to be ethically 
feasible. Also, we have demonstrated that the HCT population has a much more severe TMA phenotype 
and much higher eculizumab clearance than reported in patients with aHUS and PNH,7,8 so we need to 
determine optimal dosing regimen in HCT recipients with TMA to be used as standard of care in the future.  
This prospective clinical study will result in novel eculizumab dosing regimen for HCT recipients with high 
risk TMA that is effective in preventing TMA-associated MODS.
1.4 Previous work done in this area
TMA-associated MODS in HCT recipients
In our prospective study we documented overall TMA incidence in 39% (39/100) of children undergoing 
HCT and identified TMA risk criteria. HCT recipients with TMA who had proteinuria ≥30 mg/dL and 
elevated sC5b-9 at TMA diagnosis had worse 1-year post-transplant survival (<20%, high risk patients). 
Patients with TMA, but without proteinuria and without elevated sC5b-9, all survived without targeted 
intervention (low risk group). Having one risk factor, proteinuria or elevated sC5b-9 placed patients in 
moderate risk group. We now confirmed our data in 500 prospectively monitored HCT recipients and 
continue to observe total TMA incidence at 34% (mild to severe phenotype). Severe TMA phenotype TMA 
with MODS occurred in 11% of all transplanted patients. All these patients had evidence of terminal 
complement activation and required therapy with eculizumab. 
We also showed that pediatric intensive care unit (PICU) admissions for MODS were much higher in 
children with TMA as compared  to those without TMA (46% vs 15%, p=0.01)(Jodele et al Blood 2015).9 
Overall non-relapse mortality in children with TMA and MODS was over 90% without TMA targeted 

CCHMC IRB#: 2018-7119C
      
Page 10 of 43
therapy. The historical rate from our prospective study had survival documented in 2/11 (18%) patients 
with high risk TMA with MODS without relapse who did not receive any targeted TMA therapy within 24 
weeks from TMA diagnosis and overall survival was with 10 of 11 patients dying within one year post 
HCT. Similar rates are consistently reported in retrospective studies showing over 80% non-relapse 
mortality (NRM) with TMA and MODS with patients dying within 6 months of TMA diagnosis.2,3,10-12 Cho 
et al reported 29% incidence of TMA (n=148) 
with 
<20% 
survival 
in 
patient 
meeting 
hematologic 
and 
renal 
diagnostic 
criteria 
(“definite TMA”), and concluded that TMA 
should be treated as soon as it is suspected, to 
avoid irreversible organ damage since therapeutic 
interventions like plasma exchange, defibrotide or 
discontinuation of calcineurin inhibitors had the 
greatest benefit if therapy was initiated early, but 
there are no clinical trials evaluating any TMA 
targeted treatment methods. Oran et al reported 55 
of 66 patients (83%) dying at a median of 3 
months after TMA diagnosis. Median survivals 
from the date of the first TMA episode for non-
responders to plasmapheresis was 1.07 months vs 
7.5 months in responders (p=0.0001). Survival at 
6 months was 0% and 50.7% for TMA non-
responders and responders to plasmapheresis, 
respectively. 
Genetic predisposition to TMA after HCT: We 
performed a hypothesis-driven analysis of 17 
candidate genes known to play a role in 
complement activation as part of a prospective 
study (n=100) of TMA in HCT recipients. We 
examined the functional significance of gene 
variants by using gene expression profiling. 
Sixty-five percent of patients with TMA had 
genetic variants in at least one gene compared 
with 9% of patients without TMA (p < 0.0001) 
(Fig.1). Gene variants were increased in patients of all races with TMA, but nonwhites had more variants 
than whites (2.5 [range, 0-7] vs 0 [range, 0-2]; p <0.0001). Variants in ≥3 genes were identified only in 
nonwhites with TMA and were associated with high mortality (71%). RNA sequencing analysis of pre-
transplantation samples showed upregulation of multiple complement pathways in patients with TMA who 
had gene variants, including variants predicted as possibly benign by computer algorithm, compared with 
those without TMA and without gene variants.  
Kidney injury: Consistent with our previous studies, we observed that proteinuria and hypertension were 
the earliest signs of TMA in HCT recipients, along with an elevation in the lactate dehydrogenase (LDH). 
In contrast, kidney dysfunction assessed by serum creatinine was a late marker, highlighting its limitations 
as it remains an insensitive marker to detect impaired renal function in pediatric HCT recipients who 
generally have low muscle mass and thus low creatinine generation rates.4 In a prospective 94 patient cohort 
we showed that pediatric equations including Cystatin C (Cyst C) performed better than those including 
only creatinine,13 therefore we have adopted Cystatin C based glomerular filtration rate (GFR) monitoring 
of acute kidney injury (AKI) for children undergoing HCT. In the group of 30 children treated with 
eculizumab for high risk TMA in Cincinnati, the median decline in CycC GFR due to TMA was 75% from 
pre-transplant baseline, indicating severe kidney injury occurs with the microangiopathic process. Thirty 
six percent of these patients progressed to ≥ stage 3 chronic kidney disease. By reports in the literature, 
patients with TMA as compared with HSCT patients without TMA are 4 times more likely to develop 
chronic kidney disease (CKD) and 9 times more likely to have hypertension with kidney function declining 
to as low as 40% of normal 2 years after HCT.14,15 

CCHMC IRB#: 2018-7119C
      
Page 11 of 43
Cardiac and pulmonary injury: We showed in autopsy specimens that HCT-TMA can be associated with 
significant pulmonary vascular injury. This presents clinically as hypoxemic respiratory failure with acute 
pulmonary hypertension (PH). Of note, echocardiography can identify vascular injury associated with TMA 
as early as 7 days after HCT.16 In our prospective TMA study (n=100) pulmonary hypertension was 
diagnosed exclusively in the TMA group, and respiratory failure and pericardial effusions were strongly 
associated with TMA (p<0.01).4 A separate prospective cardiac screening study of 227 patients at our 
institution supported our initial observations, confirming that clinically significant pericardial effusions 
were associated with TMA (p<0.01).
 
Gastrointestinal (GI) injury: In our prospective study severe gastrointestinal bleeding occurred only in 
subjects with TMA; notably only those who received TMA targeted therapy survived.4 Patients with 
intestinal TMA presenting as ischemic colitis who were treated with eculizumab sometimes had intestinal 
strictures requiring surgical resection. A retrospective blinded review of pathology samples we performed 
showed that histologic evidence of TMA can be identified in the bowel of subjects with systemic high risk 
TMA features.17
Blood 
stream 
infections 
(BSI): 
In 
a 
prospective analysis of 374 children who 
underwent HCT at our institution to 
determine the incidence, risk factors, and 
outcomes of patients that developed a 
bloodstream infection (BSI) we showed that 
nearly 50% of all patients with a BSI 
developed sepsis, 25% were transferred to the 
PICU, and 10% died within 10 days of the 
positive 
culture. 
One-year 
non-relapse 
mortality (NRM) was significantly increased 
in patients with one BSI (34%) and more than 
one BSI (56%) in the first year post-HCT 
compared with those who did not develop 
BSIs (14%) (p ≤ 0.0001). TMA was 
significantly associated with development of 
a BSI in HCT recipients (OR, 2.94; p < 0 
.0001) likely due to impaired intestinal 
vascular barriers due to microangiopathy.  
TMA risk stratification
Our prospective monitoring study showed 
that 
children 
with 
both 
proteinuria 
(≥30mg/dL) and terminal complement activation as measured by elevated plasma sC5b-9 level 
(>244ng/mL) in addition to hematologic TMA markers (elevated LDH, de novo anemia and 
thrombocytopenia, low haptoglobin and schistocytes) at TMA diagnosis had very poor a 1-year HCT 
survival (<20%), whereas subjects without complement activation (normal plasma sC5b-9) and no 
proteinuria all survived without any interventions (20% vs 100%, p<0.0006).4  These data again suggest 
that complement activation plays a significant role in the pathogenesis and severity of TMA after HCT and 
allowed us to propose risk stratification criteria to identify subjects who may benefit from complement 
blocking therapy. HCT recipients with TMA who have elevated sC5b-9 and proteinuria now are stratified 
as “high risk TMA” due to high risk for MODS and death and are offered eculizumab therapy, those with 
normal sC5b-9 and no proteinuria are “low risk TMA” and are closely monitored without interventions. 
Interventions for patients with one high risk feature are offered case by case based on TMA-associated 
organ injury Fig.2.   

CCHMC IRB#: 2018-7119C
      
Page 12 of 43
Eculizumab therapy and pharmacokinetics/pharmacodynamics (PK/PD) in HCT recipients: 
As we were studying complement blocking therapy in HCT patients with high-risk TMA, we discovered 
that eculizumab pharmacokinetics in HCT recipients differ significantly from those reported for other 
diseases (aHUS and PNH). We measured eculizumab serum concentrations, total hemolytic complement 
activity (CH50), and plasma sC5b-9 concentrations in 18 HCT recipients with high-risk TMA presenting 
with complement activation. Population PK/PD analyses correlated eculizumab concentrations with 
complement blockade and clinical response and determined inter individual differences in PK parameters. 
Our first cohort included 6 HCT recipients that were treated using an aHUS dosing regimen.5 Two critically 
ill patients died before ever achieving therapeutic drug levels. Eculizumab and total complement activity 
(CH50) levels that were measured at the same time points strongly correlated with each other. Specifically, 
a CH50 level of <10% normal corresponded with an eculizumab concentration >100 mg/mL, considered to 
be the therapeutic target concentration for complete complement blockade. Subsequently, 12 patients were 
treated using PK/PD dose guided regimen.6 In the PK analysis, we found significant interpatient variability 
in eculizumab clearance, ranging from 16 to 237 mL/hr/70 kg in the induction phase. The degree of 
complement activation measured by sC5b-9 concentrations at the start of therapy, in addition to actual body 
weight, was a significant determinant of eculizumab clearance and disease response. 
All subjects with elevated sC5b-9 above normal (>244ng/mL) cleared eculizumab below therapeutic of 
100µg/mL in less than 72 hours during first 2 weeks of therapy while sC5b-9 was elevated, indicating that 
HCT recipients with TMA require loading doses at least Q72h to sustain adequate drug level to control 
complement activation, so currently recommended weekly dosing given for aHUS is not adequate for HCT 
recipients with TMA. The clearance progressively declined as the disease was controlled and became 
similar to what is reported in aHUS after the 5th week of therapy. Drug trough levels ≥100µg/mL were 
required to sustain TMA control in maintenance therapy. We validated a more frequent early-dosing 
algorithm in another 11 patients. We also showed that therapeutic eculizumab serum concentrations of 
≥100µg/mL correlated well with total complement activity (CH50) suppression below detectable, <10% of 
normal lab value allowing us to use CH50 as accurate marker for eculizumab dose adjustments. In a 
publication of first 30 treated patients, we reported that 64% of patients had complete resolution of TMA 
and were able to safely discontinue eculizumab without disease recurrence. Overall survival was 
significantly higher in treated subjects compared with untreated patients (62% versus 9%, p =0.0007).6 To 
date we have treated 50 patients with severe TMA using eculizumab therapy at CCHMC with an overall 
survival of 72% (36 survivors, 14 non-survivors). Median treatment time was 10 weeks (range 2-32, 
including survivors and non-survivors). Out of 50 Eculizumab treated patients 94.3% of responders were 
free of TMA with less than or equal to 24 weeks of treatment. We developed an eculizumab clearance 
prediction algorithm using pre-therapy sC5b-9 value, actual body weight and first eculizumab dose (mg). 
This algorithm was used to develop the dosing schedule for this study. 
Eculizumab use for treatment of TMA in HCT recipients includes dealing with the issue of the FDA Risk 
Evaluation Mitigation Strategy (REMS) requirement of meningococcal vaccination. TMA after HCT 
usually occurs within the first 100 days after transplantation when patients are severely 
immunocompromised and are not able to mount a response to vaccines. We evaluated 30 HCT recipients 
treated with eculizumab for high-risk TMA without meningococcal vaccine. All patients received 
antimicrobial prophylaxis adequate for Neisseria meningitides during eculizumab therapy and for 8 weeks 
after discontinuation of the drug. Median time to TMA diagnosis was 28 days after transplant (range, 13.8 
to 48.5). Study subjects received a median of 14 eculizumab doses (range, 2 to 38 doses) for HCT-associated 
TMA therapy. There were no episodes of meningococcal infection. The incidences of bacterial and fungal 
bloodstream infections were similar in patients treated with eculizumab (n=30) as compared with those 
with HSCT-associated TMA who did not receive any complement blocking therapy (n=39). Our data 
indicate that terminal complement blockade in the early post-transplant period can be performed without 

CCHMC IRB#: 2018-7119C
      
Page 13 of 43
meningococcal vaccination while using appropriate antimicrobial prophylaxis until complement function 
is restored after therapy completion.18
2.
STUDY PLAN
2.1 Study synopsis
We propose a prospective single arm multi-institution study in patients undergoing allogeneic or autologous 
HCT. The study will be performed at Cincinnati Children’s (CCHMC), Children’s Hospital Los Angeles 
(CHLA), Children’s Hospital of Philadelphia (CHOP), and Dana-Farber Cancer Institute (DFCI)/Boston 
Children’s Hospital (BCH), all large pediatric transplant centers (~400 transplant/year combined). All 
patients are prospectively monitored for TMA after starting HCT as part of clinical care. Patients with high 
risk TMA2 will be enrolled on this study after meeting eligibility criteria. The eculizumab dosing regimen 
for this study was derived from our clinical and PK/PD data in 50 eculizumab treated HCT recipients and 
was designed with a goal of being effective in majority of HCT recipients with high risk TMA, avoiding 
under treatment that allows ongoing organ damage.  Loading doses are given ≤72h intervals based on ultra-
high clearance during the first 2 weeks of therapy until sC5b-9 normalizes. Induction doses are given 
weekly to sustain therapeutic eculizumab trough level of ≥100µg/mL, since eculizumab clearance in HCT 
patients remains much higher than in aHUS during first 5 weeks of therapy. Maintenance dosing for HCT 
recipients will be identical to the regimen used for aHUS, since eculizumab clearance is similar in both 
populations when complement activation is controlled. All patients will receive total of 24 weeks of therapy 
before eculizumab is stopped and patients continue close clinical monitoring (Table 1). Survival will be 
assessed at 6 months from TMA diagnosis as the primary study endpoint. We hypothesize that this dosing 
regimen should be feasible at institutions that don’t have availability of monitoring drug PK/PD in real 
time. PK/PD data obtained during this study will be used to further optimize eculizumab dosing schedule 
and to determine patients in whom shorter therapy might be safe. All study patients will receive 
antimicrobial prophylaxis adequate to cover N. Meningitides while complement is blocked (refer to Section 
6.1).
Figure 1. Overview of the study design
2.2 Hypotheses
1. Early intervention with complement blocker eculizumab will double survival in HCT recipients with 
high risk TMA, as compared to historical untreated controls. 2.  An optimal eculizumab dosing schedule 
can be determined for this population through eculizumab PK/PD testing.  
2.3 Number of subjects
This study will enroll 21 consecutive HCT recipients with high risk TMA (plus replacements if needed 
for early death or relapse or inability to receive therapy as noted in the statistics section) at participating 
institutions. 

CCHMC IRB#: 2018-7119C
      
Page 14 of 43
2.4 Selection
This study will be conducted at Cincinnati Children’s Hospital (CCHMC), Children’s Hospital Los Angeles 
(CHLA), Children’s Hospital of Philadelphia (CHOP), and Dana-Farber Cancer Institute (DFCI)/Boston 
Children’s Hospital (BCH) in patients undergoing allogeneic or autologous hematopoietic stem cell 
transplant and have a diagnosis of TMA with high risk disease features.  
2.5 Recruitment
The study will enroll 21 consecutive patients with high risk TMA (see statistics section for details). Dr. 
Jodele or one of the other Bone Marrow Transplant Physicians who are co-investigators at CCHMC or 
investigators at participating sites will consult with the patient and/or the parent/legal guardian to explain 
the procedures, risks and benefits of the study at the patient/parent’s level of understanding. Opportunity 
will be given to consider the study and have questions answered. Information will be given in a written 
format in the form of a description of the study, which will include a signature space for consent to be 
given. Participation is voluntary, and all subjects/parents/guardians will give informed consent to 
participate. 
2.6 Expected duration of the study
Expected study duration is 4 years: we anticipate enrolling 7-10 patients each year for 2-3 years with 1 year 
post-transplant follow-up.
3.
STUDY ENDPOINTS
3.1 Primary study endpoint
The primary study endpoint is survival at 6 months post the date of TMA diagnosis.  
In our 100 patient prospective observational study, overall TMA incidence was 39% (39/100) with 11 of 
these 39 patients having high risk TMA with MODS (Jodele et al, Blood 2014). The historical survival rate 
for these patients with high risk TMA with MODS from our prospective study who did not receive any 
TMA targeted therapy was 2/11 (18%) children alive 24 weeks from TMA diagnosis and overall survival 
of 9% (1/11) at 1 year after HCT. Similar rates are consistently reported in retrospective studies from others 
showing <20% survival with TMA and MODS with patients dying within 6 months of TMA diagnosis. 
3.2 Secondary study endpoints

Cumulative incidence of organ dysfunction at 6 months after TMA diagnosis and 1 year after 
HCT, compared with historical controls with high risk TMA using MODS definition is shown in 
APPENDIX II. Organ systems evaluated will be:
o
Renal 
o
Includes  hypertension evaluation
o
Cardiac
o
Pulmonary 
o
Gastrointestinal 
o
CNS function
o
Pericardial effusion

Timing and extent of resolution of organ dysfunction in the first year after therapy.

1 year non-relapse mortality (NRM) compared with historical controls. 

Characterization of eculizumab PK/PD. 

CCHMC IRB#: 2018-7119C
      
Page 15 of 43
4.
ELIGIBILITY 
The study participants will include patients undergoing allogeneic or autologous HCT at participating 
institutions. All HCT patients will be assessed for eligibility by their attending bone marrow transplant 
physician. Eligible patients/parents will be approached for their interest in participation. Identification, 
screening, and enrollment of patients will be performed by one of the investigators participating in the 
study. The study is open to all eligible patients regardless of gender or ethnicity. 
4.1 Inclusion Criteria
Patients of any age undergoing allogeneic or autologous HCT with: 

Histologic TMA diagnosis 

OR clinical TMA diagnosis and presenting with high risk disease features including:
o
elevated plasma sC5b-9 above laboratory normal value (≥244ng/ml). 
AND
o
proteinuria: measured as ≥30mg/dL of protein on random urinalysis x2 or 
protein/creatinine ratio ≥1mg/mg or patient receiving renal replacement therapy.
             TMA diagnostic criteria are shown in APPENDIX I.  

Minimum weight of ≥ 5kg.

ADAMTS13 Activity lab sample must be drawn during or prior to screening (results can be 
pending and are not required for initial eligibility).  Development of TMA can be a medical 
emergency and thus if patient meets all other eligibility criteria, patient may proceed with 
enrollment and study treatment even if ADAMTS13 results are not available.  If test results 
confirm diagnosis of TTP defined by ADAMTS13 activity test <10%, then study treatment will 
be immediately halted and patient will be removed from study.
4.2 Exclusion Criteria

Known hypersensitivity to any constituent of the study medication.

Subjects with unresolved serious Neisseria meningitides infection or

Progressive severe infection.

Patients previously treated with eculizumab or other complement blocker for TMA within the 60 
days prior to first dose of study treatment.
5.
STUDY DRUG
5.1 Eculizumab availability for study
Eculizumab (Soliris) will be provided by Alexion Pharmaceuticals at no cost to study subjects. 
5.2 Eculizumab mechanism of action
Eculizumab, the active ingredient in Soliris, (Alexion Pharmaceuticals) is a monoclonal antibody that 
specifically binds to the complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a 
and C5b and preventing the generation of the terminal complement complex C5b-9. Eculizumab inhibits 
terminal complement mediated intravascular hemolysis in patients with PNH and blocks complement-
mediated TMA in patients with aHUS. It has received regulatory approval in multiple countries for these 
two diseases. At CCHMC eculizumab has been used in 50 pediatric HCT recipients using PK/PD based 
dosing regimen and was shown to be safe in HCT population when antimicrobial prophylaxis is provided 
for the duration of complement blockade (Jodele et al, BBMT 2015).6

CCHMC IRB#: 2018-7119C
      
Page 16 of 43
5.3 Study drug management 
Please refer to the Investigator’s Brochure for additional information as follows:

Study Drug Storage and Handling: Please see Section 3.2.4 and 3.2.5 of the Investigator’s 
Brochure. 

Preparation and Administration: Please see Section 6.2 of the Investigator’s Brochure. 

Pregnancy: Please see Section 6.3.1 of the Investigator’s Brochure. 
5.4 Eculizumab safety profile
Eculizumab Expected Adverse Reactions
MedDRA System 
Organ Class
Very 
Common 
(>1/10)
Common (≥1/100 to 
<1/10)
Uncommon (≥1/1,000 to <1/100)
Blood and 
lymphatic system 
disorders 
Thrombocytopenia, 
Leukopenia, 
Haemolysis
Coagulopathy, Red blood cell 
agglutination, Abnormal clotting factor, 
Anaemia, Lymphopenia 
Cardiac disorders 
Palpitation 
Ear and labyrinth 
disorders 
Tinnitus, Vertigo 
Eye disorders 
Vision blurred, Conjunctival irritation
Endocrine disorders 
Basedow's disease 
Gastrointestinal 
disorders 
Diarrhoea, Vomiting, 
Nausea, Abdominal 
pain, Constipation, 
Dyspepsia
Peritonitis, Gastroesophagal reflux 
disease, Abdominal distension, Gingival 
pain
General disorders 
and administration 
site condition 
Oedema, Chest 
discomfort, Pyrexia, 
Chills, Fatigue, 
Asthenia, Influenza like 
illness
Chest pain, Infusion site paraesthesia, 
Infusion site pain, Extravasation, 
Feeling hot, 
Hepatobiliary 
disorders 
Jaundice 
Immune system 
disorders 
Anaphylactic reaction 
Hypersensitivity 
Infection and 
infestations
Meningococcal sepsis, 
Arthritis bacterial, 
Upper respiratory tract 
infection, 
Nasopharyngitis, 
Bronchitis, Oral 
Herpes, Urinary tract 
infection, Viral 
infection, Aspergillus 
Infection
Meningococcal meningitis, Neisseria 
infection, Sepsis, Septic shock, 
Pneumonia, Gastrointestinal infection, 
Cystitis, Lower respiratory tract 
infection, Fungal infection, 
Haemophilus influenzae infection, 
Abscess, Cellulitis, Influenza, Gingival 
infection, Infection, Sinusitis, Tooth 
infection, Impetigo
Investigations 
Coombs test positive
Alanine Aminotransferase increased, 
Aspartate Aminotransferase increased, 
Gammaglutamyltransferase increased, 
Haematocrit decreased, Haemoglobin 
decreased

CCHMC IRB#: 2018-7119C
      
Page 17 of 43
MedDRA System 
Organ Class
Very 
Common 
(>1/10)
Common (≥1/100 to 
<1/10)
Uncommon (≥1/1,000 to <1/100)
Injury, poisoning 
and procedural 
complication
Infusion related reaction
Metabolism and 
Nutrition disorders 
Decreased appetite 
Anorexia 
Musculoskeletal 
and connective 
tissue disorders
Arthralgia, Myalgia, 
Muscle spasms, Bone 
pain, Back pain, Neck 
pain, Pain in extremity
Trismus, Joint swelling,
Neoplasms benign, 
malignant and 
unspecified 
(including cysts and 
polyps)
Malignant melanoma, Myelodysplastic 
syndrome
Nervous system 
disorders 
Headache 
Dizziness, Dysgeusia 
Syncope, Tremor, Paraesthesia 
Psychiatric 
disorders 
Depression, Anxiety, Insomnia, Sleep 
disorder, Abnormal dreams, Mood 
swings 
Renal and urinary 
disorders
Renal impairment, Haematuria, Dysuria
Reproductive 
system and breast 
disorders
Spontaneous penile erection, Menstrual 
disorder
Respiratory, 
thoracic and 
mediastinal 
disorders 
Dyspnoea, Cough, 
Nasal congestion, 
Pharyngolaryngeal 
pain, Rhinorrhoea 
Epistaxis, Throat irritation 
Skin and 
subcutaneous tissue 
disorders 
Rash, Alopecia, 
Pruritus, 
Urticaria, Dermatitis, Erythema, 
Petechiae, Skin depigmentation, 
Hyperhidrosis, Dry skin
Vascular disorders 
Hypotension
Accelerated hypertension Hypertension, 
Haematoma, Hot flush, Vein disorder 
6.
TREATMENT PLAN
6.1 Eculizumab dosing and administration for HCT recipients with TMA

Patients who meet all of the inclusion criteria and none of the exclusion criteria are recommended 
to be treated as early as possible with eculizumab.

Healthcare professionals who prescribe eculizumab (Soliris) must enroll in the Soliris REMS 
program. 

Vaccination of study subjects with meningococcal vaccine according to current ACIP guidelines 
will be considered if immune response to vaccine is expected based on timing after-HCT. 
Decision to vaccinate study subjects will be based on the primary treating physician’s assessment. 

CCHMC IRB#: 2018-7119C
      
Page 18 of 43

All study subjects will be counseled for risk of meningococcal infection due to terminal 
complement blockade.

Beginning with the first dose of eculizumab, all study subjects will be started on antimicrobial 
prophylaxis using an agent with activity against Neisseria meningitides, if not already receiving 
systemic antibiotics providing adequate coverage.
o
Recommended agents for patients not receiving broad spectrum antibiotics for other 
clinical reasons that would cover N. meningitis:

Tier 1: Age/weight based therapeutic dosing of ciprofloxacin (PO and IV).

Tier 2: Age/weight based therapeutic dosing of oral amoxicillin.

If local strains of N. meningitis bacteria are resistant to either of these antibiotics 
or the patient is allergic or cannot otherwise tolerate the standard prophylactic 
treatment, the choice of antibiotic will be made upon local guidelines or the 
recommendation of the local Infectious Disease (ID) consultant.

Antibiotic prophylaxis will be continued until eculizumab clearance is documented (serum drug 
concentration <25 µg/ml) and CH50 recovery to normal or above normal levels (based on 
performing laboratory value) is documented.

Eculizumab will be stored and dispensed by the pharmacy as listed in medication insert 
information (Soliris USPI Jan 2016 NH).

Eculizumab will be administered as intravenous infusion (IV) over 60 minutes using dosing 
schedule outlined in Table 1. 

No pre-medications are required, but may be given based on the primary treating physician’s 
decision.

If an adverse reaction occurs during the administration of eculizumab, the infusion may be 
slowed or stopped at the discretion of the study investigator and institute any appropriate 
measures. If the infusion is slowed, the total infusion time should not exceed four hours. The 
adverse reaction must be recorded. 

Patients may remain on current immunosuppressive therapy, including steroids.

Fresh frozen plasma (FFP) or therapeutic plasma exchange (TPE) should NOT be used during 
eculizumab therapy, unless there is a strong clinical indication that may affect patient safety. 
Study subjects who require FFP or TPE for clinical indications will require supplemental doses of 
eculizumab as listed in Table 2. 

Patients may receive fibrinogen, albumin and IVIG and other monoclonal antibodies as clinically 
indicated without restrictions.  
6.2 Eculizumab dosing schedule for HCT recipients: 
 
 
    

CCHMC IRB#: 2018-7119C
      
Page 19 of 43
6.2.1 Eculizumab dosing schedule modifications from listed in Table 1
Eculizumab therapy may be extended past the number of doses listed in Table 1 or dose (mg) and dosing 
intervals may be modified if deemed by the treating physician that the listed regimen is placing the patient 
at risk for TMA or MODS progression due to drug under dosing as evidenced by increased drug clearance 
(for example in patients with intestinal bleeding). Dose modification must be discussed with the Lead PI 
and the reason to modify doses must be documented. 
Eculizumab therapy may be shortened to less than 24 weeks of total therapy, with prior discussion and 
approval by the Lead PI, if deemed by treating physician to be in the best interest to the patient under the 
following conditions:

where TMA is adequately controlled or resolved and additional eculizumab doses will not 
be of benefit, 

or if continuation of eculizumab would interfere with other clinical interventions deemed 
more essential for patient’s wellbeing.
This does not include study drug discontinuation for safety reasons or therapy intolerance.  These patients 
will remain on study and should complete assessments as per Early Termination visit at the time of 
discontinuation of eculizumab.  Refer to the Schedule of Assessments Table for the list of required 
assessments.  Additionally, V37 (Day 180) and V38 (Day 365 post-transplant) visits should be complete 
according to original protocol schedule.  
If eculizumab was held because of other therapeutic interventions and there is no clinical concern for active 
TMA, then eculizumab can be resumed at the dosing regimen used prior to holding/stopping the drug.
In the event eculizumab is held/stopped early according to the above criteria and the patient has a 
reactivation or progression of TMA, eculizumab study treatment may be resumed at a more intensified 
dosing regimen. The dosing regimen to be resumed should be discussed with the Lead PI. 
6.2.2 Supplemental eculizumab dosing for patients receiving FFP and TPE
Study subjects requiring fresh frozen plasma (FFP) or therapeutic plasma exchange (TPE) will receive 
supplemental eculizumab dosing as listed in Table 2.  Subjects receiving FFP or TPE will continue to 
have study assessments performed as per the Schedule of Assessment table.  Eculizumab serum 
concentration (drug level) and CH50 should be performed prior to each supplement eculizumab dose if 
clinically feasible, for at least first 5 FFP/TPE sessions to assure that drug supplementation is adequate. 
Research Biomarker Panel is not required before supplement eculizumab doses. 
 
 
 
 
 
 
 
 
6.2.3 Patient monitoring during eculizumab therapy
Laboratory monitoring is summarized in Tables 3 and 4. Dose changes will NOT be made in real time 
from those listed in Table 1 based on the PK/PD data with exception of patients meeting dosing 

CCHMC IRB#: 2018-7119C
      
Page 20 of 43
modification criteria as listed in section 6.2.1. PK/PD data will be used to establish optimal fixed dosing 
schedule required for HCT recipients with high risk TMA to prevent MODS in future clinical use.

CCHMC IRB#: 2018-7119C
      
Page 21 of 43
Table 3: Schedule of Assessments (Baseline, Loading and Induction Phases)
Screening
**
Base
Line
Loading                                                                      
Induction●
Study Visits*& 
V1
V2
V3
V4
V5
V6
V7
V8
V9
V10
V11
V12
V13
V15
V16
V17
V18
Days
Prior to 
First 
Eculizumab 
Infusion
Day 
0
Day 
1
Day 
2
Day 
3
Day
4
Day 
5
Day
6
Day 
7
Day 
8
Day 
9
Day 
10
Day 
11
Day 
12
Day 
19
Day 
26
Day
 33
Day 
40
UNS+ 
visit
Informed Consent
X
Inclusion/ Exclusion 
laboratory and clinical 
assessmentsa
X
Medical 
history/Demographics
X
ADAMTS13 activity
 X~
Complete Complement 
Profile (CCHMC Lab) 
X
CFH auto-antibody b 
(CCHMC Lab)
X
CH50 b 
X
X
X
X
X
X
X
X
X
X
X
X
X
X 
X 
X 
X 
X
Plasma sC5b-9b,c 
(CCHMC Lab)
X
X
X
X
X
X
X
X
X
X
X
X
X
X c 
X c 
X c 
X c 
X
Haptoglobin 
X
Urine protein or random 
urine protein creatinine 
ratio^
X
Eculizumab infusiond,±
X
X
X
X
X
X
X
X
X
X
Eculizumab serum 
concentrationb (CCHMC 
Lab)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Research Biomarker 
Panele
X
X
X
X
X
X
X
X
X
X
X
Safety Assessmentsf
X
Performed as per institutional standard of care.
AEs/SAEsg 
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Concomitant Medications
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CBC/Diff, LDH, 
Schistocytes
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Other Laboratory Testsh
X
X
X
X
X
X
X
X
X
MODS Assessmentsi
X
X
X
X
X
X
X
X
Repository Samplesj
X
X
X
X
X
X
X
X

CCHMC IRB#: 2018-7119C
      
Page 22 of 43
Screening
**
Base
Line
Loading                                                                      
Induction●
Study Visits*& 
V1
V2
V3
V4
V5
V6
V7
V8
V9
V10
V11
V12
V13
V15
V16
V17
V18
Days
Prior to 
First 
Eculizumab 
Infusion
Day 
0
Day 
1
Day 
2
Day 
3
Day
4
Day 
5
Day
6
Day 
7
Day 
8
Day 
9
Day 
10
Day 
11
Day 
12
Day 
19
Day 
26
Day
 33
Day 
40
UNS+ 
visit
PE/PI, Dialysis, 
RBC/Platelet Transfusion
Procedures to be completed as deemed medically necessary by treating physician. If completed, data will be captured.
X
Abbreviations: AE=Adverse Event; EOS=End-of-Study; ET=Early Termination; PE/PI=Plasma Exchange/Plasma Infusion; UNS=Unscheduled Visit
** Screening and Baseline may occur on the same day. All pre-therapy laboratory assessments should be completed within 7 days prior to initiating therapy with 
     Eculizumab. Any labs that were completed as part of standard clinical care prior to consent may be used and will not be repeated.
~  ADAMTS13 Activity lab sample must be drawn during or prior to screening.  If patient meets all other eligibility criteria, the patient may proceed with 
enrollment and study treatment even if ADAMTS13 results are not available.  If test results confirm diagnosis of TTP defined by ADAMTS13 activity test 
<10%, then study treatment will be immediately halted and patient will be removed from study.
●  A +/- 48 hours window will be added to accommodate scheduling changes during the induction phase.   
* If a patient completes all the Study Visits (Visits 1-38), Visit 38, the last Study Visit, will be the end-of-study (EOS) visit, at which time the patient completes 
the study.  
& If a patient withdraws early from the study, prior to completing Visit 36, an Early Termination (ET) Visit will be performed within one week of 
withdrawal (see Table 4). Any assessments not performed within 7 days of ET visit will need to be completed – any assessments performed within 7 days do 
not need to be repeated or recollected.
+ Unscheduled visit and procedures will be performed at the Investigator’s discretion and results will be recorded on the CRF.
^ Please note urine protein ≥30 mg/dL x2 is required for eligibility.  Urine protein or random urine protein creatinine ratio are not required if the patient is     
   already receiving renal replacement therapy (RRT).  RRT requirement is sufficient to meet study eligibility criteria.  
a Up to 7 days prior to the baseline visit (Screening), laboratory and clinical assessments demonstrating fulfillment of inclusion criteria are performed
b TMA Test Panel includes CFH autoantibody, plasma sC5b-9 and eculizumab pharmacokinetic panel (eculizumab serum concentration, CH50) and is to be 
performed at CCHMC, as feasible. (Refer to Appendix III for link for test requisition and additional information.) For patients requiring eculizumab serum 
level and CH50 on the same day, testing for both may be ordered as Eculizumab Pharmacokinetic Panel on the CCHMC Test Requisition and performed from 
the same blood sample (1 mL blood in serum tube).  Blood may be collected during routine draws.  On days of eculizumab administration, the eculizumab 
serum concentration sample is to be collected PRIOR to administration of eculizumab, preferably within 90 minutes before eculizumab infusion.   Among 
patients receiving plasma exchange/plasma infusion (PE/PI), dialysis or transfusion, blood will be collected prior to initiation of PE/PI, dialysis or transfusion, 
as feasible.  Eculizumab pharmacokinetic panel (eculizumab serum concentration and CH50) should be performed prior to each supplement eculizumab dose if 
clinically feasible, for at least first 5 FFP/TPE sessions to assure that drug supplementation is adequate. Additional blood samples may be collected at 
scheduled clinical visits or unscheduled visits, at the discretion of the Treating Physician and/or Principal Investigator.  Following discontinuation of 
eculizumab treatment, eculizumab serum concentration and CH50 will be monitored weekly until normalized or above normal as per protocol section 
6.2.4.

CCHMC IRB#: 2018-7119C
      
Page 23 of 43
c sC5b-9 will be evaluated twice weekly from Day 19 through Day 40 while patient is an inpatient; once discharged, sC5b-9 will be collected weekly with each 
visit, as feasible. Following discontinuation of eculizumab treatment, sC5b-9 will be monitored weekly until eculizumab serum concentration and CH50 have 
normalized or above normal as per protocol section 6.2.4.
d Eculizumab will be administered by IV infusion over 60 minutes according to the dosing information on Table 1. For patients receiving PE/PI, supplemental 
eculizumab doses should be administered according to Table 2. If supplemental eculizumab doses are given on a day in which eculizumab is not scheduled, 
they will be recorded on the CRF as an unscheduled visit. Following discontinuation of eculizumab treatment, eculizumab serum concentration and 
CH50 will be monitored weekly until normalized or above normal as per protocol section 6.2.4.
e Research Biomarker Panel: plasma and serum samples for measures as outlined in the research laboratory manual will be collected for shipment to an Alexion 
designated laboratory. (Refer to lab manual for biomarker collection and shipping information.) Among patients receiving PE/PI, dialysis or transfusion, blood 
will be collected prior to initiation of PE/PI, dialysis or transfusion, as feasible. On days when eculizumab is administered, blood samples should be collected 
PRIOR to administration of eculizumab, preferably within 90 minutes before eculizumab administration. Research Biomarker panel samples are not required 
before supplemental eculizumab doses.  If a pre-transplant DNA sample is available, it may be requested for a TMA-associated genetic panel. 
f Safety assessments (i.e., vital signs, physical examination) will be performed as per SOC.  Weight and height (height may be pre-transplant value) will be 
collected for all patients at Screening and at the end of study. Use vital signs collected at the start of day shift, i.e., at approximately 8 AM.
g AEs will be collected for 60 days (5 half-lives) after the last eculizumab infusion and all SAEs will be collected.  
h Other laboratory tests will include, but are not limited to full panel blood chemistry, serum creatinine, cystatin C GFR, haptoglobin, urinalysis and random 
urine protein creatinine ratio, as per institutional SOC.   
i Clinical assessments of renal, cardiac, gastrointestinal, pulmonary and neurological signs and symptoms will be assessed as part of SOC, approximately once a 
week using MODS Form in Appendix II. 
j Patients will be consented to enable the collection of blood, urine and tissue research samples for the tissue repository as listed in APPENDIX IV. Blood 
samples collected from the tissue repository will include testing to assess the immunogenicity of eculizumab. Patients who are already enrolled in an HCT 
tissue repository at participating institutions will not be approached for this study to avoid duplicate specimen collection.  Baseline repository samples must 
be drawn within 24 hours prior to first dose of eculizumab. 
k PE/PI may include fresh frozen plasma (FFP), plasma exchange or plasma infusion. 
±  Eculizumab therapy course may be shortened according to criteria in Section 6.2.1.   At the time of discontinuation of eculizumab, complete all study assessments
   as listed for the Early Termination visit.  Any assessments not performed within 7 days of stopping therapy will need to be completed – any assessments performed 
   within 7 days do not need to be repeated or recollected.  Patient should be monitored for adverse events and MODS assessments should be completed for 60 days 
   after the last eculizumab infusion.  Following discontinuation of eculizumab treatment, eculizumab serum concentration and CH50 will be monitored 
   weekly until normalized or above normal as per protocol section 6.2.4.  Patient will remain on study and should complete V37 (Day 180) and V38 (Day 365 
   post-transplant) visit according to original protocol schedule.

CCHMC IRB#: 2018-7119C
      
Page 24 of 43
Table 4: Schedule of Assessments (Maintenance Phase and End of Study/Early Termination)
Maintenance#
EOS
Study 
Visits*
V19
V20
V21
V22
V23
V24
V25
V26
V27
V28
V29
V30
V31
V32
V33
V34
V35
V36
V37
ET&
±
V38
Days
Day
47
Day
54
Day
61
Day
68
Day
75
Day
82
Day
89
Day
96
Day
103
Day
110
Day 
117
Day 
124
Day 
131
Day 
138
Day 
145
Day 
152
Day 
159
Day 
166
Day 
180
--
Day 
365§
UNS+
Visit
ADAMTS13 
activity
X○
X○
Complete 
Complement 
panela 
(CCHMC 
Lab)
X○
X○
CFH auto-
antibodya 
(CCHMC 
Lab)
X○
X○
CH50a 
X
X
X
X
X
X
X
X
X
X
X
Plasma 
sC5b-9a 
(CCHMC 
Lab)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Eculizumab 
infusionb,±
X
X
X
X
X
X
X
X
X
X
X
Eculizumab 
serum 
concentrationa 
(CCHMC 
Lab)
X
X
X
X
X
X
X
X
X
X
X
Research 
Biomarker 
Panelc
X
X
X
X
X
X
X
X
X
X
X
X
Safety 
Assessmentsd
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AEs/SAEse
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Concomitant 
Medications
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

CCHMC IRB#: 2018-7119C
      
Page 25 of 43
CBC/Diff, 
LDH and 
Schistocytes
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Other 
Laboratory 
Testsf
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
MODS 
Assessmentsg
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X j
X
X
X
Repository 
Samplesh
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
PE/PIi, 
Dialysis, 
RBC/Platelet 
Transfusions
Procedures to be performed as deemed medically necessary by treating physician. If completed, data will be captured.
X
Abbreviations: AE=Adverse Event; EOS=End-of-Study; PE/PI=Plasma Exchange/Plasma Infusion; ET=Early Termination; UNS=Unscheduled Visit
#  During Maintenance phase, study assessments will be performed at a minimum of every 2 weeks, a maximum of every week. Study visit windows during   
   Maintenance phase will be +/- 48 hours for study infusions, eculizumab serum concentration, CH50, and research biomarker panel to accommodate patient   
   scheduling.  All other labs can be collected the same day or any day within the same week of the scheduled study visit. 
* If a patient completes all the Study Visits (Visits 1-38), Visit 38, the last Study Visit, will be the end-of-study (EOS) visit, at which time the patient completes 
the study. 
& If a patient withdraws early from the study, prior to completing Visit 36, an Early Termination (ET) Visit will be performed within one week of 
withdrawal (see Table 4). Any assessments not performed within 7 days of ET visit will need to be completed – any assessments performed within 7 days do 
not need to be repeated or recollected.  
+ Unscheduled visits and procedures will be performed at the Investigator’s discretion and results will be recorded on the CRF.
○  Obtain only at Visit 36 or Early Termination Visit if abnormal prior to starting therapy.
§  EOS/Day 365 study visit is to be performed approximately one year, ± 60 days, from the date of transplant.
a TMA Test Panel includes CFH autoantibody, plasma sC5b-9 and eculizumab pharmacokinetic panel (eculizumab serum concentration, CH50) and is to be 
performed at CCHMC, as feasible. (Refer to Appendix III for link for test requisition and additional information.) For patients requiring eculizumab serum 
level and CH50 on the same day, testing for both may be ordered as Eculizumab Pharmacokinetic Panel on the CCHMC Test Requisition and performed from 
the same blood sample (1 mL blood in serum tube). Blood may be collected during any routine draws before eculizumab administration.  On days of 
eculizumab administration, the eculizumab serum concentration sample is to be collected PRIOR to administration of eculizumab, preferably within 90 
minutes before eculizumab infusion. Among patients receiving plasma exchange/plasma infusion (PE/PI), dialysis or transfusion, blood will be collected prior 
to initiation of PE/PI, dialysis or transfusion, as feasible. Eculizumab pharmacokinetic panel (eculizumab serum concentration and CH50) should be performed 
prior to each supplement eculizumab dose if clinically feasible, for at least first 5 FFP/TPE sessions to assure that drug supplementation is adequate. Additional 
blood samples may be collected at scheduled clinical visits or unscheduled visits, at the discretion of the Treating Physician and/or Principal Investigator. 
Following discontinuation of eculizumab treatment, eculizumab serum concentration and CH50 will be monitored weekly until normalized or above 
normal as per protocol section 6.2.4.
b Eculizumab will be administered by IV infusion over 60 minutes according to the dosing information on Table 1. For patients receiving PE/PI, supplemental 
eculizumab doses should be administered according to Table 2. If supplemental eculizumab doses are given on a day in which eculizumab is not scheduled to 

CCHMC IRB#: 2018-7119C
      
Page 26 of 43
be they will be recorded on the CRF as an unscheduled visit. Following discontinuation of eculizumab treatment, eculizumab serum concentration and 
CH50 will be monitored weekly until normalized or above normal as per protocol section 6.2.4.
c Research Biomarker Panel: plasma and serum samples for measures as outlined in the research laboratory manual will be collected for shipment to an Alexion 
designated laboratory. (Refer to lab manual for biomarker collection and shipping information.) Among patients receiving PE/PI, dialysis or transfusion, blood 
will be collected prior to initiation of PE/PI, dialysis or transfusion, as feasible. On days when eculizumab is administered, blood samples should be collected 
prior to administration of eculizumab, preferably within 90 minutes before eculizumab administration.  Research Biomarker panel samples are not required 
before supplemental eculizumab doses.  
d Safety assessments (i.e., vital signs, physical examinations) will be performed as per SOC. Weight and height (height for baseline may be pre-transplant value) 
   will be collected for all patients at Screening and at the end of study.  Use vital signs collected at the start of day shift, i.e., at approximately 8 AM.
e AEs will be collected for 60 days (5 half-lives) after the last eculizumab infusion and all SAEs will be collected (see protocol section 8.3 for additional details).  
f Other laboratory tests will include, but are not limited to full panel blood chemistry, serum creatinine, cystatin C GFR, haptoglobin, urinalysis and random 
urine protein creatinine ratio, as per institutional SOC.   
g Clinical assessments of renal, cardiac, gastrointestinal, pulmonary and neurological signs and symptoms will be assessed as part of SOC, approximately once a 
week using the MODS form in Appendix II. MODS Assessments must be completed for 60 days following the last eculizumab infusion, either weekly as 
inpatient or if outpatient, then with each clinic visit but not more than once a week.
h Patients will be consented to enable the collection of blood, urine and tissue research samples for the tissue repository as listed in APPENDIX IV. Blood 
samples collected from the tissue repository will include testing to assess the immunogenicity of eculizumab. Patients who are already enrolled in an HCT 
tissue repository at participating institutions will not be approached for this study to avoid duplicate specimen collection. Baseline repository samples must be 
drawn within 24 hours prior to first dose of eculizumab. 
i  PE/PI may include fresh frozen plasma (FFP),  plasma exchange or plasma infusion
j  MODS Assessments must be completed for 60 days following the last eculizumab infusion, either weekly as inpatient or if outpatient, then with each clinic visit
  but not more than once a week.
±  Eculizumab therapy course may be shortened according to criteria in Section 6.2.1.  At the time of discontinuation of eculizumab, complete all study assessments 
   as listed for the Early Termination visit.  Any assessments not performed within 7 days of stopping therapy will need to be completed – any assessments performed 
   within 7 days do not need to be repeated or recollected.  Patient should be monitored for adverse events and MODS assessments should be completed for 60 days 
   after the last eculizumab infusion.  Following discontinuation of eculizumab treatment, eculizumab serum concentration and CH50 will be monitored  
   weekly until normalized or above normal as per protocol section 6.2.4.  Patient will remain on study and should complete V37 (Day 180) and V38 (Day 365 
   post-transplant) visit according to original protocol schedule.

CCHMC IRB#: 2018-7119C
      
Page 27 of 43
6.2.4 Patient monitoring after eculizumab therapy completion
         The procedures listed below apply for patients who complete the therapy as prescribed by the protocol 
         or who have received a shortened course of study therapy as per the criteria listed in section 6.2.1.

Weekly CH50 levels will be checked until they return to normal or above normal values (see normal 
CH50 values for performing laboratory) to document that patients have recovered from 
complement suppression.

Weekly serum eculizumab serum concentration will be checked until it is documented to be below 
measurable (<25 µg/mL) to document that drug is completely cleared from the blood. 

Weekly sC5b-9 will be monitored until normalization of CH50 levels (levels may also be above 
normal) and eculizumab drug clearance is documented (eculizumab serum concentration is <25 
µg/mL) to assure that terminal complement does not get activated again after the eculizumab is 
cleared, then as clinically indicated.

Anti-meningococcal prophylaxis will continue until the CH50 level is normal and eculizumab 
serum concentration is unmeasurable (<25 µg/mL). 

MODS assessments are to be completed weekly through 60 days following the last eculizumab 
infusion, either weekly as inpatient or if outpatient, then with each clinic visit, but not more than 
once a week.

Patients are to be monitored for adverse events through 60 days following the last eculizumab 
infusion.
6.3 Concomitant HCT medication and supportive care guidelines
All study subjects will follow routine HCT monitoring and supportive care procedures as per standard 
institutional practices.
6.4 Post-transplant follow-up
After study therapy and required monitoring is completed, patients will be followed per institutional 
standards through one year post-transplant.
7.
TOXICITY MONITORING
7.1 Eculizumab safety
Eculizumab is generally well tolerated in HCT recipients (section 1.4).18 Because of the risk of 
meningococcal infections (black box warning), eculizumab is available only through a restricted program 
under a Risk Evaluation and Mitigation Strategy (REMS). Under the Soliris REMS, all eculizumab 
prescribers will be enrolled in the REMS program.
7.2 Risk for meningococcal infections during eculizumab therapy
Life-threatening and fatal meningococcal infections have occurred in patients with aHUS treated with 
eculizumab and may be fatal if not recognized and treated early. The Advisory Committee on Immunization 
Practices (ACIP) recommends meningococcal vaccination in patients with complement deficiencies. It is 
recommended that patients are immunized with a meningococcal vaccine at least 2 weeks prior to 
administering the first dose of eculizumab, unless the risks of delaying eculizumab therapy outweigh the 
risks of developing a meningococcal infection. Patients on this trial will not be able to respond to vaccine, 
and will instead receive antimicrobial prophylaxis (section 7.3). Patients should be monitored for early 
signs of meningococcal infections, and evaluated immediately if infection is suspected. For this reason, 

CCHMC IRB#: 2018-7119C
      
Page 28 of 43
eculizumab is available only through a restricted program under a Risk Evaluation and Mitigation Strategy. 
(REMS). Under the eculizumab (Soliris) REMS, prescribers must enroll in the program. 
7.3 Prevention of meningococcal infections in HSCT recipients receiving eculizumab
TMA after HCT usually occurs within the first 100 days after transplantation when patients are severely 
immunocompromised and are not able to mount a response to vaccines. We evaluated 30 HCT recipients 
treated with eculizumab for high-risk TMA without meningococcal vaccine. All patients received 
antimicrobial prophylaxis adequate for Neisseria meningitides during eculizumab therapy and for 8 weeks 
after discontinuation of the drug. Median time to TMA diagnosis was 28 days after transplant (range, 13.8 
to 48.5). Study subjects received a median of 14 eculizumab doses (range, 2 to 38 doses) for HCT-associated 
TMA therapy. There were no episodes of meningococcal infection. The incidences of bacterial and fungal 
bloodstream infections were similar in patients treated with eculizumab as compared with those with HCT-
associated TMA who did not receive any complement blocking therapy. There were no other clinically 
significant side effects attributed to eculizumab. Our data indicate that terminal complement blockade in 
the early post-transplant period can be safely performed without meningococcal vaccination while using 
appropriate antimicrobial prophylaxis until complement function is restored after therapy completion 
(section 1.4).

All study subjects will be counseled regarding risk of meningococcal infection due to terminal 
complement blockade.

All study subjects will be started on antimicrobial prophylaxis using an agent with activity against 
Neisseria meningitides if not already receiving systemic antibiotics providing adequate coverage 
beginning with the first dose of eculizumab (refer to Section 6.1). 

Anti-meningococcal prophylaxis will continue until the CH50 level is normal and the eculizumab 
serum concentration is unmeasurable (<25 µg/mL). 
7.4 Risk to an unborn fetus
While eculizumab had been used in pregnant women with preeclampsia, PNH, and aHUS, this drug is 
listed as Category C (not enough research has been done to determine if these drugs are safe). 
8.
ASSESSMENT OF SAFETY
8.1 Study monitoring and auditing
Monitoring and auditing procedures will be followed to ensure that the study is conducted, documented, 
and reported in accordance with the IRB approved protocol, all applicable federal regulations and 
guidelines, and applicable regulatory requirements at participating institutions. 
Verification of eligibility will be performed and appropriate documentation of informed consent will be 
documented for all subjects enrolled into the study. The timeliness of Adverse Event and Serious Adverse 
Event reporting will be monitored to ensure regulatory compliance. All case report forms (CRF) for the 
first subject enrolled into the study will be monitored for completeness and quality by comparing data in 
the case report forms to data in the source documents. Thereafter, a minimum of 10% of enrolled subjects’ 
CRFs will be monitored for completeness and quality by comparing data in the case report forms to data in 
the source documents.
The extent of monitoring activities will be subject to change based on enrollment, the degree of risk or 
significance of monitoring findings, and other study management issues.

CCHMC IRB#: 2018-7119C
      
Page 29 of 43
Each participating site will be responsible for maintaining all source documents, research records, all IRB 
approval documents, Drug Accountability Record forms, patient registration lists, response assessments 
reports, etc. for their site’s participation in this study.
A study monitor will audit study documents to ensure compliance.
8.2 Data safety monitoring plan 
A Data and Safety Monitoring Board (DSMB) will be convened for this study. The Board will be 
comprised of qualified physicians, not associated with this protocol. The DSMB will meet with the Lead 
PI or designees and review study data/progress a minimum of approximately every 6 months or more 
often at the discretion of the Lead PI and/or DSMB.
The DSMB will be notified immediately and will review all unanticipated problems involving risk to 
subjects or others, unanticipated serious adverse events and all subject deaths associated with the protocol 
and provide an unbiased written report of the review. Based on the review of these events, the DSMB should 
make a recommendation regarding study continuation.
8.3 Adverse events (AE)
8.3.1 Adverse event definitions
Adverse event means any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug related.
An adverse event (also referred to as an adverse experience) can be any unfavorable and unintended sign 
(e.g., an abnormal laboratory finding), symptom, or disease temporally associated with the use of a drug, 
and does not imply any judgment about causality. An adverse event can arise with any use of the drug (e.g., 
off-label use, use in combination with another drug) and with any route of administration, formulation, or 
dose, including an overdose.
Serious Adverse Event (SAE)
A serious adverse event is an undesirable experience that results in any of the following outcomes:

Death

A life-threatening adverse event 

Inpatient hospitalization or prolongation of existing hospitalization. Hospitalizations for the 
following reasons should not be reported as serious adverse events: 
o
Non-life-threatening hospitalization due to clinical problems associated with stem cell 
transplantation process, initiation or adjustments of care of transplant-associated 
complications, diagnostic evaluations, or social reasons. 
o
Non-life-threatening hospitalization due to clinical problems associated with study 
subjects’ primary medical condition, therapy targeting primary medical condition, or for 
initiation or adjustments of care associated with primary condition management, 
diagnostic evaluations or social reasons. 
o
Hospital admission for a planned diagnostic workup/procedure/disease treatment.
o
Admission for known complications of TMA will be recorded on the MODS assessments 
and not upgraded to a serious adverse event solely on the basis of hospitalization.

A persistent or significant incapacity or substantial disruption of the ability to conduct normal 
life functions

In a congenital anomaly or occurrence of malignancy

CCHMC IRB#: 2018-7119C
      
Page 30 of 43

Important medical event that jeopardizes the participant AND requires medical or surgical 
intervention to prevent one of the outcomes above 
Note: Events that may not meet criteria as serious should be reviewed and captured as a non-
serious adverse event according to the requirements for reporting AEs (see section 8.3.2).
Attribution to the study drug:

Unrelated: The AE is clearly NOT related to the intervention

Unlikely: The AE is doubtfully related to the intervention

Possible: The AE may be related to the intervention

Probable: The AE is likely related to the intervention

Definite: The AE is clearly related to the intervention
Expected and Unexpected Event:

Expected: Any experience previously reported (in nature, severity, or incidence) in the current 
Investigator’s Brochure or as specified in the protocol.

Unexpected: Any experience not previously reported (in nature, severity, or incidence) in the 
current Investigator’s Brochure or as specified in the protocol.
8.3.2 Adverse event reporting
Safety and tolerability for the study drug will be assessed according to the Common Terminology Criteria 
for Adverse Events v5.0 (CTCAE published November 27, 2017). The principal investigator or designee 
at each site will review adverse events closely and assess the event’s relationship to study procedures to 
determine whether the event is unrelated or, unlikely, possibly, probably or definitely related to the study 
procedures, especially in relation to the underlying disease and baseline lab values for the patient.
All expected and unexpected Grade 3 and higher adverse events possibly, probably or definitely related to 
the study drug occurring during this study through 60 days following the last dose of eculizumab will be 
recorded on the case report forms. The site principal investigator will review each event and assess its 
relationship to study procedures to determine whether the event is unrelated or, unlikely, possibly, probably 
or definitely related to the study therapy.
Expected events are those that have been previously identified as resulting from administration of the 
protocol therapy, those that can be attributed to the underlying condition, and/or those associated with 
transplant. An adverse event is considered unexpected, for reporting purposes only, when either the type of 
event or the severity of the event is not listed in the Investigator’s Brochure, consent and/or protocol.
Additionally for this study, events previously identified as resulting from administration of a stem cell 
transplant procedure will be considered as expected. The transplant regimen is well known to commonly 
affect multiple systems such as the hematologic, immunologic and, pulmonary, gastrointestinal systems. 
The following are known complications of transplant- graft failure, graft versus host disease, disseminated 
intravascular coagulation, febrile neutropenia, viral, bacterial and fungal infections, hemolysis, septic 
shock, thrombotic microangiopathy, veno-occlusive disease of liver, adrenal insufficiency, diarrhea, 
enterocolitis, gastrointestinal pain and bleeding, malabsorption, mucositis, nausea, pancreatitis, vomiting, 
dyspepsia, fever, pain, cholecystitis, allergic reaction, serum sickness, upper respiratory infection, urinary 
tract infection, weight gain/loss, electrolyte imbalance, elevation of liver enzymes, acidosis, alkalosis, 
anorexia, dehydration, glucose intolerance, iron overload, generalized muscle weakness, reversible 
posterior leukoencephalopathy syndrome, bladder spasms, cystitis, hematuria, urinary frequency, urinary 
urgency, irregular menstruation, pruritis, hypertension, purpura, and petechiae, polyserositis, seizures, 
multi-organ failure, death.

CCHMC IRB#: 2018-7119C
      
Page 31 of 43
Hematologic toxicities of any grade which are attributable to the underlying hematological disease and/or 
HCT preparative regimen will not be considered adverse events. In the event that any of these known 
complications of transplant or hematologic toxicities are thought to be at least possibly attributable 
to the study drug, the event will be recorded and subsequently reported to the IRB and FDA 
according to current reporting requirements, as outlined in the preceding paragraphs.
Medical conditions/diseases present before starting study drug are only considered adverse events if they 
worsen after starting study drug. This excludes TMA since disease progression is anticipated in some 
patients after initiation of complement blocking therapy and TMA is the subject of this study. Please refer 
to APPENDIX V for AE reporting requirements for TMA associated conditions. Abnormal laboratory 
values or test results constitute adverse events only if they are outside expected laboratory abnormalities 
seen during HCT process, induce clinical signs or symptoms, are considered clinically significant, or require 
therapy as determined by the PI at participating institutions. 
Each site will be responsible for reporting all SAEs to their IRB according to institutional guidelines, current 
regulations and applicable federal regulations. All SAEs will be reported to the Lead PI/Sponsor or designee 
via fax or e-mail within 2 business days of the site principal investigator’s knowledge of the SAE.
If any serious adverse events occur, current guidelines will be followed for expedited reporting to the IRB, 
DSMB, and FDA.  
All serious and medically significant adverse events considered related to eculizumab by the investigator 
will be followed until resolved or considered stable.  
Serious Adverse Event (SAE) Reporting Guidelines for External Site 
Any SAE must be reported to CCHMC as soon as possible but no later than 2 business days of the site 
principal investigator’s knowledge of the SAE. The SAE report (CRF) along with applicable source 
documentation (de-identified) is required to be submitted via fax or email to Stephanie Edwards 
(StephanieL.Edwards@cchmc.org) and contain the following information:

Subject’s initials

Unique study ID

The date the adverse event occurred

The adverse event

Relationship of the adverse event to the treatment (study drug, other drug, device, or 
intervention)

If the AE was expected

The severity of the AE

The intervention

The reason the event is serious

Detailed text that includes the following information:

An explanation of how the AE was handled

A description of the subject's condition

Indication if the subject remains on the study

Relevant supporting source documents
The PI’s signature and the date it was signed are required on the completed report.
The Lead PI is responsible for reporting all grade 3-5 unexpected, definite, probable, possible related 
SAEs on protocol to all participating sites within 5 calendar days of receipt. All serious and medically 
significant adverse events considered related to eculizumab by the investigator will be followed until 
resolved or considered stable.

CCHMC IRB#: 2018-7119C
      
Page 32 of 43
9.
RISK/BENEFIT ANALYSIS
This study will be more than minimal risk but with potential for direct benefit to participants. 
9.1 Potential benefits
Prevention of or treatment resulting in better outcomes after TMA associated multi-organ dysfunction 
syndrome (MODS) is a potential direct benefit of the study.
9.2 Potential risks, discomforts, and inconveniencies 
Risk associated with study therapy:  There are risks to the patients which include acute allergic reaction to 
the drug and increased risk of meningococcal meningitis. There are single case reports of meningococcal 
meningitis with long-term use of eculizumab in patients who received meningococcal vaccine. We have 
reported that eculizumab was safe to use in HSCT patients who are unable to receive vaccines but are on 
antibiotics prophylaxis for the duration on complement blockade by eculizumab, there were no cases of 
meningococcal infection in the HCT patients treated with eculizumab at CCHMC.
Potential risks, discomforts, inconveniences, and precautions with study blood draws: Any research 
samples will be obtained in accordance with institutional standards to ensure patient safety and without 
compromising needed diagnostic/clinical blood samples or patient health.  The total amount of blood drawn 
will not exceed 5% of the estimated blood volume in any 24 hour period.  The total volume of blood in any 
24 hour period will include blood drawn for clinical testing, research and waste samples combined. Blood 
will be drawn through patients’ existing central lines whenever possible.  Peripheral needle sticks will only 
be required in the event of no central access. Since patients undergoing HCT have daily laboratory studies 
performed as routine clinical care, additional study-related tests will be added-on to already collected blood 
samples whenever possible. Extra blood would only be drawn if specific collection tubes are required. 
Whenever possible, study blood samples will be obtained at the same time as routine blood draws to 
eliminate or minimize additional central line access. Urine will be collected by clean catch or cotton balls 
placed in the diaper as is routinely done during transplantation so catheterization will not be required. 
However, if a catheter is inserted for clinical indications, urine from the Foley bag will be obtained.
10.
STATISTICAL ANALYSIS
Statistical Analysis for primary endpoints
This prospective single arm study will test the null hypothesis of 18% survival against an alternative of 
increasing survival to 45% at 24 weeks from TMA diagnosis, resulting in a 2.5 times increase in survival 
rate in patients (18% vs. 45%) in this high risk population by using early therapy with eculizumab. The 
level of significance will be set to 0.05. The primary endpoint will be assessed using a 1 sided exact 
binomial distribution test. The sample size of 21 has a greater than 80% power of yielding a significant p-
value. The primary analysis will be based upon intent-to-treat. A secondary “successfully treated patient 
analysis” (defined as > 4 doses of eculizumab administered) will also be performed using a non-relapse 
mortality endpoint, including all children receiving >4 doses of therapy. Children who receive 4 or fewer 
doses of therapy, or who relapse with malignancy prior to 24 weeks on the study will be replaced. This is 
based on preliminary data showing that it takes 11-13 days to control complement activation with 
therapeutic eculizumab trough level (≥100µg/mL) in patients with severe TMA before clinical response 
can be anticipated. (Jodele et al, BBMT 2016).
Statistical analysis for secondary endpoints will be descriptive. Eculizumab PK/PD analyses and modeling 
will be performed as previously published by our group (Jodele et al, BBMT 2015).6 Interim analysis of 
eculizumab PK/PD study will be performed after the first 5 subjects complete the loading and induction 

CCHMC IRB#: 2018-7119C
      
Page 33 of 43
phases. Data will be reviewed to determine if target drug levels required for complement blockade are being 
achieved. Modifications to the dosing regimen may be implemented if interim analysis indicates inadequate 
target drug levels. 
11.
PATIENT ENROLLMENT
All patients must be enrolled at the site where they are being treated. Each participating institution will 
initiate the patient enrollment process and follow the procedures outlined below. Sites may proceed with 
study treatment following confirmation of eligibility by the site investigators. Sites must notify the Lead 
PI/Sponsor or designee within 24 hours of eligibility confirmation, and then provide the completed 
eligibility checklist and de-identified source documents (as listed below) as soon as possible. 
Study staff at participating institutions will notify the study staff at Cincinnati Children’s Hospital 
Medical Center (CCHMC) when there is a potential patient for study enrollment. See Section 12 for CRC 
contact information. All participants are to be registered with CCHMC as soon as possible after signing 
the study consent document. Study registration documents to be submitted to the CCHMC CRC via fax or 
email for review include:
1.
De-identified signed consent (and/or assent documents, as applicable)
2.
Completed registration case report form (CRF)
3.
Completed eligibility checklist and relevant de-identified source documents 
Eligibility documents will be reviewed by the Lead PI/Sponsor or designee. Once eligibility has been 
established, the patient will be assigned a unique study ID number. This number is unique to the patient 
and must be written on all data forms and correspondence for the patient. The study ID number will be 
relayed to the site via email and will serve as the enrollment confirmation. 
12.
COMMUNICATION BETWEEN PARTICIPATING CENTERS
Prior to opening the study at each center, the Lead PI and research coordinator will conduct a 
teleconference to orient and train local PIs and research coordinators on study procedures related to data 
collection and patient monitoring. When the study is open and enrolling at other centers, the Lead PI 
and/or Sponsor will conduct regularly scheduled calls with the PI/designee and/or study coordinator/nurse 
from each site. Patient eligibility, subject enrollment, study status and patient safety will be discussed 
during each call, as applicable.
13.
DATA MANAGEMENT
The PI or designee at each site will be responsible for the conduct of the study, monitoring of study progress, 
and the review of all case report forms at their institution.  
Responsibilities of designated site staff will include maintaining documentation of their site’s participation 
in the study. Each site should maintain essential study documentation (including participant case records, 
IRB approval and annual review, IRB-approved study documents, delegation logs, etc.) according to 
applicable regulations and institutional practice. Submission of essential documents to CCHMC will be 
limited as specified in the Study Site Agreement. Supporting source documentation for site participants will 
be maintained at the originating center and will be submitted with specified CRFs (paper or electronic), or 
upon request to verify participant CRF data submitted to CCHMC. Note: Each participating site is 
responsible for upholding their institution’s data management guidelines.
This protocol is being conducted as a single research study effort and data from all participating institutions 
will be included in the analysis of results. All participating sites will follow the same study protocol; 

CCHMC IRB#: 2018-7119C
      
Page 34 of 43
therefore, all protocol amendments will originate from Cincinnati Children’s Hospital Medical Center and 
will be communicated to the participating sites.  
CCHMC will be the data coordinating site for this trial. Data collection forms (CRFs) will be drafted in a 
standard format (paper or electronic) and will be provided to each participating institution by CCHMC.  
Data collected by sites and submitted to CCHMC will be managed according to CCHMC institutional data 
management standard practice. Sites will enter data in the study database on a weekly basis. Contact 
Information:
Stephanie Edwards
Cincinnati Children’s Hospital Medical Center
3333 Burnet Avenue, ML 11027
Cincinnati, Ohio 45229-3039
Telephone: (513) 636-9292
       Fax: (513) 636-6927
Email: StephanieL.Edwards@cchmc.org
Source documentation will be required for verification of study eligibility, for pivotal data points as 
indicated on the CRFs (including but not limited to, blood counts, complement studies, TMA assessments, 
organ function studies and results indicating disease recurrence or secondary malignancy or other transplant 
complications) and for reports of serious adverse events, upon request.
14.
ETHICS/PROTECTION OF HUMAN SUBJECTS
14.1 Regulatory
The protocol and informed consent document for this study will be approved in writing by the Institutional 
Review Board (IRB) of record for participating institutions prior to any patient being registered on the 
study. All changes to the protocol as well as any change of study staff will also be approved by the IRB. 
Records of the Institutional Review Board review and approval of all documents pertaining to this study 
will be kept on file by the site investigator and/or designee. Informed consent will be obtained prior to the 
treatment of participants.
Investigational New Drug Application (IND): Cincinnati Children’s will file an IND to cover the use of 
eculizumab for the proposed clinical trial at participating institutions. 
14.2 Confidentiality
Any copies of research records will be kept in locked files and any information stored on computer will be 
password protected. The information from the study may be published; however, subjects will not be 
identified in such publications. The publication will not contain information about the subjects that would 
enable someone to determine their identity as a participant without the subject’s authorization. The 
Institutional Review Board may have access to these records. The use of clinical information for research 
purposes and the protection of privacy will be done in compliance with HIPAA requirements at 
participating institutions.
To further protect the privacy of study participants, a Certificate of Confidentiality is issued by the National 
Institutes of Health (NIH). This certificate protects identifiable research information from forced disclosure. 
It allows the investigator and others who have access to research records to refuse to disclose identifying 
information on research participation in any civil, criminal, administrative, legislative, or other proceeding, 
whether at the federal, state, or local level. By protecting researchers and institutions from being compelled 
to disclose information that would identify research participants, Certificates of Confidentiality help 

CCHMC IRB#: 2018-7119C
      
Page 35 of 43
achieve the research objectives and promote participation in studies by helping assure confidentiality and 
privacy to participants.
14.3 Future use
Leftover clinical/tissue samples, tissue repository samples and medical information will be stored 
indefinitely, after subject study participation is complete. Samples and medical information will be retained 
unless the participant chooses to withdraw. If the participant withdraws from further study participation, 
previously collected and stored samples and medical information will be either destroyed or stored for 
future use based on participants request and or permission. Samples and medical information that have 
already been distributed to researchers prior to withdrawal of consent as well as any data obtained from the 
distributed sample will not be destroyed.
The samples may be used by researchers at Cincinnati Children’s Hospital Medical Center or at other 
institutions if some are left over after the tests for this study after IRB approval. Only de-identified data 
and/or samples will be provided to researchers at other institutions. 
15.
STUDY FUNDING AND COMPENSATION
Alexion Pharmaceutical will provide study drug at no cost to study participants. Additionally, Alexion will 
receive and analyze the Research Biomarker Panel samples at no cost to study participants. Any other 
research laboratory tests will be covered by the study. Clinically indicated laboratory studies and supportive 
care are part of HCT care for patients receiving eculizumab and payment will be requested from the 
patient’s insurance.  There will be no compensation to patients.
16.
REFERENCES
1.
Oran B, Donato M, Aleman A, et al. Transplant-associated microangiopathy in patients receiving 
tacrolimus following allogeneic stem cell transplantation: risk factors and response to treatment. Biol Blood 
Marrow Transplant. 2007;13(4):469-477.
2.
Cho BS, Min CK, Eom KS, et al. Clinical impact of thrombotic microangiopathy on the outcome 
of patients with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. 
Bone Marrow Transplant. 2008;41(9):813-820.
3.
Cho BS, Yahng SA, Lee SE, et al. Validation of recently proposed consensus criteria for thrombotic 
microangiopathy 
after 
allogeneic 
hematopoietic 
stem-cell 
transplantation. 
Transplantation. 
2010;90(8):918-926.
4.
Jodele S, Davies SM, Lane A, et al. Diagnostic and risk criteria for HSCT-associated thrombotic 
microangiopathy: a study in children and young adults. Blood. 2014;124(4):645-653.
5.
Jodele S, Fukuda T, Vinks A, et al. Eculizumab Therapy in Children with Severe Hematopoietic 
Stem Cell Transplantation-Associated Thrombotic Microangiopathy. Biol Blood Marrow Transplant. 
2013:Apr;20(24):518-525.
6.
Jodele S, Fukuda T, Mizuno K, et al. Variable Eculizumab Clearance Requires Pharmacodynamic 
Monitoring to Optimize Therapy for Thrombotic Microangiopathy after Hematopoietic Stem Cell 
Transplantation. Biol Blood Marrow Transplant. 2015.
7.
Keating GM. Eculizumab: a review of its use in atypical haemolytic uraemic syndrome. Drugs. 
2013;73(18):2053-2066.
8.
Legendre CM, Licht C, Loirat C. Eculizumab in atypical hemolytic-uremic syndrome. N Engl J 
Med. 2013;369(14):1379-1380.
9.
Jodele S, Zhang K, Zou F, et al. The genetic fingerprint of susceptibility for transplant associated 
thrombotic microangiopathy. Blood. 2015.

CCHMC IRB#: 2018-7119C
      
Page 36 of 43
10.
Fernandez-Garcia M, Gonzalez-Vicent M, Mastro-Martinez I, Serrano A, Diaz MA. Intensive Care 
Unit Admissions Among Children After Hematopoietic Stem Cell Transplantation: Incidence, Outcome, 
and Prognostic Factors. J Pediatr Hematol Oncol. 2015;37(7):529-535.
11.
Han W, Han Y, Chen J, et al. [Allogeneic hematopoietic stem cell transplantation associated 
thrombotic microangiopathy: 16 cases report and literature review]. Zhonghua Xue Ye Xue Za Zhi. 
2016;37(8):666-670.
12.
Ye Y, Zheng W, Wang J, et al. Risk and prognostic factors of transplantation-associated thrombotic 
microangiopathy in allogeneic haematopoietic stem cell transplantation: a nested case control study. 
Hematol Oncol. 2016.
13.
Laskin BL, Nehus E, Goebel J, Furth S, Davies SM, Jodele S. Estimated versus measured 
glomerular filtration rate in children before hematopoietic cell transplantation. Biol Blood Marrow 
Transplant. 2014;20(12):2056-2061.
14.
Changsirikulchai S, Myerson D, Guthrie KA, McDonald GB, Alpers CE, Hingorani SR. Renal 
thrombotic microangiopathy after hematopoietic cell transplant: role of GVHD in pathogenesis. Clin J Am 
Soc Nephrol. 2009;4(2):345-353.
15.
Glezerman IG, Jhaveri KD, Watson TH, et al. Chronic kidney disease, thrombotic 
microangiopathy, and hypertension following T cell-depleted hematopoietic stem cell transplantation. Biol 
Blood Marrow Transplant. 2010;16(7):976-984.
16.
Jodele S, Hirsch R, Laskin B, Davies S, Witte D, Chima R. Pulmonary arterial hypertension in 
pediatric patients with hematopoietic stem cell transplant-associated thrombotic microangiopathy. Biol 
Blood Marrow Transplant. 2013;19(2):202-207.
17.
El-Bietar J, Warren M, Dandoy C, et al. Histologic Features of Intestinal Thrombotic 
Microangiopathy in Pediatric and Young Adult Patients after Hematopoietic Stem Cell Transplantation. 
Biol Blood Marrow Transplant. 2015;21(11):1994-2001.
18.
Jodele S, Dandoy CE, Danziger-Isakov L, et al. Terminal Complement Blockade after 
Hematopoietic Stem Cell Transplantation Is Safe without Meningococcal Vaccination. Biol Blood Marrow 
Transplant. 2016.
19.
National High Blood Pressure Education Program Working Group on High Blood Pressure in 
Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood 
pressure in children and adolescents. Pediatrics. 2004 Aug;114(2 Suppl 4th Report):555-76. 

CCHMC IRB#: 2018-7119C
      
Page 37 of 43
17.
APPENDIX I:   TMA DIAGNOSIS IN HSCT RECIPIENTS
TMA diagnosis in HCT recipients is confirmed by A or B
A. Histologic TMA diagnosis in tissue biopsy
OR
B. Laboratory and clinical markers 

For diagnosis of high risk TMA, patient must have proteinuria (#6) and terminal 
complement activation as measured by elevated plasma sC5b-9 level (#7).

Total of 4 out of 7 markers are required to meet TMA diagnosis. 
No
TMA marker
Date
1
[   ] LDH above normal value for age
_ _/_ _/_ _ _ _ 
2
[   ] Schistocytes on peripheral blood smear
_ _/_ _/_ _ _ _ 
3
[   ] De novo thrombocytopenia or require platelet transfusions
_ _/_ _/_ _ _ _ 
4
[   ] De novo anemia or require RBC transfusions
_ _/_ _/_ _ _ _ 
5
[   ] Hypertension >99% for age (<18y of age) or 140/90 (≥18y of age)   
or receiving antihypertensive therapy19
_ _/_ _/_ _ _ _ 
6
[   ] Proteinuria ≥30mg/dL on random urinalysis x2 or random urine 
protein creatinine ratio >1mg/mg or patient receiving renal replacement 
therapy.
_ _/_ _/_ _ _ _ 
7
[   ] Terminal complement activation: elevated plasma sC5b-9 above 
normal limit of (≥244ng/ml)
_ _/_ _/_ _ _ _ 

CCHMC IRB#: 2018-7119C
      
Page 38 of 43
18.
APPENDIX II:  DEFINITIONS OF TMA-ASSOCIATED MODS IN HSCT RECIPIENTS
MODS will be defined as: evidence of TMA as listed in APPENDIX 1 and at least one of below listed 
organ impairment. 
Organ 
Dysfunction
Definition
Start date
Resolution date
Renal
≥50% reduction of Cystatin C GFR from pre-
HSCT value or the lowest value during or 
prior to diagnosis of TMA, whichever is lower
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
Pulmonary
Any need for positive pressure ventilation 
(non-invasive or invasive) for ≥24 hours
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
Cardiovascular
Pulmonary hypertension (PH) diagnosed  by 
cardiologist using cardiac catheterization or 
PH criteria on echo (RV pressure ≥50% of 
systemic pressure, ventricular septal 
flattening, or right ventricular dysfunction)
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
Pericardial 
Effusion
Clinically significant pericardial effusion 
requiring medical therapy (like diuretics) or 
drainage (like pericardiocentesis)
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
Severe 
hypertension
Hypertension requiring > 2 antihypertensive 
medications for > 24 hours or continuous 
antihypertensive infusion for ≥12 hours or 
resulting in complications like CNS bleeding 
or posterior reversible encephalopathy 
syndrome (PRES).
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
CNS
CNS bleeding or seizures clinically 
attributable to posterior reversible 
encephalopathy syndrome (PRES)
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
Gastro-
intestinal
GI Bleeding and/or intestinal strictures 
attributable to TMA requiring medical or 
surgical interventions
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _

CCHMC IRB#: 2018-7119C
      
Page 39 of 43
19.
APPENDIX III: TMA TEST REQUISITION SHEET
TMA laboratory test requisition for can be downloaded from Cincinnati Children’s website by searching 
“TMA” or using this link: 
https://www.cincinnatichildrens.org/service/t/thrombotic-microangiopathy/requisitions

CCHMC IRB#: 2018-7119C
      
Page 40 of 43
20.
APPENDIX IV: STUDY SAMPLE COLLECTION FOR REPOSITORY
Research samples as described below will be collected from study participants who are not currently 
enrolled onto the Hematopoietic Stem Cell Transplant (HSCT) Tissue Repository (CCHMC Study #: 2012-
1156) or a similar repository study at participating sites. Blood samples collected from the tissue repository 
will include testing to assess the immunogenicity of eculizumab.
Peripheral blood [including plasma, serum and nucleated cells (MNCs or PBMC)],  and urine samples will 
be collected weekly through 100 days post-transplant (blood twice weekly), approximately monthly for the 
first year or at follow-up visits, or during scheduled clinical visits, if less often, till the first year after 
transplant, and at the time of any transplant complications. Stool samples will be collected weekly as 
feasible at the site PI’s discretion. Other tissue samples (like tissues from clinically obtained biopsies or 
bone marrow aspiration samples) will be collected as available. If a pre-transplant DNA sample is available, 
it may be requested for a TMA-associated genetic panel. 
These samples will be processed, frozen, and stored at the site where they were collected. Then samples 
will be shipped in batches to CCHMC. These samples may be used in current and future research studies.
Procedures
1) Peripheral Blood Draw*
Patients undergoing a peripheral blood draw will undergo venipuncture after an appropriate site 
has been identified and cleaned per standard procedure. Topical lidocaine or similar topical 
anesthetic may be applied prior to the venipuncture. A central line would be used in patients who 
have this access. 
*Blood volumes will be based on patient weight and estimated blood volume. No more than 5 
ml/kg of the patient’s body weight will be taken for both clinically indicated and research purposes 
(per standard transplant practice). The first priority will be clinically indicated volumes. 
2) Urine
Urine is to be collected, stored and shipped in batches to CCHMC. 
3) Stool
Stool will be collected as per institutional standard of practice. 
4) Leftover Clinical Samples
Blood, tissue and body fluids that are leftover after clinical testing (peripheral blood, urine, stool, 
bone marrow, tumor specimens, immortalized B-cell lines, oral specimens, DNA), that would 
otherwise be discarded, may be stored. 
5) Database
Access to study database will be limited to the Principal Investigator and her designees via 
password protected security measures. Each specimen collected will be entered into the specimen 
database, along with all information collected.
6) Release of Specimens to Investigators
Release of any specimen to investigators must be approved by the Principal Investigator or 
designee. The procedures for release of specimens are described below.
a.
CCHMC investigators
In order for a CCHMC investigator to receive specimens and/or data, the following must 
be submitted to CCHMC study staff: 
1)
Completed application 

CCHMC IRB#: 2018-7119C
      
Page 41 of 43
2)
Documentation of CCHMC IRB approval (IRB #) for the proposed research 
project if the use of the samples and/or data released from the repository 
constitutes human subjects research per 45 CFR 46 or genetic research.
Upon receipt of the above application and approval by the principal investigator or 
designee, the specimen(s) will be released to the CCHMC investigator. 
b.
External investigators
As this will become a valuable resource for potential research, it is anticipated that it will 
serve as a tissue repository for investigators at other centers. The external investigators can 
apply for de-identified specimens alone, and/or de- identified patient clinical information. 
No identifying information will be released to external investigators at any point.
In order for an investigator at another center to receive any data or specimens, the following 
must be submitted to CCHMC study staff: 
1)
Completed application
2)
Local IRB or Ethics Committee (country specific IRB equivalent) approval 
document if the use of the samples and/or data released from the repository 
constitutes human subjects research per 45 CFR 46 or genetic research. (If this 
document is in a language other than English, it must be translated and verified 
by a CCHMC employee fluent in that language. This can be a member of the 
CCHMC interpreter team).
Upon receipt of the above documents and approval by the principal investigator or 
designee, the specimen(s) will be shipped to the external investigator. 
Special considerations:
Genetic studies: There is potential for genetic studies involving these specimens, including, but not 
limited to complement genes and other genetic pathways possibly implicated in TMA or organ 
dysfunction after HCT. 
Other Repositories: Additional samples may be collected from other repositories, if available, in 
special circumstances (i.e. in the event pre-transplant samples are needed for genetic testing). 

CCHMC IRB#: 2018-7119C
      
Page 42 of 43
21.
APPENDIX V: ADVERSE EVENT REPORTING OF TMA ASSOCIATED CONDITIONS
TMA associated conditions that will not be reportable as AEs
Medical conditions/diseases present before starting study drug are only considered adverse events if they 
worsen after starting study drug. This excludes TMA since disease progression is anticipated in some 
patients after initiation of complement blocking therapy and TMA is the subject of this study.
Below is a list of conditions/symptoms that are considered part of TMA for which sites would not have to 
report as AEs if they worsen after start of eculizumab (i.e., are considered worsening or progressive 
TMA). Conditions/symptoms, that in and of themselves would be considered serious, as per the criteria in 
section 8.3.1, will need to be reported immediately as SAEs.
Please contact Lead Site study staff with any questions regarding these requirements. 
Will not be reportable as AE*
Requires to be reported as SAE
Renal
Proteinuria
Drop in GFR
Increase in creatinine
Electrolyte imbalance not requiring 
renal replacement tx
Weight gain
Tissue edema
*not resulting in renal replacement 
support needs listed under SAE
CRRT, HD, aqua filtration
Pulmonary
O2 requirement
Abnormal radiologic studies 
Abnormal blood gases and pulmonary 
function tests 
*not resulting in ventilatory support 
needs listed under SAE
Pulmonary dysfunction and or bleeding 
requiring positive pressure ventilation 
(invasive or non-invasive)
Cardiac
Abnormal cardiac echo or cardiac 
catheterization tests, including 
elevated RV pressure, RV 
dysfunction, pulmonary hypertension, 
effusions requiring monitoring or 
support and/or medical therapy.
Cardiac function abnormalities resulting 
in hemodynamic instability requiring 
inotropic support, invasive or non-
invasive ventilatory support or surgical 
procedures
Serositis
Pleural, pericardiac effusions, ascites 
requiring support care, monitoring 
and/or medical therapy
Effusions resulting in impending 
tamponade and/or hemodynamic,  
pulmonary instability, or compartment 
syndrome requiring surgical 
interventions

CCHMC IRB#: 2018-7119C
      
Page 43 of 43
Severe 
hypertension
Hypertension requiring medical 
management on any number of 
medications or continues infusions 
Hypertension resulting in acute 
clinically significant complications like 
PRES, seizures, CNS bleeding
CNS dysfunction
Altered mental status requiring clinical 
monitoring or medical interventions
Seizures, PRES, CNS bleed
GI dysfunction
Upper and/or lower GI bleed requiring 
transfusion support and/or medical 
interventions
GI dysfunction requiring surgical 
interventions or resulting in 
hemodynamic/respiratory instability 
requiring inotropic support and/or 
invasive or non-invasive respiratory 
support
Hematologic 
Laboratory evidence of hemolysis, 
anemia, thrombocytopenia requiring 
transfusion support
Hemolysis resulting in hemodynamic 
instability or thrombocytopenia 
resulting in life threatening bleeding 
requiring  inotropic support and/or 
invasive or non-invasive respiratory 
support
ID
Documented bacterial infections 
requiring monitoring and medical 
treatment 
Infections resulting in septic shock, 
meningitis, and/or requiring surgical 
procedures
Ophthalmologic
Visual acuity changes attributable to 
hypertension or TMA-associated 
vascular injury requiring monitoring 
and medical interventions
Acute vision loss (blindness)
GU
Hematuria requiring monitoring, 
medical therapy or bladder irrigation
Hematuria requiring surgical 
interventions or resulting in 
hemodynamic instability