A Single Center, Pilot Clinical Investigation of Surgical Bleeding in Burn Patients, and Chronically Transfused Patients With Haematologic Malignancies, Who Are Transfused With Hypoxic Red Blood Cells Manufactured With Hemanext ONE System
Conditions: Hematologic Neoplasms, Burns
Sponsor: Hemanext

Study Protocol 
 
PRO-CLIN-0012 
 
A Single Center, Pilot Clinical Investigation of Surgical 
Bleeding in Burn Patients, and Chronically Transfused 
Patients With Haematologic Malignancies, Who Are 
Transfused With Hypoxic Red Blood Cells Manufactured 
With Hemanext ONE System 
 
NCT: NCT05549232 
 
Document Date:  16 MAR 2023 

 
 
Clinical Investigation Plan (CIP) 
 
“A Single Center, Pilot Clinical Investigation of Surgical Bleeding in Burn Patients, and 
Chronically Transfused Patients with Haematologic Malignancies, who are Transfused with 
Hypoxic Red Blood Cells Manufactured with Hemanext ONE system” 
 
Type of investigation: 
Clinical investigation involving a blood product (O2/CO2 reduced red 
blood cells) made with a class IIb medical device (blood container). 
 
Registration: 
Hemanext Inc. will comply with the Research Council of Norway on 
requirements and guidelines for registration and disclosure of 
medical and health-related studies involving human participants, 
through: www.ISRCTN.org 
 
Identifier: 
 
Sponsor’s clinical investigation ID: CLIN-0012 
 
Principal Investigator and 
Sponsor 
Principal Investigator: 
Stian Kreken Almeland, MD 
Address:  
Haukeland University Hospital, Jonas Lies vei 65,  
5021 Bergen 
Norway 
Phone: 
 
E-mail: 
 
 
Sponsor: 
Hemanext Inc. 
Address:  
99 Hayden Avenue, Suite 620, Lexington, MA 02421 
United States of America 
 
 
Chief Medical Officer 
Laurel Omert, MD, FACS, 
Telephone: 
 
E-mail: 
 
 
 
Clinical Project Manager 
Kimberly Dorsch 
Telephone: 
 
Email: 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Sponsor representative 
LINK Medical Research 
Gjerdrums vei 19 
NO-0484 Oslo 
Norway 
 
Medical Device: 
 
Hemanext ONE – A blood container set used to process and store 
CPD/PAGGSM Red Blood Cells, Leukocytes Reduced, and O2/CO2 
Reduced. 
 
UDI number: 0856186008TECH-0001W9 
 
CIP Version and Date: 
PRO-CLIN-0012 Rev. AB dated March 16, 2023 
 
CONFIDENTIAL 
The information contained in this document is confidential and the property of Hemanext, Inc. (or 
“Sponsor”). The information may not - in full or in part - be transmitted, reproduced, published, or 
disclosed to others than the applicable Competent Ethics Committee(s) and Regulatory Authority(ies)  
without prior written authorisation from the Sponsor except to the extent necessary to obtain informed 
consent from those who will participate in the investigation. 
 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Revision history of amendments 
 
Version 
Comments 
Changes in subject 
information/informed 
consent 
Version 25 APR 2022 
Final version for submission to 
the Ethics Committee 
 
Version 16 MAR 2023 
The blood bank at Haukeland 
University Hospital in Bergen 
has validated the Hemanext 
ONE system and hypoxic 
RBCs will be manufactured for 
the study in both Bergen and 
Oslo 
None 
 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Signature Page(s)  
 
ID number of the 
investigation: 
CLIN-0012 
Hemanext Inc. will comply with the Research Council of Norway 
on requirements and guidelines for registration and disclosure of 
medical and health-related studies involving human participants, 
through: www.ISRCTN.org  
 
Title: 
“A single center, pilot clinical investigation of surgical bleeding in 
burn 
patients, 
and 
chronically 
transfused 
patients 
with 
haematologic malignancies, who are transfused with hypoxic red 
blood cells manufactured with Hemanext ONE system” 
 
The Sponsor and the Principal Investigator have approved PRO-CLIN-0012 Rev. AA dated April 25, 
2022 and confirm hereby to conduct the investigation according to the CIP, the current version of the 
World Medical Association Declaration of Helsinki, ISO14155 norm, ICH-GCP as far as applicable, and 
the local legally applicable requirements. 
 
 
Sponsor: 
 
 
Place/Date 
 
Signature 
 
 
 
 
Principal Investigator: 
 
 
Place/Date 
 
Signature 
 
Site:  
Haukeland University Hospital, 
Jonas Lies vei 65 
5021 Bergen 
Norway 
 
 
 
 
 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Table of Contents 
 
1. 
SYNOPSIS ....................................................................................................................................... 9 
1. 
Background and rationale for hypoxic blood use: ....................................................................... 10 
2. 
Consequences of Current RBC Storage Process ....................................................................... 11 
3. 
Hypoxic storage and HEMANEXT blood product ....................................................................... 11 

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2. 
ABBREVIATIONS  ......................................................................................................................... 21 
SUMMARY OF THE REVISION HISTORY IN CASE OF AMENDMENTS .......................................... 22 
3. 
INVESTIGATION ADMINISTRATIVE STRUCTURE .................................................................... 22 
3.1 Sponsor ......................................................................................................................................... 22 
3.2 Principal Investigator(s) .............................................................................................................. 22 
3.3 Statistician ("Biostatistician") .................................................................................................... 23 
3.4 Laboratory..................................................................................................................................... 23 
3.5 Monitoring institution .................................................................................................................. 23 
3.6 Data Monitoring Committee ........................................................................................................ 23 
3.7 Any other relevant Committee, Person, Organisation, Institution .......................................... 23 
4. 
ETHICAL AND REGULATORY ASPECTS .................................................................................. 24 
4.1 Registration of the investigation ................................................................................................ 24 
4.2 Competent Ethics Committee (CEC) .......................................................................................... 24 
4.2.1 Reporting duties to the Competent Ethics Committee ......................................................... 24 
4.3 Competent Authorities (CA) ........................................................................................................ 24 
4.3.1 Reporting duties to the competent authorities ...................................................................... 24 
4.4 Ethical Conduct of the Investigation .......................................................................................... 24 
4.5 Declaration of interests ............................................................................................................... 24 
4.6 Patient Information and Informed Consent ............................................................................... 25 
4.7 Subject privacy and confidentiality ............................................................................................ 25 
4.8 Early termination of the investigation ........................................................................................ 25 
4.9 Clinical investigation plan amendments ................................................................................... 25 
4.10 Deviation from the Clinical Investigation Plan .......................................................................... 26 
5. 
BACKGROUND AND RATIONALE .............................................................................................. 26 
5.1 Background and Rationale for the clinical investigation ......................................................... 26 
5.1.1 Background and Rationale for Hypoxic Blood: ..................................................................... 26 
5.1.2 Consequences of Current RBC Storage Process .................................................................. 26 
5.1.3 Hypoxic storage and HEMANEXT product ............................................................................. 27 
5.1.4 Background on Blood Use in Burn Patients: ......................................................................... 27 
5.1.5 Background on Blood Use in Hematological Malignancies: ................................................ 28 
5.1.6 Potential Benefits of Hypoxic Blood ....................................................................................... 29 
5.1 Identification and description of the Investigational Medical Device ..................................... 31 
5.1.1 Description of Hemanext Process: .......................................................................................... 33 
5.2 Preclinical Evidence .................................................................................................................... 34 
5.3 Clinical Evidence to Date ............................................................................................................ 35 
5.4 Justification for the design of the clinical investigation .......................................................... 35 
5.5 Explanation for choice of comparator ....................................................................................... 36 
5.6 Risk evaluation (Risk-to-Benefits rationale) .............................................................................. 36 
5.6.1 Potential Benefits ...................................................................................................................... 36 
5.7 Anticipated risks .......................................................................................................................... 36 
5.8 Justification of the choice of the investigation population ..................................................... 37 
6. 
CLINICAL INVESTIGATION OBJECTIVES ................................................................................. 38 
6.1 Overall Objective .......................................................................................................................... 38 
6.2 Primary Objective ......................................................................................................................... 38 
6.3 Secondary Objectives .................................................................................................................. 38 
6.4 Safety Objectives ......................................................................................................................... 38 

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7. 
CLINICAL INVESTIGATION OUTCOMES ................................................................................... 39 
7.1 Primary Outcome ......................................................................................................................... 39 
7.2 Secondary Outcomes .................................................................................................................. 39 
7.3 Other Outcomes of Interest......................................................................................................... 39 
7.4 Safety Outcomes .......................................................................................................................... 39 
8. 
CLINICAL INVESTIGATION DESIGN .......................................................................................... 39 
8.1 General clinical investigation design and justification of design ........................................... 39 
8.2 Methods for minimising bias ...................................................................................................... 39 
8.2.1 Randomisation .......................................................................................................................... 40 
8.2.2 Blinding procedures ................................................................................................................. 40 
8.2.3 Other methods for minimising bias ......................................................................................... 40 
8.3 Unblinding Procedures (Code break) ........................................................................................ 40 
9. 
CLINICAL INVESTIGATION POPULATION ................................................................................. 40 
9.1 Eligibility criteria .......................................................................................................................... 40 
9.1.1 Inclusion Criteria ....................................................................................................................... 40 
9.1.2 Exclusion Criteria – both patients groups ................................................................................. 40 
9.2 Recruitment and screening ......................................................................................................... 41 
9.2.1 Hematological Malignancies Group ........................................................................................ 41 
9.2.2 Burn Group ................................................................................................................................ 41 
9.3 Assignment to investigation groups .......................................................................................... 41 
9.4 Criteria for withdrawal / discontinuation of subjects ............................................................... 41 
10. CLINICAL INVESTIGATION INTERVENTION ............................................................................. 41 
10.1 Identity of the medical device under investigation .................................................................. 41 
10.1.1 Experimental Intervention (medical device) ........................................................................... 42 
10.1.2 Control Intervention (standard/routine/comparator) ............................................................. 42 
10.1.3 Labelling and Supply ................................................................................................................ 42 
10.1.4 Storage Conditions ................................................................................................................... 42 
10.2 Discontinuation or modifications of the intervention .............................................................. 42 
10.3 Compliance with clinical investigation intervention ................................................................ 43 
10.4 Data Collection and Follow-up for withdrawn subjects ........................................................... 43 
10.5 Clinical investigation specific preventive measures ................................................................ 43 
10.6 Concomitant Interventions (treatments) .................................................................................... 43 
10.7 Medical Device Accountability.................................................................................................... 43 
10.8 Return, Analysis or Destruction of the Medical Device ........................................................... 44 
11. CLINICAL INVESTIGATION ASSESSMENTS ............................................................................. 44 
11.1 Clinical investigation flow chart(s) / table of clinical investigation procedures and 

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assessments ........................................................................................................................................ 45 
11.1.1 Hematogical Malignancies Group: .......................................................................................... 45 
11.1.2 Burn patients Group: ................................................................................................................ 46 
11.2 Assessments of outcomes.......................................................................................................... 47 
11.2.1 Assessment of primary outcome ............................................................................................ 47 
11.2.2 Assessment of secondary outcomes...................................................................................... 47 
11.2.3 Assessment of other outcomes of interest ............................................................................ 47 
11.2.4 Assessment of safety outcomes ............................................................................................. 47 
11.2.5 Assessments in subjects who prematurely stop the clinical investigation........................ 47 
11.2.6 Follow-up of the subjects after the regular termination of the clinical investigation ........ 47 
11.3 Procedures at each visit .............................................................................................................. 48 
11.3.1 Patient Information Contact ..................................................................................................... 48 
11.3.2 Screening Visit .......................................................................................................................... 48 
11.3.3 Transfusion Visit ....................................................................................................................... 48 
11.3.4 First Follow-Up Visit.................................................................................................................. 48 
11.3.5 Second Follow-Up Visit ............................................................................................................ 49 
11.3.6 Final Follow-Up .......................................................................................................................... 49 
12. SAFETY ......................................................................................................................................... 50 
12.1 Definition and Assessment of (Serious) Adverse Events and other safety related events . 50 
12.2 Documentation and reporting in Medical Device clinical investigations ............................... 51 
12.3 Foreseeable adverse events and anticipated adverse device effects .................................... 51 
12.4 Reporting of (Serious) Adverse Events, device deficiencies, and other safety related events
 
52 
12.4.1 Reporting to the Sponsor: ........................................................................................................ 52 
12.4.2 Reporting to the Competent Ethics Committee: .................................................................... 52 
12.5 Follow-up of (Serious) Adverse Events ..................................................................................... 53 
12.6 Documentation and reporting in Medical Device clinical investigations ............................... 53 
12.7 Reporting of Safety related events ............................................................................................. 54 
12.7.1 Reporting to the Competent Ethics Committee: .................................................................... 54 
12.7.2 Periodic safety reporting: ......................................................................................................... 54 
12.8 Procedure...................................................................................................................................... 54 
12.8.1 Initiation of Adverse Event Reporting ..................................................................................... 54 
12.8.2 Reporting Requirements .......................................................................................................... 56 
12.8.3 Reporting Timelines .................................................................................................................. 57 
12.9 List of foreseeable adverse events and anticipated adverse device effects, together with 

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their likely incidence, mitigation or treatment .................................................................................. 57 
12.10 Assessment, notification and reporting on the use of radiation sources........................... 58 
13. STATISTICAL METHODS ............................................................................................................. 59 
13.1 Hypothesis .................................................................................................................................... 59 
13.2 Determination of Sample Size .................................................................................................... 59 
13.3 Statistical criteria of termination of the investigation .............................................................. 59 
13.4 Planned Analyses ........................................................................................................................ 59 
13.4.1 Datasets to be analysed, analysis populations ..................................................................... 59 
13.4.2 Primary Analysis ....................................................................................................................... 59 
13.4.3 Secondary Analyses ................................................................................................................. 59 
13.4.4 Interim analyses ........................................................................................................................ 59 
13.4.5 Deviation(s) from the original statistical plan ........................................................................ 59 
13.5 Handling of missing data and drop-outs ................................................................................... 59 
14. QUALITY ASSURANCE AND CONTROL .................................................................................... 60 
14.1 Data handling and record keeping / archiving .......................................................................... 60 
14.1.1 Case Report Forms ................................................................................................................... 60 
14.1.2 Specification of source data and source documents ............................................................ 61 
14.1.3 Archiving of essential clinical investigation documents ...................................................... 61 
14.2 Data management ........................................................................................................................ 61 
14.2.1 Data Management System ........................................................................................................ 61 
14.2.2 Data security, access and back-up ......................................................................................... 61 
14.2.3 Analysis and archiving ............................................................................................................. 61 
14.2.4 Electronic and central data validation .................................................................................... 61 
14.3 Monitoring ..................................................................................................................................... 62 
14.4 Audits and Inspections ................................................................................................................ 62 
14.5 Confidentiality, Data Protection ................................................................................................. 62 
14.6 Storage of biological material and related health data ............................................................ 63 
15. PUBLICATION AND DISSEMINATION POLICY.......................................................................... 64 
16. FUNDING AND SUPPORT ............................................................................................................ 65 
16.1 Funding ......................................................................................................................................... 65 
16.2 Other Support ............................................................................................................................... 65 
17. INSURANCE .................................................................................................................................. 65 
18. REFERENCES ............................................................................................................................... 65 
19. APPENDICES ................................................................................................................................ 67 
19.1 Investigator Brochure .................................................................................................................. 67 
19.2 Hemanext Storage Bag (HSB) labelling ..................................................................................... 67 
19.3 Hemanext ONE Instructions for Use .......................................................................................... 67 
 
1. SYNOPSIS  

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Sponsor  
Hemanext Inc. 
99 Hayden Avenue, Suite 620  
Lexington, MA 02421 
United States of America 
 
Title: 
 
“A Single Center, Pilot Clinical Investigation of Surgcal Bleeding in Burn Patients, and Chronically 
Transfused Patients with Haematologic Malignancies, who are Transfused with Hypoxic Red Blood 
Cells Manufactured with Hemanext ONE system” 
 
Short title / 
Investigation 
ID: 
 
“Hypoxic Red Blood Cells for Burns and Hematological Malignancies at Haukeland University Hospital” 
 
CLIN-0012 
 
Clinical 
Investigation 
Plan, version 
and date: 
 
 PRO-CLIN-0012 Rev. AA dated 25 April 2022 
 
Registration: 
Hemanext Inc. will comply with the Research Council of Norway on requirements and guidelines for 
registration and disclosure of medical and health-related studies involving human participants, through: 
www.ISRCTN.org 
 
Name of the 
MD, Unique 
Device 
Identification 
(UDI), name of 
the 
manufacturer 
Medical device:  
Hemanext ONE – A blood container set used to process and store CPD/PAGGSM Red Blood Cells, 
Leukocytes Reduced, and O2/CO2 Reduced. 
 
UDI number: 0856186008TECH-0001W9 
 
Manufacturer:  
Hemanext Inc. 
99 Hayden Avenue 
Building B, Suite 620 
Lexington, MA 02421 
USA 
 
 
Stage of 
development: 
Medical device: 
Hemanext ONE 
CE Marked since April 2021 (Post-Market stage) 
 
Blood Product: 
CPD/PAGGSM Red Blood Cells, Leukocytes Reduced, and O2/CO2 Reduced 
The Norwegian National Directorate of Health will be notified that this blood product is under evaluation.  
In Norway, this blood product is currently not registered with the Norwegian Directorate of Health 
(Helsedirektoratet).   
 
Background 
and rationale: 
1. Background and rationale for hypoxic blood use: 
 

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Red blood cells (RBCs) comprise the only tissue in the body that provides oxygen transport.  Anemia 
results from either the acquired loss of RBCs due to disease, injury, or surgery or the inability of the 
patient to produce their own RBCs due inherited disorders.  While the overall clinical settings of 
anemia can differ greatly between acute or chronic causes, the primary therapeutic goal of RBC 
transfusion is to increase the oxygen-carrying capacity and prevent tissue hypoxia1. Red blood cells 
can be stored for up to 42 days before transfusion but, surprisingly, there are few quality parameters 
that predict the efficacy and safety of a transfusion2.  
2. Consequences of Current RBC Storage Process 
 
A review of the literature2,3,4,5 identifies substantial evidence suggesting decreased quality of RBCs 
from substances that accumulate during RBC storage. These include nitric oxide (NO) scavengers 
and inhibitors of NO generation that affect vascular tone, procoagulant microparticles, free and non-
transferrin bound iron, and bioactive lipids. Additionally, RBCs show progressively diminished 
deformability over time, characteristics necessary to adequately perfuse the microcirculation4. 
D’Alessandro and colleagues observed significant changes in the plasma levels of hemolytic markers, 
oxidized purines, plasticizers, and oxidized lipids in recipients of blood stored for 42 days, compared 
with 5 days3. 
Yoshida and colleagues performed an exhaustive review of the oxidative and metabolic changes that 
occur to RBCs during storage, summarizing elements of the RBC storage lesion from causes to 
associated clinical sequelae. The review identifies root causes, effects on RBCs, physiological 
consequences reported from in vitro experiments or animal models, and finally, potential clinical 
sequelae of RBC transfusion, each element being identified with its pertinent reference(s)2. 
3. Hypoxic storage and HEMANEXT blood product 
 
Hypoxic storage, where the oxygen content of RBC units is reduced to low levels [e.g., less than 20% 
oxy-hemoglobin (SO2)6 prior to refrigeration and maintained throughout storage], was proposed as an 
alternative to antioxidant-based additive solutions to reduce oxidative stress during hypothermic RBC 
storage5,7-11. The rationale for implementing hypoxic storage is to reduce oxygen, the essential 
substrate for hemoglobin oxidation that generates the multitude of untoward physiologic and 
biochemical events described previously.  
Hypoxic storage was also shown to counteract some metabolic impairments without requiring novel 
additive ingredients5,7 independent of the reduction in oxidative stress. During pre-storage processing 
to reduce oxygen content in the RBC, carbon dioxide is also reduced. Carbon dioxide depletion 
increases cytosolic pH that was lowered from its physiological level by exposure to acidic 
anticoagulant and additive solutions. The resulting more neutral pH in the early phase of storage 
results in sustained flux through the glycolytic pathway and elevated 2,3-DPG levels, which are highly 
sensitive to pH and normally depleted early during hypothermic storage7,11,12. Additionally, 
deoxyhemoglobin causes metabolic modulation to release glycolytic enzymes, such as 
phosphofructokinase  and glyceraldehyde dehydrogenase, sequestered at the band 3 binding domain, 
thereby enhancing overall glycolytic flux during hypoxic storage13,14. 
 
Metabolomics work by D’Alessandro et al has shown that hypoxic storage diminishes damaging 
mediators of oxidative stress and increases energy biomarkers without requiring novel additive 
ingredients15. The same group investigated the metabolomics of hypoxic storage in a two-arm cross-
sectional clinical study. Hypoxic storage was found to ameliorate the metabolic phenotypes of stored 
RBCs (lower markers of oxidant stress such as lipids and purines and higher levels of high-energy 
phosphate compounds) and improve post-transfusion recovery (PTR). The study also correlated 
metabolic parameters to hemolysis and PTR, highlighting the role of purine and lipid oxidation (e.g., 
hypoxanthine and 9-HODE), so that these can be used as markers in fresh and stored units to predict 
end of storage blood quality15.  

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Population:  
The Hemanext ONE System may be used to manufacture hypoxic RBCs for any patient requiring a 
blood transfusion.  This pilot investigation aims to study safety of hypoxic RBCs in 2 patient groups: 
acute burn and hematologic malignancies.  Burn patients undergoing surgical excision routinely require 
large quantities of blood to be transfused.  Those patients with hematologic malignancies often require 
regular transfusions. 
  
Burn Patients  
Major burn trauma has been found to trigger an inflammatory cascade of events which leads to oxidative 
stress and tissue damage. These injurious responses, which include complement activation, excessive 
histamine release, decreased blood pressure, and release of reactive oxygen species, may ultimately 
lead to the development of multiple organ dysfunction16. Early excision and grafting of large burn wounds 
is currently performed to attenuate the post-burn hypermetabolic state and remove the biological nidus 
for infection. These operative procedures can result in considerable bleeding. In one report, 
intraoperative blood loss was estimated at approximately 9.2% of blood volume for every 1% of total 
body surface area (TBSA) burn excised20.  
 
Patients with Hematological Malignancies
 
Hematologic malignancies such as myelodysplastic syndromes (MDS), multiple myeloma, and leukemia 
are increasing in prevalence in Norway. Collectively, hematologic malignancies refers to various 
disorders of the bone marrow which result in abnormal blood cell production. Leukemia presents with 
increased numbers of leucocytes in the blood and bone marrow23. Multiple myeloma is characterized 
by uncontrolled growth of plasma cells in the bone marrow. MDS consist of bone marrow diseases 
associated with ineffective hematopoiesis, resulting in morphologically abnormal blood cells24. In all 
cases, anemia can result from the overcrowding or ineffective production of normal blood cells, leading 
to inadequate oxygen delivery. Patients often require regular blood transfusions at some time during 
their treatment to alleviate the symptoms of severe anemia, which can include fatigue, weakness, and 
exacerbation of other underlying medical conditions. The treatment goal is to minimize morbidity and 
mortality with the lowest possible exposure26. Some studies show reduced survival with increased 
transfusion density27. Iron overload with organ impairment, a consequence of transfusion dependency, 
may be fatal in those who are heavily iron-overloaded28,29. Therefore, where a patient has no fatigue-
induced limitation on quality of life or function at home, a more conservative approach may be preferred 
to avoid potential adverse effects and improve outcomes31. 
 
 
Potential B enefits of Hypoxic RBC Use
 
In vitro and pre-clinical data support the hypothesis that hypoxic blood carries the potential to benefit 
patients suffering from hematological malignancies and burn injuries. Hypoxic storage may reduce 
oxidative stress, as shown in metabolomics work by D’Alessandro et al highlighting diminished 
mediators of oxidative stress in hypoxically stored blood vs conventional15. The use of hypoxically stored 
blood may improve oxygen delivery, as evidenced in CLIN-0001 signifying that hypoxically stored blood 
showed improvements in ATP, 2,3 DPG, and RBC deformability32. The increases in 2,3 DPG levels 
contribute to a rightward shift of the O2 dissociation curve, which may translate to improved oxygen 
delivery34. Additionally, hypoxically stored blood may decrease the required number of RBC 
transfusions. A study by D’alessandro et al demonstrates that hypoxic storage yields more viable RBCs, 
as indicated by greater PTR24 values15. The increase in viable RBCs demonstrated in the 
aforementioned study supports a potential 15% reduction in blood requirements for both patient 
groups15. Because transfusion-related iron overload is directly associated with the number of RBC units 
transfused in patient who require chronic transfusions, this reduction in blood requirements may lead to 
lower transfusion density and decreased risk of iron overload5,9 in patients with hematological 
malignancies. Furthermore, hypoxic blood may improve resuscitation time and/or volume in burn 
patients, as demonstrated in a pre-clinical animal model of resuscitation from hemorrhagic shock35. 
 

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Objective(s): 
 
Primary Objective  – for both patients groups 
Hypoxic RBCs safety and tolerance assessment up to 24 hours following the transfusion initiation and 
overall up to 7 days (+/- 1 day) after the transfusion episode (single transfusion course). 
 
Secondary Objectives :  
 
A. For both patients groups 
  
1. Assessment of pre and post transfusion hemoglobin levels 
2. Assessment of hemoglobin level before the following transfusion, if applicable  
3. Assessment of AEs occurence:  
i. 
Up to 7 days (+/- 1 day) post transfusion, in comparison with historical 
control (including but not limited to infection, deep vein thrombosis, acute 
respiratory distress syndrome, transfusion-related acute lung injury, 
transfusion associated circulatory overload, anaphylactic shock, acute 
haemolytic transfusion reaction). 
 
ii. 
Up to the subsequent transfusion episode or up to 28 days (+/- 1 day) after 
the initial transfusion, whichever comes first. 
 
iii. 
From enrollment, up to their subsequent transfusion or 28 days (+/- 1 day) 
post transfusion, whichever comes first, through the assessment of patient’s 
diary 
 
 
4. Assessment of the vital signs during and up to 15 minutes after the transfusion 
 
B. For burn patients group only: 
 
1. Assessment of arterial blood gases: 
i. pre-operative 
ii. intra-operative 
iii. post operative 
 
 
Outcome(s): 
Primary Outcome  – for both patients groups 
 
Number of participants who experienced an adverse event (all types/grades) within a time frame up to 
24 hours following the transfusion and overall up to 7 days (+/- 1 day) after the transfusion.  
 
 
The type and the grade of each adverse event will be categorized according to: 
• 
Association for the Advancement of Blood and Biotherapies (AABB) technical manual, 20th 
edition (2020) 
• 
Biomedical Excellence for Safer Transfusion (BEST) Collaborative  review - Lancet 2016; 388: 
2825–36 
• 
Local AEs database (for reference) 
• 
ISO 14155-2020 definitions 
 
 Secondary Outcomes : - for both patients groups 
1. Evolution of the hemoglobin level before and after the transfusion. 
2. Calculation oft he Hemoglobin increment after transfusion corrected for patient blood 
volume and hemoglobin dose 
3. Comparison of  the Hemoglobin level before the index transfusion to that prior to the 

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undergo the informed consent process: 
 
A. Hematological malignancies patients group:  
1. Male or female patients at least 18 years of age 
2. Patients expected to require > 2 units of red blood cells in a single transfusion event 
3. Patients who have the capacity to consent to particpate and are willing to comply with 
the study procedures. 
4. Patients identified by a Transfusion hemoglobin trigger of  less than 9 g/dL 
5. Patients with a documented diagnosis of leukemia, myelomatosis or MDS requiring 
chronic transfusions 
 
B. Burn patients group:  
1. Male or female patients at least 18 years of age  
2. Patients who have the capacity to consent by themselves to participate to the clinical 
investigation  
3. Smaller burn patients, hospitalized with a Total Body Surface Area (TBSA%) burn ≥ 
10% and  ≤ 50% 
4. Patients expected to require > 2 unit of red blood cells in a single transfusion event 
 
EXCLUSION CRITERIA  
Patients meeting any of the exclusion criteria may not participate in the clinical investigation. 
A. Both patients groups 
 
1. Patients with any positive antibody screening test 
2. Patients for whom consent has not been obtained 
3. Patients with a known hemolytic anemia (congenital or acquired) 
4. Patients < 18 years old 
5. Patients with a known or suspected pregnancy 
6. Patients with a history of major transfusion reactions 
7. Patients whom the Investigator deems clinical trial participation is not in their best 
interest.  
 
B. Burn patients specific exclusion criteria : 
1. Patients who do not  have the capacity to consent by themselves to participate to the 
clinical investigation  
2. Patients hospitalized with a Total body surface area (TBSA%) burn more than 50% 
3. Patients with combined trauma in need of blood transfusions for treatment other than 
the burn excision 
 
Measurements 
and 
procedures: 
The following information will be collected, from enrollment throughout end of study visit, when 
applicable:  
 
1. Informed consent  
2. Documentaton of Inclusion/Exclusion criteria 
3. Demographics 
4. Medical history 
5. Physical examination 
6. Pregnancy test (if applicable) 
7. Height  
8. Weight 
9. RBC unit weight and volume 
10. Age (days) of the RBC unit at the time of the transfusion 
11. Hemoglobin measurement - maximum 4 hours before the transfusion and, at 
minimum, 15 minutes before transfusion 
12. Hemoglobin measurement 15 to 60 minutes after transfusion 
13. Hemoglobin measurement, at a minimum, 15 minutes before the following transfusion  

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14. Blood pressure every 15 minutes during the transfusion and until 15 minutes after the 
end of the transfusion  
15. Heart rate every 15 minutes during the transfusion and until 15 minutes after the end 
of the transfusion 
16. Body temperature every 15 minutes during the transfusion and until 15 minutes after 
the end of the transfusion 
17. Respiratory rate every 15 minutes during the transfusion and until 15 minutes after the 
end of the transfusion 
18. Oxygen saturation every 15 minutes and until 15 minutes after the end of the 
transfusion 
19. Patient diary for collection of concomittant medications and changes in health status 
from enrollment up to their subsequent transfusion or 28 days (+/- 1 day) post-
transfusion, whichever comes first 
20. Routine laboratory analyses, including blood gases when applicable. 
 
 
 
Intervention:  
For both clinical investigation patient populations:  
• 
Transfusion of two units of Red Blood Cells, Leukocytes reduced, O2/CO2 reduced (single 
transfusion course) manufactured with the Hemanext ONE System, combined with PRN 
standard Red Blood Cells, as applicable. 
• 
Patient’s diary 
 
Control 
intervention (if 
applicable): 
Not applicable   
 
Number of 
subjects with 
rationale: 
 
10 acute burn patients and 10 patients with haematological malignancies, who require transfusion of 
red cells concentrates and who fulfil all eligibility criteria will be enrolled in this clinical investigation at 
Haukeland University Hospital.   
 
A total of twenty patients will be sufficient to assess preliminary safety of O2/CO2 reduced RBCs, as the 
standard rate of transfusion related adverse events is usually low and these expected events are well 
known. If any unexpected adverse events (any type or grade) should occur, they will be identified as 
such. 
 
 
Duration of the 
investigation: 
This clinical investigation is estimated to last for a period of approximately 6 months. 
 
Investigation 
schedule: 
Anticipated Start Date:  May –  June 2022 
Anticipated End Date: November – December 2022 
 
Investigator(s): 
Principal Investigator: Stian Almeland, MD 
Address:  
Haukeland University Hospital, Jonas Lies vei 65,  
5021 Bergen 
Norway 
Phone: 
 
E-mail: 
 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Sub-Investigator: Haakon Reikvam, MD  
Address:  
Haukeland University Hospital, Jonas Lies vei 65,  
5021 Bergen 
Norway 
E-mail: 
 
 
 
Investigational 
Site(s): 
This clinical investigation will only involve one single clinical site: 
 
Haukeland University Hospital 
Jonas Lies vei 65,  
5021 Bergen 
Norway 
 
 
Blood Bank 
 
Oslo: 
 
 
Address: 
Department of Immunology and Transfusion Medicine 
Section for Blood processing 
Oslo University Hospital Ullevål 
Norway 
 
 
 
Bergen:  
 
 
Address: 
Haukeland University Hospital 
Department of Immunology and Transfusion Medicine 
Jonas Lies vei 65, 
5021 Bergen 
Norway 
E-mail:  
 
 
 
Data 
Monitoring 
Committee 
(DMC) 
Membership: 
 
 
Professor of intensive care medicine 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Haukeland University Hospital, Bergen 
 
 
Chief of Burns, Plastic and reconstructive surgeon 
Haukeland University Hospital, Bergen 
 
 
Blood Bank - Haukeland University Hospital, Bergen 
 
 
Blood Bank - Haukeland University Hospital, Bergen 
 
 
Blood Bank - Haukeland University Hospital, Bergen 
 
Statistical 
considerations: 
This clinical investigation is not statistically powered – only descriptive statistical methods will be applied  
 
Compliance 
statement: 
This investigation will be conducted in compliance with the CIP, the current version of the Declaration 
of Helsinki, ISO14155-2020, ICH-GCP (as far as applicable) as well as all national legal and regulatory 
requirements.  
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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2. ABBREVIATIONS  
 
AE 
Adverse Event  
ADE 
Adverse Device Effect 
ASADE 
Anticipated Serious Adverse Device Effect 
ASR 
Annual Safety Report 
CA 
Competent Authority  
CEC 
Competent Ethics Committee 
CIP 
Clinical investigation plan 
CRF 
Case Report Form (pCRF paper CRF; eCRF electronic CRF) 
DD 
Device Deficiency 
DMC / DSMC 
Data Monitoring Committee, Data Safety Monitoring Committee 
IB 
Investigator’s Brochure 
HSB 
Hemanext Storage Bag 
ICF 
Informed Consent Form 
ICH-GCP 
International Council for Harmonisation – guidelines of Good Clinical Practice 
IFU 
Instruction For Use 
ISF 
Investigator Site File 
ISO 
International Organisation for Standardisation 
MD 
Medical Device  
MDR 
Medical Device Regulation (EU) 2017/745 of 5 April 2017 
ORB 
Oxygen Reduction Bag 
PI 
Principal Investigator 
SADE 
Serious Adverse Device Effect 
SAE 
Serious Adverse Event 
SDV 
Source Data Verification  
SOP 
Standard Operating Procedure 
USADE 
Unanticipated Serious Adverse Device Effect 
 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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SUMMARY OF THE REVISION HISTORY IN CASE OF AMENDMENTS 
Version Nr, 
Version Date 
Chapter 
Description of change 
Reason for the change 
A00 
11 January 
2022 
All 
Initial release 
Initial release 
AA 28 April 
2022 
All 
Based on REK letter dated March 
07th, 2022 
Amendment 1 
 
3. INVESTIGATION ADMINISTRATIVE STRUCTURE  
3.1 
Sponsor 
 
Chief Medical Officer 
Laurel Omert, MD, FACS, 
Telephone
 
E-mail: 
 
 
Clinical Project Manager 
Kimberly Dorsch 
Telephone: 
 
Email: 
 
 
Address: 
Hemanext Inc. 
99 Hayden Avenue 
Building B, Suite 620 
Lexington, MA 02421 
USA 
 
Responsibilities:  
Hemanext Inc, as the Sponsor of this Clinical Investigation will have the responsibility – as per ISO 
14155:2020 - and liability for the initiation or implementation and management of this clinical 
investigation, and arranging its financial setup. 
 
3.2 
Principal Investigator(s)  
 
Principal Investigator: Dr Stian Almeland 
Address:  
Haukeland University Hospital, Jonas Lies vei 65,  
5021 Bergen 
Norway 
Phone: 
 
E-mail: 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Sub-Investigator: Dr Haakon Reikvam  
Address:  
Haukeland University Hospital, Jonas Lies vei 65,  
5021 Bergen 
Norway 
E-mail: 
 
 
3.3 
Statistician ("Biostatistician")  
 
 
Transplantation Research Center 
Brigham and Women’s Hospital and Children’s Hospital 
Harvard Medical School, 
Boston, MA  
USA 
 
3.4 
Laboratory 
Not applicable. Only standard of care laboratory assessments will be performed.   
 
3.5 
Monitoring institution 
Monitoring will be performed by the Sponsor or designee. 
 
3.6 
Data Monitoring Committee 
 
 A Data Monitoring Committee (DMC) will be formed to ensure the safety of the patients participating in 
the investigation.  
This group will provide review and adjudication of all adverse events collected during the clinical 
investigation. The DMC members will be selected in collaboration between the principal investigator and 
Hemanext before initiation of the trial.  
All DMC members are free from any direct involvement with the trial. Any competing interests, both real 
and potential, must be declared.  
A report outlining the review of adverse events will be included in the Final Study Report.  
A DMC charter will be established to document the following but not limited to: 
a) the responsibilities and scope of activities of the DMC; 
b) the frequency, format, and documentation of meetings; 
c) arrangements for handling emergency situations. 
 
3.7 
Any other relevant Committee, Person, Organisation, Institution  
 
The hypoxic RBCs will be processed and provided to the clinical site from either of the following 
locations: 
Department of Immunology and Transfusion 
Medicine 
Oslo University Hospital Ullevål 
Oslo, Norway 
Department of Immunology and Transfusion 
Medicine 
Haukeland University Hospital 
Bergen, Norway 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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4. ETHICAL AND REGULATORY ASPECTS  
The final positive decision of the CEC on the conduct of the investigation will be made and given in 
writing to the Sponsor before the investigation can begin. Additional requirements set by the CEC must 
be implemented. 
 
4.1 
Registration of the investigation 
 
Registration status: 
Hemanext Inc. will comply with the Research Council of Norway on requirements and guidelines for 
registration and disclosure of medical and health-related studies involving human participants, through: 
www.ISRCTN.org 
 
4.2 
Competent Ethics Committee (CEC)  
The Sponsor or designee will submit the investigation to the CEC and obtain ethical committee approval 
before the start of the investigation. The PI ensures that approval from the CEC is obtained and filed in 
the Investigator site file before the investigation starts.  
 
4.2.1 
Reporting duties to the Competent Ethics Committee 
CIP Amendments will be reported according to the applicable requirements and timeframes. 
The regular or premature end of the investigation as well as the interruption of the investigation must be 
reported to the CEC within 15 days (within 24 hours if it is due to security reasons). The reasons for a 
premature end or an interruption must be explained.  
A final report will be submitted within one year after the regular end of the investigation and within 3 
months after a premature end of the investigation. 
 
4.3 
Competent Authorities (CA)  
Notification of this clinical investigation and of the use of hypoxic blood will be made prior the start of 
this clinical investigation. 
4.3.1 
Reporting duties to the competent authorities 
Notification of this clinical investigation and of the use of hypoxic blood will be made prior the start of 
this clinical investigation. 
 
4.4 
Ethical Conduct of the Investigation  
The investigation will be carried out according to the CIP and with principles enunciated in the current 
version of the Declaration of Helsinki, the European Regulation on medical devices 2017/745 (MDR), 
the Norms ISO14155 and ISO14971, the ICH-guidelines of Good Clinical Practice (GCP) as applicable, 
and local regulatory authority’s requirements. The CEC, if applicable, will receive the Annual Safety 
Report (ASR) and interim reports and be notified about investigation stop/end in agreement with local 
requirements.  
 
4.5 
Declaration of interests  
Investigators and sub-investigators will provide the sponsor with sufficient, accurate financial 
information as requested to allow the sponsor to submit complete and accurate financial certification 
or disclosure statements to the appropriate regulatory authorities.  Investigators are responsible for 
providing information on financial interests during the study and for 1 year after completion of the 
study. 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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4.6 
Patient Information and Informed Consent 
All potential subjects are given a Patient Information Sheet and an Informed Consent Form describing 
the investigation and providing sufficient information for the subject to make an informed decision about 
his/her participation in the investigation. The Patient Information Sheet must be provided prior to the 
Screening Visit. The PI must explain to each subject the nature of the investigation, its purpose, the 
procedures involved, the expected duration, the potential risks and benefits and any discomfort it may 
entail. Each subject must be informed that the participation in the investigation is voluntary and that 
he/she may withdraw from the investigation at any time and that withdrawal of consent will not affect 
his/her subsequent medical assistance and treatment. The subject should be informed that he/she can 
ask any question, and consult with family members, friends, their treating physicians or other experts 
before deciding about their participation in the investigation. Enough time must begiven to the subjects 
prior to providing informed consent.  
The formal consent of a subject, using the approved consent form, is obtained before the subject is 
submitted to any investigation procedure. The subject should read, understand, and voluntarily agree 
before signing and dating the informed consent form.  The consent form is signed and dated by the subject 
and the PI (or her/his designee). The subject must be given a copy of the signed document.  The original 
signed and dated consent form is retained as part of the investigation records.  
The subjects must be informed that authorised individuals other than their treating physician may 
examine his/her medical records. 
 
4.7 
Subject privacy and confidentiality  
The Sponsor and the PI affirm and uphold the principle of the subjects’ right to privacy and that they 
shall comply with applicable privacy laws. Especially, anonymity of the subjects shall be guaranteed 
when presenting the data at scientific meetings or publishing them in scientific journals.  
Individual subject medical information obtained because of this investigation is considered confidential 
and disclosure to third parties is prohibited. 
For data verification purposes, authorised representatives of the Sponsor or the CEC may require direct 
access to parts of the medical records relevant to the investigation, including subjects’ medical history. 
 
To protect the rights and freedoms of participants about the processing of personal data, participants 
will be assigned a single, participant specific numerical code.  Any participant records or data sets that 
are transferred to the sponsor will contain the numerical code only; participant names will not be 
transferred. All other identifiable data transferred to the sponsor will be identified by this single, 
participant specific code.  The study site will maintain a confidential list of participants who participated 
in the study, linking each participant’s numerical code to his or her actual identity and medical record 
identification. In case of data transfer, the sponsor will protect the confidentiality of participants’ 
personal data consistent with the clinical study agreement and applicable privacy laws. 
 
4.8 
Early termination of the investigation 
The Sponsor, DMC, or CEC may terminate the investigation prematurely according to certain 
circumstances, for example: 
• 
ethical concerns, 
• 
insufficient subject recruitment, 
• 
when the safety of the subjects is doubtful or at risk, respectively, 
• 
alterations in accepted clinical practice that make the continuation of the investigation unwise,  
• 
early evidence of benefit or harm of the experimental intervention. 
 
4.9 
Clinical investigation plan amendments 
Substantial amendments are only implemented after approval by the CEC. The use of waivers from the 
CIP is prohibited (Annex XV, Chapter 2, Art. 3.10 MDR). 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Under emergency circumstances, deviations from the CIP to protect the rights, safety and well-being of 
the subjects may proceed without prior approval by the Sponsor and the CEC. Such deviations shall be 
documented and reported to the Sponsor and the CEC within 2 days. 
All non-substantial amendments are communicated to the CEC together with the Annual Safety Report 
(ASR). The ASR shall include any deviations from the CIP that may have affected the rights, safety or 
well-being of the subject or the scientific integrity of the investigation (ISO14155:2020). 
 
All protocol amendments will be submitted to the CEC when any revision is made to the original 
protocol or subsequent version of the protocol that significantly affects the safety of subjects and/or 
any change is made that significantly affects the scope of investigation or scientific quality of the study.  
 
The amended protocol will be reviewed, approved and documented by the same method in which the 
original protocol was reviewed and approved. Once the amended protocol and all associated 
documents are reviewed and approved, the protocol number and effective date will be changed on the 
title page.  
 
The final approved amended protocol will be distributed to participating investigator(s) at each site. 
 
4.10 Deviation from the Clinical Investigation Plan 
The use of waivers from the CIP is prohibited (Annex XV, Chapter 2, Art. 3.10 MDR). 
Investigators are not allowed to deviate from the clinical investigation plan. Under emergency 
circumstances, deviations from the CIP to protect the rights, safety and well-being of human subjects 
may proceed without prior approval of the Sponsor and the CEC. Such deviations shall be 
documented and reported to the Sponsor and the CEC as soon as possible, but in no event later than 
5 working days after the emergency occurred.  
 
CIP deviations are to be reported in the deviation/violation log provided with the investigator site file and 
the CRF. Serious CIP deviations are to be reported in writing with the corresponding log to the Sponsor 
and the CEC within 24 hours. Investigators will be retrained by the Sponsor or its representative. 
Investigators not complying with the protocol might be disqualified from participation in the clinical trial 
at the discretion of the Sponsor. 
 
5. BACKGROUND AND RATIONALE  
5.1 
Background and Rationale for the clinical investigation 
5.1.1 
Background and Rationale for Hypoxic Blood: 
Red blood cells (RBCs) comprise the only tissue in the body that provides oxygen transport.  Anemia 
results from either the acquired loss of RBCs due to disease, injury, or surgery or the inability of the 
patient to produce their own RBCs due inherited disorders.  While the overall clinical settings of 
anemia can differ greatly between acute or chronic causes, the primary therapeutic goal of RBC 
transfusion is to increase the oxygen-carrying capacity and prevent tissue hypoxia1. Red blood cells 
can be stored for up to 42 days before transfusion but, surprisingly, there are few quality parameters 
that predict the efficacy and safety of a transfusion2.  
5.1.2 
Consequences of Current RBC Storage Process 
A review of the literature2,3,4,5 identifies substantial evidence suggesting decreased quality of RBCs 
from substances that accumulate during RBC storage. These include nitric oxide (NO) scavengers 
and inhibitors of NO generation that affect vascular tone, procoagulant microparticles, free and non-
transferrin bound iron, and bioactive lipids. Additionally, RBCs show progressively diminished 
deformability over time, characteristics necessary to adequately perfuse the microcirculation4. 
D’Alessandro and colleagues observed significant changes in the plasma levels of hemolytic markers, 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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oxidized purines, plasticizers, and oxidized lipids in recipients of blood stored for 42 days, compared 
with 5 days3. 
Yoshida and colleagues performed an exhaustive review of the oxidative and metabolic changes that 
occur to RBCs during storage, summarizing elements of the RBC storage lesion from causes to 
associated clinical sequelae. The review identifies root causes, effects on RBCs, physiological 
consequences reported from in vitro experiments or animal models, and finally, potential clinical 
sequelae of RBC transfusion, each element being identified with its pertinent reference(s)2. 
5.1.3 
Hypoxic storage and HEMANEXT product 
Hypoxic storage, where the oxygen content of RBC units is reduced to low levels (e.g., less than 20% 
oxy-hemoglobin (SO2)6 prior to refrigeration and maintained throughout storage, was proposed as an 
alternative to antioxidant-based additive solutions to reduce oxidative stress during hypothermic RBC 
storage5,7-11. The rationale for implementing hypoxic storage is to reduce oxygen, the essential 
substrate for hemoglobin oxidation that generates the multitude of untoward physiologic and 
biochemical events described previously.  
Hypoxic storage was also shown to counteract some metabolic impairments without requiring novel 
additive ingrdients5,7 independent of the reduction in oxidative stress. During pre-storage processing to 
reduce oxygen content in the RBC, carbon dioxide is also reduced. Carbon dioxide depletion 
increases cytosolic pH that was lowered from its physiological level by exposure to acidic 
anticoagulant and additive solutions. The resulting more neutral pH in the early phase of storage 
results in sustained flux through the glycolytic pathway and elevated 2,3-DPG levels, which are highly 
sensitive to pH and normally depleted early during hypothermic storage7,11,12. Additionally, 
deoxyhemoglobin causes metabolic modulation to release glycolytic enzymes, such as 
phosphofructokinase  and glyceraldehyde dehydrogenase, sequestered at the band 3 binding domain, 
thereby enhancing overall glycolytic flux during hypoxic storage13,14. 
Metabolomics work by D’Alessandro et al has shown that hypoxic storage diminishes damaging 
mediators of oxidative stress and increases energy biomarkers without requiring novel additive 
ingredients15. The same group investigated the metabolomics of hypoxic storage in a two-arm cross-
sectional clinical study. Hypoxic storage was found to ameliorate the metabolic phenotypes of stored 
RBCs (lower markers of oxidant stress such as lipids and purines and higher levels of high-energy 
phosphate compounds) and improve post-transfusion recovery (PTR). The study also correlated 
metabolic parameters to hemolysis and PTR, highlighting the role of purine and lipid oxidation (e.g., 
hypoxanthine and 9-HODE), so that these can be used as markers in fresh and stored units to predict 
end of storage blood quality15. 
 
5.1.4 
Background on Blood Use in Burn Patients: 
Major burn trauma has been found to trigger an inflammatory cascade of events which leads to 
oxidative stress and tissue damage. These injurious responses, which include complement activation, 
excessive histamine release, decreased blood pressure, and release of reactive oxygen species, may 
ultimately lead to the development of multiple organ dysfunction16. Cardiac dysfunction and acute 
kidney injury, for example, have been well described as sequelae of burn injury and contribute to 
multi-organ failure17,18,19. 
Early excision and grafting of large burn wounds is currently performed to attenuate the post-burn 
hypermetabolic state and remove the biological nidus for infection, thereby reducing the risk of burn 
wound sepsis. These operative procedures can result in considerable bleeding. In one report, 
intraoperative blood loss was estimated at approximately 9.2% of blood volume for every 1% of total 
body surface area (TBSA) burn excised20. Burn surgeons also report progressive development of 
microvascular bleeding and evidence of coagulopathy requiring plasma and platelets as well as RBC 
transfusions21. Coagulopathic bleeding post-op can continue for several days, requiring additional 
transfusions. 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Pasch and colleagues compared estimated blood loss for TBSA burns > and < 20% to provide insight 
for transfusion ratios for the coagulopathy of burns and also to illustrate the importance of blood loss 
as a benchmark in these patients to improve care22.  
Table 1 
 
 
Table 2 below illustrates number of units of RBCs transfused per TBSA burn as published by different 
authors. 
Table 2: Blood Loss During Excision and Grafting 
Author 
%TBSA 
Units RBCs transfused 
Posluszny and 
Gamelli8 
>10% TBSA 
Average 19.7 units (range of 0 to 201 units) 
Vasko et al9 
 
>10% TBSA 
Average of 8.94 units 
>30% TBSA 
Mean 17 units transfused 
Palmieri et al 10 
 
≥20% TBSA. 
Average 13.7 ± 1.1 units 
≥50% TBSA 
>30 units of blood transfused per patient 
Yogore et al11 
 
<10% TBSA  
4 ± 0.6 
11 to 19% TBSA 
8 ± 1 units 
20 to 40% TBSA 
12 ± 3 units 
>40% TBSA 
20 ± 4 units 
 
5.1.5 
Background on Blood Use in Hematological Malignancies: 
Hematologic malignancies such as myelodysplastic syndromes (MDS), multiple myeloma, and leukemia 
are increasing in prevalence in Norway as the population average age continues to increase. 
Collectively, hematologic malignancies refers to various disorders of the bone marrow which result in 
abnormal blood cell production. Leukemia consists of several malignant disorders that present with 
increased numbers of leucocytes in the blood and bone marrow23. Multiple myeloma is characterized 
by uncontrolled growth of plasma cells in the bone marrow. MDS consist of bone marrow diseases 
associated with ineffective hematopoiesis, resulting in morphologically abnormal blood cells24. In all 
cases, anemia can result from the overcrowding or ineffective production of normal blood cells, leading 
to inadequate oxygen delivery. 
Patients with hematologic malignancies often require regular blood transfusions at some time during 
their treatment to alleviate the symptoms of severe anemia, which can include fatigue, weakness, and 
exacerbation of other underlying medical conditions. While treatment varies with disease severity, 
transfusions are given at approximately weekly intervals in intensive treatment25. In relying on stored 
donor RBCs to address anemia, the goal is not to rapidly rebuild a normal red cell mass, but to minimize 
morbidity and mortality with the lowest possible exposure26. No consensus exists on the appropriate 
time to commence transfusions or on the correct transfusion threshold for optimal care. Some studies 
show reduced survival with increased transfusion density27. Iron overload, a consequence of transfusion 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Summary:  In burn patients, hypoxic RBC transfusions can be provided early in resuscitation if there is 
concomitant trauma, during excision and grafting, and during the post-op period of coagulopathic 
“oozing”. Hypoxic blood presents the potential to alleviate oxidative stress, improve oxygen delivery, 
and improve resuscitation efficiency with fewer RBC transfusions. The clinical ramifications that may be 
observed include decreased organ dysfunction in these critically ill patients as well as reduction in 
thromboembolic events secondary to the improved deformability of the cells. In patients with 
hematological malignancies, hypoxic RBC transfusions can be provided in the management of anemia 
and resulting symptoms. Hypoxic blood presents the potential to alleviate oxidative stress and improve 
oxygen delivery with fewer RBC transfusions. The clinical ramifications that may be observed include 
decreased density of transfusions and decreased incidence of iron overload, which could improve 
outcomes for patients who receive chronic transfusions. 
 
5.2 
Identification and description of the Investigational Medical Device 
Hemanext ONE is a blood container set used to process and store CPD/PAGGSM Red Blood Cells, 
Leukocytes reduced, and O2/CO2 Reduced. The Hemanext ONE system is an assembly of two 
disposables: the Oxygen Reduction Bag (ORB) and the Hemanext Storage Bag (HSB).  
See Figure 3 below for the concept configuration. The larger bag is the ORB and the smaller bag is 
the HSB.  
Figure 3: Hemanext ONE Processing and Storage System 
 
 
The ORB consists of the following elements: (a) an inner bag; (b) outer barrier bag; (c) spacer and 
(d) quilt of 9 sorbent sachets.  The inner bag holds the PAGGSM LR RBC and is housed in an outer 
barrier bag.  The outer barrier bag ensures that there is no ingress of oxygen into the ORB during 
or post O2 /CO2 reduction.  The inner bag is physically separated from the outer barrier bag by 
polyester fabric elements surrounding the outer surface of the inner bag.  The materials of 
construction of the inner bag ensure that oxygen released from the LR RBC is transferred to the 
surrounding space. The sorbent quilt captures and stores oxygen released from the LR RBC.  The 
spacer (perforated patterned polyethylene stabilizer) is placed in the space between the inner bag 
and the sorbent quilt to ensure that all of the surface area of the inner bag is clear and able to 
transfer oxygen. The oxygen indicator is designed to change color if exposed to oxygen. The ORB 
has tubing to allow sterile docking of the LR RBC bag (see Figure 4 below).  The ORB is connected 
to the HSB bag via integral tubing.  The connections facilitate the transfer of the oxygen reduced 
LR RBC blood.   

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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Figure 5: HSB Assembly View 
 
 
 
 
5.2.1 
Description of Hemanext Process:  
A LR RBC unit bag is connected using a sterile docking device to the ORB. The sorbent quilt 
between the inner bag and the barrier bag creates an O2 /CO2 depleted environment. LR RBC are 
then transferred by gravity to the ORB inner bag.  
Once the full unit volume is in the ORB inner bag; the Hemanext system is transferred to a tray on 
an agitator (the platelet agitator should operate at 72 cycles/minute) at room temperature (22+2°C). 
Its contents are evenly distributed, creating a large thin layer of LR RBC contacting the inner surface 
of the ORB inner bag. The agitator moves in a side to side motion causing the LR RBC to travel 
within the inner bag in a wave-like motion at the same rate as the shaker, maintaining a constant 
agitation of RBC and additive solution.  
The red blood cells in direct contact with the inner bag surface release oxygen through the material 
and into the O2/CO2 starved environment between the inner bag and barrier bag of the ORB. 
Maintaining this agitation of red blood cells and residual plasma/additive solution ensures that 
oxygen on the RBCs that are furthest from the walls of the bag exchange oxygen molecules with 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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5.6 
Explanation for choice of comparator 
 
Not applicable – no comparator will be used during this clinical investigation 
 
5.7 
Risk evaluation (Risk-to-Benefits rationale)  
5.7.1 
Potential Benefits 
Hemanext has found that red cell degradation is O2 dose dependent, and that if the O2 concentration is 
reduced at the time of storage, it is possible to minimize degradation and optimize red cell quality37. 
Hemanext designed a product and process to manage a broad range of % of SO2 values in transfused 
RBC for oxygen-management. This product moves the entire broad % SO2 distribution starting with a 
mean of 52% ranging from 10-90% SO2 to mean of less than 20%. This is achieved on Day 0 and the 
product is designed to maintain this figure for 42 days of storage37. Metabolomics results show improved 
energy and anti-oxidant status of RBC and reduced stress, and production of those agents associated 
with adverse events11. Hemanext technology may potentially improve outcomes for those patients 
dependent on RBC transfusions to survive by improving the following: 
 
• 
Reducing transfusion volume 
• 
Increasing transfusion interval 
• 
Increasing hemoglobin increment 
• 
Improving oxygen delivery 
• 
Reducing iron overload 
• 
Reducing sequelae of hemorrhagic shock and transfusion 
• 
Improved quality of life 
In summary, based on pre-clinical data, hypoxic red cells have the potential to improve patient outcomes 
and attenuate transfusion -sequelae. These improvements may be especially effective in patient 
populations who receive high volumes of RBCs (chronically or acutely). These patients comprise 50% 
of total RBC usage while only making up 20% of patients transfused8,12.  
 
5.8 
Anticipated risks 
5.8.1.1 
Risks associated with the use of Hemanext ONE system 
The current risk management report RMR-001 for the HEMANEXT ONE product concludes that all risks 
have been reduced as far as possible and no additional residual risks were identified requiring additional 
clinical evaluation. The documentation demonstrates that the potential benefits outweigh all residual 
risks. 
As part of red blood cell processing and storage there are known risks which may include, but are not 
limited to risks related to biocompatibility, leak leading to biohazard exposure and or loss of sterility, 
exposure to endotoxin, hemolysis of red blood cells, and exposure of blood to non-biocompatible 
materials.  
Based on the analysis of the benefit / risk assessment the documentation in RMR-001 supports the 
following conclusion:  
The Hemanext ONE System was demonstrated to be substantially equivalent to commercial red cell 
products and to meet all requirements for red blood cell manufacture. Through product verification, in 
vitro, in vivo, and animal studies, the system has shown improved metrics for blood quality.  
The potential clinical benefit(s) will need to be demonstrated in patients. The risks also remain equivalent 
to currently commercially available RBC. 
 

PRO-CLIN-0012 Rev. AB – 16-MAR-2023 
 
 
 
 
 
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5.8.1.2 
Risks associated with RBCs transfusions (Non-exhaustive): 
Transfusion of hypoxic RBCs has equivalent risk as transfusion of conventional RBCs, such as38: 
  
• 
Transfusion-associated graft versus host disease 
• 
Transfusion-related acute lung injury (TRALI) 
• 
Post transfusion purpura 
• 
Transfusion-associated circulatory overload (TACO) 
• 
Transfusion-transmitted infection (TTI) 
• 
Allergic reaction 
• 
Transfusion-associated dyspnea (TAD) 
• 
Febrile non-hemolytic transfusion reaction (FNHTR) 
• 
Hypotensive transfusion reaction 
• 
Delayed hemolytic transfusion reaction (DHTR) 
• 
Delayed serologic transfusion reaction (DSTR) 
• 
Acute hemolytic transfusion reaction (AHTR) 
• 
Major cardiac event (MCE) 
• 
Haematoma (bruise) 
• 
Arterial puncture 
• 
Delayed bleeding (re-bleeding) 
• 
Nerve injury/irritation 
• 
Localized infection/inflammation 
• 
Deep venous thrombosis (DVT) 
• 
Arteriovenous fistula 
• 
Compartment syndrome 
• 
Brachial artery pseudoaneurysm 
• 
Vasovagal reactions 
 
 
5.9 
Justification of the choice of the investigation population  
See sections 5.1.4, 5.1.5, and 5.1.6. 
 

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6. CLINICAL INVESTIGATION OBJECTIVES 
 
6.1 
Overall Objective 
The overall objective of this study is to collect preliminary safety data on the transfusion of hypoxic RBCs, 
manufactured with Hemanext ONE device, in patients with burns and patients with hematological 
malignancies. 
 
6.2 
Primary Objective 
 
Primary Objective  – for both patients groups 
Hypoxic RBCs safety and tolerance assessment up to 24 hours following the transfusion initiation and 
overall up to 7 days (+/- 1 day) after the transfusion episode (single transfusion course). 
 
6.3 
Secondary Objectives 
 
Secondary Objectives :  
 
A. For both patients groups 
  
1. Assessment of pre and post transfusion hemoglobin levels 
2. Assessment of hemoglobin level before the following transfusion, if applicable  
3. Assessment of AEs occurence:  
i. 
Up to 7 days (+/- 1 day) post transfusion, in comparison with historical 
control (including but not limited to infection, deep vein thrombosis, acute 
respiratory distress syndrome, transfusion-related acute lung injury, 
transfusion associated circulatory overload, anaphylactic shock, acute 
haemolytic transfusion reaction). 
 
ii. 
Up to the following tranfusion episode or up to 28 days (+/- 1 day)  after the 
initial transfusion, whichever comes first. 
 
iii. 
From enrollment, up to their subsequent transfusion or 28 days (+/- 1 day) 
posttransfusion, whichever comes first, through the assessment of patient’s 
diary 
 
 
4. Assessment of the vital signs during and up to 15 minutes after the transfusion 
 
B. For burn patients group only: 
 
1. Assessment of arterial blood gases: 
i. 
pre-operative 
ii. 
intra-operative 
iii. 
post operative 
 
6.4 
Safety Objectives 
All safety objectives are addressed in the primary and secondary objectives. 
 
 
 

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7. CLINICAL INVESTIGATION OUTCOMES  
7.1 
Primary Outcome 
 
Primary Outcome  – for both patients groups 
 
Number of participants who experienced an adverse event (all types/grades) within a time frame up to 
24 hours following the transfusion and overall up to 7 days (+/- 1 day) after the transfusion.  
 
The type and the grade of each adverse event will be categorized according to: 
• 
Association for the Advancement of Blood and Biotherapies (AABB) technical manual, 20th 
edition (2020) 
• 
Biomedical Excellence for Safer Transfusion (BEST) Collaborative  review - Lancet 2016; 388: 
2825–36 
• 
Local AEs database (for reference) 
• 
ISO 14155-2020 definitions 
 
7.2 
Secondary Outcomes 
 
Secondary Outcomes : - for both patients groups 
1. Evolution of the hemoglobin level before and after the transfusion. 
2. Hemoglobin increment from transfusion corrected for patient blood volume and hemoglobin 
dose 
3. Hemoglobin level before the following transfusion 
4. Evaluate the frequency of all AEs, including transfusion related AEs up to 7 days (+/- 1) post-
transfusion compared to historical data of patient registries (ex. The National Burn Registry) 
5. Evaluate AEs up to 28 days after the initial transfusion, whichever comes first. 
6. Evaluation the frequency of all AEs, from enrollment, up to 7 days (+/- 1 day) post transfusion, 
through the assessment of patient’s diary, when applicable. 
7. Evaluation of patient’s vital signs over the course of the transfusion and up to 15 minutes post-
transfusion 
 
7.3 
Other Outcomes of Interest 
Not applicable. 
 
7.4 
Safety Outcomes 
All safety outcomes are addressed in the primary and secondary outcomes. 
 
8. CLINICAL INVESTIGATION DESIGN  
8.1 
General clinical investigation design and justification of design  
This clinical investigation will be the first use of hypoxic blood manufactured with the Hemanext ONE 
device and is designed as a safety trial to detect any safety issues related to the hypoxic RBCs.. 
Subjects will receive two units of hypoxic RBCs. 
 
8.2 
Methods for minimising bias  
Not applicable. This clinical investigation does not include a comparator. 
 

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8.2.1 
Randomisation  
Not applicable. This clinical investigation does not include a comparator. 
8.2.2 
Blinding procedures  
Not applicable. This clinical investigation does not include a comparator. 
 
8.2.3 
Other methods for minimising bias  
Not applicable. This clinical investigation does not include a comparator. 
 
8.3 
Unblinding Procedures (Code break)  
Not applicable. This clinical investigation does not include a comparator. 
 
9. CLINICAL INVESTIGATION POPULATION  
9.1 
Eligibility criteria  
9.1.1 
Inclusion Criteria 
 
A. Hematological malignancies patients group:  
1. Patients > 18 years of age 
2.  Patients expected to require > 2 unit of red blood cells in a single transfusion event 
3. Patients who have consented to participate 
4. Transfusion trigger less than 9 g/dL 
5. Diagnosis of leukemia, myelomatosis or MDS requiring chronic transfusions 
 
B. Burn patients group:  
1. Patients > 18 years of age  
2. Patients who have the capacity to consent by themselves to participate to the clinical 
investigation  
3. Smaller burn patients, hospitalized with a Total Body Surface Area (TBSA%) burn ≥ 
10% less and  ≤ than 50% 
4. Patients expected to require > 2 unit of red blood cells in a single transfusion event 
 
9.1.2 
Exclusion Criteria – both patients groups 
 
1. Patients with positive antibody screen 
2. Patients who do not have the capacity to consent by themselves to participate to the 
clinical investigation  
3. Patients with a known hemolytic anemia (congenital or acquired) 
4. Patients for whom consent has not been obtained 
5. Patients < 18 years old 
6. Known or suspected pregnancy 
7. Patients with a history of major transfusion reactions 
 
Burn patients specific: 
1. Total body surface area (TBSA%) burn more than 50% 
2. Patients with combined trauma in need of blood transfusions other than the burn 
 

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9.2 
Recruitment and screening  
9.2.1 
Hematological Malignancies Group 
Participants will be recruited by the investigators from among the patients with hematological 
malignancies at the site who receive regular transfusions and who meet the inclusion/exclusion criteria. 
The purpose and procedures of the study will be explained to prospective participants and their written 
consent obtained prior to their taking part in the study. It will be emphasised to each prospective subject 
that, should they wish to withdraw from the study at any stage, they are free to do so without prejudicing 
their clinical care. Potential participants will be given the opportunity to ask any questions they may have 
on the design of the clinical investigation and what their participation will entail. Potential participant will 
be given sufficient time to decide whether they wish to participate in this clinical investigation. Once a 
patent has decided that they wish to participate in this clinical investigation they will be asked to sign an 
informed consent form. 
 
9.2.2 
Burn Group 
Participants will be recruited by the investigators from among the burn patients at the site who will require 
transfusions and who meet the inclusion/exclusion criteria. The purpose and procedures of the study 
will be explained to prospective participants and their written consent obtained prior to their taking part 
in the study. It will be emphasised to each prospective subject that, should they wish to withdraw from 
the study at any stage, they are free to do so without prejudicing their clinical care.  
Potential participants will be given the opportunity to ask any questions they may have on the design of 
the clinical investigation and what their participation will entail. Potential participants will be given the 
opportunity to ask any questions they may have on the design of the clinical investigation and what their 
participation will entail.  Once a patent has decided that they wish to participate in this clinical 
investigation they will be asked to sign an informed consent form. 
 
9.3 
Assignment to investigation groups  
Not applicable. There is only one group in this clinical investigation. 
 
9.4 
Criteria for withdrawal / discontinuation of subjects  
A participant may be discontinued from the study for the following reasons: 
1. Serious adverse events 
2. Withdrawal of consent 
3. Investigator decision 
4. Death, any cause 
 
Any participant that enrolled in the study can withdraw from the study, effectively withdrawing consent, 
at any time, for any reason, without prejudice or consequence. Participants are to be informed that 
they are free to leave the study at any time for any reason without prejudice or consequence in the 
informed consent document. If a participant withdraws from the study the data collected up through 
the time of withdrawal (including testing results) will be included within the study database. Withdrawn 
participants will be replaced in order to meet the sample size requirements of the study. 
 
 
 
 
10. CLINICAL INVESTIGATION INTERVENTION  
10.1 Identity of the medical device under investigation  
All patients will receive one transfusion episode of at least two units of hypoxic RBCs that were 
manufactured with Hemanext ONE system.  
See section 5.2 for details on the Hemanext ONE system. 

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See sections 11.1.1 and 11.1.2 for a detailed list of all information being collected. 
 
10.1.1 Experimental Intervention (medical device) 
Units of hypoxic RBCs will be manufactured at Oslo’s University Blood Bank or Haukeland University 
Hospital’s Blood Bank using Hemanext ONE system. The hypoxic RBCs manufactured in Oslo will be 
shipped to the Blood Bank at Haukeland University Hospital where they will be stored at 1-6°C for up to 
42 days. Participants who would normally receive a transfusion of units of conventional RBCs will 
instead receive a transfusion of 2 units of hypoxic RBCs and any additional conventional RBCs as 
needed. All transfusions will be performed according to the site’s SOPs. 
 
10.1.2 Control Intervention (standard/routine/comparator)  
Not applicable. 
 
10.1.3 Labelling and Supply 
The Hemanext ONE blood processing system (medical device) will be supplied by Hemanext to the 
Blood Banks after the study contract is executed. All devices will be supplied to the site before  start of 
manufacturing. 
The medical device will be a commercial product labelled with CE Mark.  The hypoxic blood 
manufactured by Oslo’s or Haukeland’s Blood Bank will be labelled (on Hemanext Storage Bag / HSB) 
per local blood bank, Norwegian Directorate of Health and regulatory requirements, i.e. “Exclusively for 
Clinical Investigations”.   
See Appendix section for reference 
 
Hemanext ONE blood processing  system may not be used in any capacity until proof of CEC approval 
for the study have been received by the Sponsor and PI.  
 
10.1.4 Storage Conditions  
The Hemanext ONE kits must be stored at room temperature in a secure location. Any exposure of the 
kits to excessive heat or freezing must be avoided. 
 
The hypoxic RBCs must be stored in cold storage at 1-6°C for up to 42 days. 
 
10.2 Discontinuation or modifications of the intervention 
Hemanext may suspend or prematurely terminate either a clinical investigation in an individual 
investigation site or the entire clinical investigation for significant and documented reasons. A Principal 
Investigator, DMC, CEC, or regulatory authority may suspend or prematurely terminate participation in 
a clinical investigation at the investigation sites for which they are responsible. If suspicion of an 
unacceptable risk to subjects arises during the clinical investigation, or when so instructed by the DMC, 
CEC, or regulatory authorities, Hemanext shall suspend the clinical investigation while the risk is 
assessed. Hemanext shall terminate the clinical investigation if an unacceptable risk is confirmed.  
 
Hemanext shall consider terminating or suspending the participation of a particular investigation site or 
investigator in the clinical investigation if monitoring or auditing identifies serious or repeated deviations 
on the part of an investigator. If suspension or premature termination occurs, the terminating party shall 
justify its decision in writing and promptly inform the other parties with whom they are in direct 
communication. The Principal Investigator and Hemanext shall keep each other informed of any 
communication received from either the DMC, CEC, or the regulatory authority. 
 
If, for any reason, Hemanext suspends or prematurely terminates the investigation at an individual 
investigation site, Hemanext shall inform the responsible regulatory authority as appropriate and 

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ensure that the CEC is notified, either by the Principal Investigator or by Hemanext. If the suspension 
or premature termination was in the interest of safety, Hemanext shall inform all other Principal 
Investigators.  
 
If suspension or premature termination occurs,  
• 
Hemanext shall remain responsible for providing resources to fulfill the obligations from the 
protocol and existing agreements for following up the subjects enrolled in the clinical 
investigation, and  
• 
the Principal Investigator or authorized designee shall promptly inform the enrolled subjects at 
his/her investigation site, if appropriate.  
 
When Hemanext concludes an analysis of the reason(s) for the suspension, implements the 
necessary corrective actions and decides to lift the temporary suspension, Hemanext shall inform the 
Principal Investigators, the DMC, the CECs, and, where appropriate, the regulatory authority of the 
rationale and provide them with the relevant data supporting this decision. 
  
Concurrence shall be obtained from the CECs and, where appropriate, regulatory authorities before the 
clinical investigation resumes. If subjects have been informed of the suspension, the Principal 
Investigator or authorized designee shall inform them of the reasons for resumption. 
 
10.3 Compliance with clinical investigation intervention  
A participant being lost to follow-up will be the main risk of noncompliance in this study. If a participant 
is lost to follow-up, the investigator will take all necessary measures to re-establish contact with the 
participant to ascertain the reasons for discontinuation and the participant’s state of health. The case 
report form (CRF) will be completed up to the participant’s last visit. 
 
10.4 Data Collection and Follow-up for withdrawn subjects  
If a participant withdraws from the study, the investigator will take all necessary measures to establish 
contact with the participant to ascertain the participant’s state of health. The case report form (CRF) will 
be completed up to the participant’s last visit. 
 
10.5 Clinical investigation specific preventive measures 
There are no specific recommendations for preventative measures. All standard/routine measures will 
apply. 
 
10.6 Concomitant Interventions (treatments)  
There are no specific recommendations for concomitant interventions. All standard/routine interventions 
will apply. 
 
10.7 Medical Device Accountability  
The Blood Banks will be required to document 100% accountability of the Hemanext One device until 
all product provided has been used to process hypoxic RBCs, destroyed and/or returned to Hemanext.  
A “Study Product Receipt and Disposition Log” will be supplied by Hemanext in the Clinical Trial Binder 
at the Blood Banks for documenting each receipt and disposition (i.e., used, discarded or returned) of 
the medical device. 
 
The hypoxic RBC product will be tracked via the Oslo and Bergen Blood Bank standard practice. The 
clinical site will record the hypoxic RBC product information in the Subject’s source documents. 
 

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10.8 Return, Analysis or Destruction of the Medical Device  
Unused Hemanext ONE medical device will be returned to the sponsor at the end of the trial or destroyed 
according to local procedures, unless other documented instructions are provided in advance to the 
clinical site.  
 
In case of device deficiencies, including malfunction, usability issues, or inadequacy in the information 
supplied by the manufacturer including labelling, the devices will be returned to the sponsor for analysis.  
11. CLINICAL INVESTIGATION ASSESSMENTS  
The following information will be collected, from enrollment throughout end of study visit, when 
applicable:  
 
1. Patient consent  
2. Inclusion/Exclusion criteria 
3. Demographics 
4. Medical history 
5. Physical examination 
6. Pregnancy test (if applicable) 
7. Height  
8. Weight 
9. RBC unit weight and volume 
10. Age of the RCC unit at the time of the transfusion 
11. Hemoglobin measurement - maximum 4 hours before the transfusion and at minimum 
15 minutes before transfusion 
12. Hemoglobin measurement 15 to 60 minutes after transfusion  
13. Blood pressure every 15 minutes during the transfusion and until 15 minutes after the 
end of the transfusion  
14. Heart rate every 15 minutes during the transfusion and until 15 minutes after the end 
of the transfusion 
15. Body temperature every 15 minutes during the transfusion and until 15 minutes after 
the end of the transfusion 
16. Respiratory rate every 15 minutes during the transfusion and until 15 minutes after the 
end of the transfusion 
17. Oxygen saturation every 15 minutes and until 15 minutes after the end of the 
transfusion 
18. Patient diary for collection of concomittant medications and changes in health status 
from enrollment up to their following transfusion or 28 days (+/- 1 day) post-
transfusion whichever comes first 
19. Routine laboratory analyses, including blood gases when applicable. 
  
 
 
 
 
 
 
 
 
 
 
 
 

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11.2 Assessments of outcomes  
 Patients will be monitored for adverse events throughout the entirety of their participation in the clinical 
investigation. Adverse events will be elicited from the patients, the medical record, and an adverse event 
diary, if applicable.  Patients enrolled will undergo standard care for their disease/ illness as prescribed 
by the Investigators.  All procedures will be performed in compliance with the site’s established policies 
and work instructions.  No additional assessments will be performed.   
11.2.1 Assessment of primary outcome  
Patients will be monitored for adverse events throughout the entirety of their participation in the clinical 
investigation. Investigators will monitor patients directly for adverse events during their transfusion visit. 
In addition, patients will be contacted by phone 24 hours and 7 days (+/- 1) after their transfusion visit 
to record any adverse events they have experienced since their transfusion visit. All adverse events will 
be recorded in the CRF and they will be assessed according to the instructions in section 12 of the CIP.  
 
11.2.2 Assessment of secondary outcomes 
For all secondary outcomes related to hemoglobin and vital sign measurements the sites will follow their 
standard practice. 
For all secondary outcomes related to AE occurrence, investigators will monitor patients directly for 
adverse events during their transfusion visit and then patients will be contacted by phone 24 hours and 
7 days (+/- 1) after their transfusion visit to record any adverse events they have experienced since their 
transfusion visit. The patient’s chart will also be checked for any AE occurrence after their following 
transfusion visit or 28 days after their initial transfusion, whichever comes first. All adverse events will 
be recorded in the CRF and they will be assessed according to the instructions in section 12.  
 
11.2.3 Assessment of other outcomes of interest 
Not applicable. 
 
11.2.4 Assessment of safety outcomes 
See section 11.2.1 and 11.2.2 for information on assessment of safety outcomes. 
 
11.2.4.1 Adverse events  
See section 11.2.1 and 11.2.2 for information on assessment of adverse events. 
 
11.2.4.2 Laboratory parameters 
Local site staff will follow their standard procedures.  
 
11.2.4.3 Vital signs 
See section 11.2.2 for information on measurement of vital signs. 
 
11.2.5 Assessments in subjects who prematurely stop the clinical investigation 
All data from patients who withdraw/drop out of the study will be recorded up to and including their last 
visit before they withdraw their participation in the study. 
 
11.2.6 Follow-up of the subjects after the regular termination of the clinical investigation 
All follow up of participants will be completed before the termination of the clinical investigation. 

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11.3 Procedures at each visit 
11.3.1 Patient Information Contact 
A Patient Information Sheet will be provided to prospective study participants by the PI or his designees.  
No information will be collected from prospective study participants during this contact. 
 
11.3.2 Screening Visit 
The following data will be collected during this visit: 
• 
Inclusion/exclusion criteria 
• 
Patient/legal representative informed consent 
• 
Demographics 
• 
Medical history 
• 
Physical examination 
• 
Pregnancy test 
• 
Height 
• 
Weight 
• 
Blood pressure 
• 
Heart rate 
• 
Body temperature 
• 
Respiratory rate 
• 
Oxygen saturation 
• 
Adverse event occurrence 
• 
Concomitant medications 
• 
Patient Diary 
 
11.3.3 Transfusion Visit 
The patients will receive a transfusion during this visit. The following data will be collected: 
• 
RBC unit weight 
• 
Patient hemoglobin pre- and post-transfusion 
• 
Blood pressure during the transfusion and for 15 minutes post-transfusion 
• 
Heart rate during the transfusion and for 15 minutes post-transfusion  
• 
Body temperature during the transfusion and for 15 minutes post-transfusion 
• 
Respiratory rate during the transfusion and for 15 minutes post-transfusion 
• 
Oxygen saturation during the transfusion and for 15 minutes post-transfusion 
• 
Infection occurrence 
• 
Adverse event occurrence  
• 
Concomitant medications 
• 
Device deficiencies 
• 
Patient Diary 
 
11.3.4 First Follow-Up Visit 
This visit will occur 24 hours post-transfusion and will be performed over the phone. The following data 
will be collected: 
• 
Infection occurrence 
• 
Adverse event occurrence 
• 
Concomitant medications 
• 
Device deficiencies 
• 
Patient Diary 

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11.3.5 Second Follow-Up Visit 
This visit will occur 7 days (+/- 1) post-transfusion and will be performed over the phone. The following 
data will be collected: 
• 
Infection occurrence 
• 
Adverse event occurrence 
• 
Concomitant medications 
• 
Device deficiencies  
• 
Patient Diary 
 
11.3.6 Final Follow-Up 
This visit will occur at the patient’s subsequent transfusion visit or 28 days (+/- 1 day) after their 
transfusion, whichever comes first. All data from this visit will be collected from the patient’s chart. The 
following data will be collected: 
• 
Adverse event occurrence 
• 
Physical examination 
• 
Concomitant medications 
• 
Pre-transfusion hemoglobin (if applicable) 
 
 

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12. SAFETY  
 
12.1 Definition and Assessment of (Serious) Adverse Events and other safety related events 
 
Adverse Event (AE) (Art. 2 Abs 57 MDR) 
Any untoward medical occurrence, unintended disease or injury or any untoward clinical signs (including 
an abnormal laboratory finding) in subjects, users or other persons whether or not related to the medical 
device. 
 
Serious Adverse Event (SAE) (Art. 2 Abs 58 MDR) 
Any adverse event that led to any of the following: 
(a) death, 
(b) serious deterioration in the health of the subject that resulted in any of the following: 
(i)  life-threatening illness or injury, 
(ii) permanent impairment of a body structure or a body function, 
(iii)  hospitalisation or prolongation of patient hospitalisation, 
(iv)  medical or surgical intervention to prevent life-threatening illness or injury or permanent 
impairment to a body structure or a body function, 
(v)  chronic disease, 
(c) foetal distress, foetal death or a congenital physical or mental impairment or birth defect. 
Note: planned hospitalization for pre-existing condition, or a procedure required by the CIP, without a 
serious deterioration of the health status of the subject, is not considered an SAE 
 
Device deficiency (Art. 2 Abs 59 MDR) 
Inadequacy of a medical device related to its identity, quality, durability, reliability, safety or performance, 
of an investigational device, including malfunction, user errors and inadequate information supplied by 
the manufacturer.  Device deficiency data will be collected by the blood banks and the clinic staff.   
The blood bank teams will use the Hemanext ONE System to manufacture hypoxic RBCs. The Oslo 
blood bank will ship the hypoxic RBCs to the Bergen blood bank team for storage.  Bergen blood bank 
team will confirm blood bag integrity prior to storage, when ordered for a subject and after each 
transfusion. 
 
Malfunction (ISO14155) 
Failure of an investigational device to perform in accordance with its intended purpose when used in 
accordance with the instructions for use or the CIP. 
 
Device deficiency with Serious Adverse Device Effect (SADE) potential (Art. 80 Abs 1 letter c MDR; 
ISO14155) 
Any device deficiency that might have led to a serious adverse event if appropriate action had not been 
taken, intervention had not occurred, or circumstances had been less fortunate. 
 
Adverse Device Effect (ADE) (ISO14155) 
Adverse event possibly, probably or causally related to the use of an investigational device or 
procedures.  
 
Serious Adverse Device Effect (SADE) (ISO14155) 
Adverse device effect (ADE) that has resulted in any of the consequences characteristic of a serious 
adverse event. 
 
 

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Unanticipated Serious Adverse Device Effect (USADE) (ISO14155) 
Serious adverse device effect (SADE) which by its nature, incidence, severity or outcome has not been 
identified in the current version of the risk analysis report. 
 
Causal Relationship of SAE (MDCG 2020-10/1) 
A causal relationship towards the medical device or the procedure of the investigation should be rated 
by the PI and the Sponsor as follows: 
• 
Not related: The relationship to the device or procedures can be excluded. 
• 
Possible: The relationship with the use of the investigational device is weak but cannot be ruled 
out completely. Alternative causes are also possible. 
• 
Probable: The relationship with the use of the investigational device seems relevant and/or the 
event cannot reasonably be explained by another cause. 
• 
Causal relationship: The serious event is associated with the investigational device or with 
procedures beyond reasonable doubt. 
 
Investigational Medical Device:  
A device that is assessed in a clinical investigation.  
Note: An investigational device can be a non-CE marked device or a CE marked device. The definition 
is understood to cover also the devices investigated in post-market surveillance investigations.  
 
Case Report Form (CRF): A printed, optical, or electronic document designed to record all of the 
protocol required information to be reported to the sponsor on each trial subject.  
 
Serious Health Threat:  
signal from any adverse event or device deficiency that indicates an imminent risk of death or a 
serious deterioration in the health in subjects, users or other persons, and that requires prompt 
remedial action for other subjects, users or other persons  
Note: This would include events that are of significant and unexpected nature such that they become 
alarming as a potential serious health hazard or possibility of multiple deaths occurring at short 
intervals.  
 
Unanticipated / Unexpected Serious Adverse Device Effect (USADE)  
- According to ISO 14155:2020: Serious adverse device effect which by its nature, incidence, severity 
or outcome has not been identified in the current risk assessment. 
 
12.2 Documentation and reporting in Medical Device clinical investigations 
 
Device deficiencies and all adverse events (AE) including all serious adverse events (SAE) are 
collected, fully investigated and documented in the source document and appropriate CRF during the 
entire investigation period, i.e. from patient’s informed consent until the last CIP-specific procedure, 
including a safety follow-up period. 
• Documentation of AEs (including SAEs) by the PI includes diagnosis or symptoms, start and stop 
dates of event, event treatment, event resolution, assessment of seriousness and causal 
relationship to MD and/or investigation procedure (ISO14155). 
• Documentation of DDs by the PI includes description of event, start date, investigational device 
information, action taken with regard to the investigational device, and whether the DD led to an 
AE. The Sponsor shall review all DDs and determine and document in writing whether they could 
have led to a SAE (DD with SADE potential) (ISO14155). 
 
The Sponsor provides the CEC with the documentation at their request 
12.3 Foreseeable adverse events and anticipated adverse device effects 
There were no adverse device effects associated with the Hemanext RBC Processing System reported 
in the earlier in vivo pivotal human trial (cf. Investigator Brochure). 

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Well established blood transfusion complications (acute and delayed transfusion related effects) known 
to occur in medical practice using a conventional method of blood processing and storage will be   
considered as expected events. These effects are listed below38: 
 
• Transfusion-associated graft versus host disease 
• Transfusion-related acute lung injury (TRALI) 
• Post transfusion purpura 
• Transfusion-associated circulatory overload (TACO) 
• Transfusion-transmitted infection (TTI) 
• Allergic reaction 
• Transfusion-associated dyspnea (TAD) 
• Febrile non-hemolytic transfusion reaction (FNHTR) 
• Hypotensive transfusion reaction 
• Delayed hemolytic transfusion reaction (DHTR) 
• Delayed serologic transfusion reaction (DSTR) 
• Acute hemolytic transfusion reaction (AHTR) 
• Major cardiac event (MCE) 
• Haematoma (bruise) 
• Arterial puncture 
• Delayed bleeding (re-bleeding) 
• Nerve injury/irritation 
• Localized infection/inflammation 
• Deep venous thrombosis (DVT) 
• Arteriovenous fistula 
• Compartment syndrome 
• Brachial artery pseudo-aneurysm  
 
12.4 Reporting of (Serious) Adverse Events, device deficiencies, and other safety related 
events 
 
12.4.1 Reporting to the Sponsor: 
The following events are to be reported to the Sponsor by the PI (or authorized designee) within 24 
hours after becoming aware of the event: 
- 
All SAEs  
- 
Health hazards that require measures 
- 
Device deficiencies 
The Sponsor will evaluate SAEs with regard to causality and seriousness. Device deficiencies are also 
assessed regarding their potential to lead to an SAE (DD with SADE potential). 
 
 
12.4.2 Reporting to the Competent Ethics Committee: 
The following events are to be reported to the CEC promptly: 
a. any serious adverse event which has a causal relation with the MD, comparator or 
procedure/test method or where a causal relation appears to be possible (SADE); 
b. any device deficiency which, in the absence of appropriate measures or intervention or in less 
favourable circumstances, could have led to serious adverse events (DD with SADE potential); 
c. any new information relating to an event already notified under points (a) and (b). 

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In order to ensure prompt notification, the Sponsor may initially submit an incomplete notification. 
If safety and health hazards that require measures must be taken immediately during the conduct of the 
investigation, the Sponsor notifies the CEC within 2 days of these measures and the circumstances 
which made them necessary. 
 
Periodic safety reporting: 
An Annual Safety Report (ASR) is submitted by the Sponsor to the CEC, yearly. The ASR contains a 
list of all SADEs and DDs and a report on their degree of seriousness, causal relationship with the MD 
and procedure and on subjects’ safety. 
 
12.5 Follow-up of (Serious) Adverse Events 
 
For serious adverse device event, and serious procedure related event the immediate report will be 
followed by detailed, written follow-up reports (using the SAE notification form found in the study site 
binder). Both the immediate and follow-up reports will identify subjects by unique code numbers 
assigned to the latter.  
 
12.6 Documentation and reporting in Medical Device clinical investigations 
Device deficiencies (DD) and all adverse events (AE) including all serious adverse events (SAE) are 
collected, fully investigated and documented in the source document and appropriate case report form 
(CRF) during the entire investigation period, i.e. from patient’s informed consent until the last CIP-
specific procedure, including a safety follow-up period. 
• Documentation of AEs (including SAEs) by the PI includes diagnosis or symptoms, start and stop 
dates of event, event treatment, event resolution, assessment of seriousness and causal 
relationship to MD and/or investigation procedure (ISO14155). 
• Documentation of DDs by the PI includes description of event, start date, investigational device 
information, action taken with regard to the investigational device, and whether the DD led to an 
AE. The Sponsor shall review all DDs and determine and document in writing whether they could 
have led to a SAE (DD with SADE potential) (ISO14155). 
There were no adverse device effects associated with the Hemanext RBC Processing System 
reported in the earlier in vivo pivotal human trial (see Investigator Brochure).  
 
Well established blood transfusion complications (acute and delayed transfusion related effects) known 
to occur in medical practice using a conventional method of blood processing and storage will be 
considered as expected events. These effects are listed below38: 
 
• 
Transfusion-associated graft versus host disease 
• 
Transfusion-related acute lung injury (TRALI) 
• 
Post transfusion purpura 
• 
Transfusion-associated circulatory overload (TACO) 
• 
Transfusion-transmitted infection (TTI) 
• 
Allergic reaction 
• 
Transfusion-associated dyspnea (TAD) 
• 
Febrile non-hemolytic transfusion reaction (FNHTR) 
• 
Hypotensive transfusion reaction 
• 
Delayed hemolytic transfusion reaction (DHTR) 
• 
Delayed serologic transfusion reaction (DSTR) 
• 
Acute hemolytic transfusion reaction (AHTR) 
• 
Major cardiac event (MCE) 
• 
Haematoma (bruise) 
• 
Arterial puncture 
• 
Delayed bleeding (re-bleeding) 
• 
Nerve injury/irritation 
• 
Localized infection/inflammation 

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• 
Deep venous thrombosis (DVT) 
• 
Arteriovenous fistula 
• 
Compartment syndrome 
• 
Brachial artery pseudo-aneurysm 
• 
Vasovagal reactions  
 
 
12.7 Reporting of Safety related events 
Reporting to the Sponsor: 
All SAEs, device deficiencies and health hazards that require measures are reported to the Sponsor by 
the PI (or authorized designee) within 24 hours after becoming aware of the event. Device deficiencies 
are assessed regarding their potential to lead to an SAE. DD are assessed regarding their potential to 
lead to an SAE. 
 
12.7.1 Reporting to the Competent Ethics Committee: 
The Sponsor reports to the CEC promptly any serious adverse event which has a causal relation with 
the MD, comparator or procedure/test method or where a causal relation appears to be possible. 
In order to ensure prompt notification, the Sponsor may initially submit an incomplete notification.  
If safety and health hazards that require measures must be taken immediately during the conduct of the 
investigation, the Sponsor notifies the CEC within 2 days of these measures and the circumstances 
which made them necessary. 
 
12.7.2 Periodic safety reporting: 
An Annual Safety Report (ASR) is submitted by the Sponsor to the CEC, yearly. The ASR contains a 
list of all SADEs and DDs and a report on their degree of seriousness, causal relationship with the MD 
and procedure and on subjects’ safety. 
 
 
12.8 Procedure 
12.8.1 Initiation of Adverse Event Reporting 
The Clinical Project Manager or designee will train the investigator and staff regarding the recording and 
reporting of adverse events. The sponsor shall implement and maintain a system to ensure that the 
reporting of the reportable events will be provided by the investigator to the sponsor immediately, but 
not later than 3 calendar days after investigation site study personnel’s awareness of the event. 
 
Adverse events (AEs) are recorded on the CRF by the sites. The following information should be 
recorded:  
• 
The description of the event with enough detail to determine if the event meets the definition 
of a serious adverse event 
• 
The date of the onset of the adverse event 
• 
Relevant medical history leading up to the event 
• 
A description of the action to treat the adverse event  
• 
The site will also classify the event using the scales below 
The investigator shall determine the AE Severity using the following scoring system which will be 
included on the CRF.  The severity score is necessary is used to determine if the event meets the 
definition of a serious adverse event. The rating may also be used to determine if an adverse device 
event is unanticipated. This may be the case if the severity is greater than previously identified. 
 

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Rating 
Description  
Definition  
5 
Catastrophic  
Patient Death  
4 
Critical  
Permanent impairment or life threatening 
injury   
3 
Serious  
Injury requiring medical intervention to 
prevent permanent impairment  
2 
Minor  
Temporary injury that does not require 
medical intervention 
1 
Negligible  
Inconvenience or temporary discomfort 
 
 
The relationship between the use of the medical device (including the medical – surgical procedure) and 
the occurrence of each adverse event shall be assessed and categorized. 
 
During causality assessment activity, clinical judgement shall be used and the relevant documents, such 
as the Investigator’s Brochure, the Clinical Investigation Plan or the Risk Analysis Report shall be 
consulted, as all the foreseeable serious adverse events and the potential risks are listed and assessed 
there. The presence of confounding factors, such as concomitant medication/treatment, the natural 
history of the underlying disease, other concurrent illness or risk factors shall also be considered. 
 
The above considerations apply also to the serious adverse events occurring in the comparison group. 
 
For the purpose of harmonizing reports, each SAE will be classified according to four different levels of 
causality: 
1. Not related 
2. Possible 
3. Probable 
4. Causal relationship 
 
The sponsor and the investigators will use the following definitions to assess the relationship of the 
serious adverse event to the investigational device, the comparator or the investigation procedure. 
 
1. Not related: Relationship to the device, comparator or procedures can be excluded when: 
- 
- the event has no temporal relationship with the use of the investigational device, or the 
procedures related to application of the investigational device; 
- 
- the serious adverse event does not follow a known response pattern to the medical device (if 
the response pattern is previously known) and is biologically implausible; 
- 
- the discontinuation of medical device application or the reduction of the level of 
activation/exposure (when clinically feasible) and reintroduction of its use (or increase of the 
level of activation/exposure), do not impact on the serious adverse event; 
- 
- the event involves a body-site or an organ that cannot be affected by the device or 
procedure; 
- 
- the serious adverse event can be attributed to another cause (e.g. an underlying or 
concurrent illness/ clinical condition, an effect of another device, drug, treatment or other risk 
factors); 
- 
- the event does not depend on a false result given by the investigational device used for 
diagnosis, when applicable; 
- 
In order to establish the non-relatedness, not all the criteria listed above might be met at the 
same time, depending on the type of device/procedures and the serious adverse event. 
 
2. Possible: The relationship with the use of the investigational device or comparator, or the 
relationship with procedures, is weak but cannot be ruled out completely. Alternative causes are 

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also possible (e.g. an underlying or concurrent illness/ clinical condition or/and an effect of another 
device, drug or treatment). Cases where relatedness cannot be assessed, or no information has 
been obtained should also be classified as possible. 
 
3. Probable: The relationship with the use of the investigational device or comparator, or the 
relationship with procedures, seems relevant and/or the event cannot be reasonably explained by 
another cause. 
 
4. Causal relationship: the serious adverse event is associated with the investigational device, 
comparator or with procedures beyond reasonable doubt when: 
- 
the event is a known side effect of the product category the device belongs to or of similar 
devices and procedures; 
- 
the event has a temporal relationship with investigational device use/application or 
procedures; 
- 
the event involves a body-site or organ that 
o 
the investigational device or procedures are applied to; 
o 
the investigational device or procedures have an effect on; 
- 
the serious adverse event follows a known response pattern to the medical device (if the 
response pattern is previously known); 
- 
the discontinuation of medical device application (or reduction of the level of 
activation/exposure) and reintroduction of its use (or increase of the level of 
activation/exposure), impact on the serious adverse event (when clinically feasible); 
- 
other possible causes (e.g. an underlying or concurrent illness/ clinical condition or/and an 
effect of another device, drug or treatment) have been adequately ruled out; 
- 
harm to the subject is due to error in use; 
- 
the event depends on a false result given by the investigational device used for diagnosis, 
when applicable; 
 
In order to establish the relatedness, not all the criteria listed above might be met at the same time, 
depending on the type of device/procedures and the serious adverse event. 
 
The sponsor and the investigators will distinguish between the serious adverse events related to the 
investigational device and those related to the procedures (any procedure specific to the clinical 
investigation). An adverse event can be related both to procedures and the investigational device. 
Complications caused by concomitant treatments not imposed by the clinical investigation plan are 
considered not related. Similarly, several routine diagnostic or patient management procedures are 
applied to patients regardless of the clinical investigation plan. If routine procedures are not imposed by 
the clinical investigation plan, complications caused by them are also considered not related. 
 
In some particular cases the event may not be adequately assessed because information is insufficient 
or contradictory and/or the data cannot be verified or supplemented. The sponsor and the Investigators 
will make the maximum effort to define and categorize the event and avoid these situations. Where an 
investigator assessment is not available and/or the sponsor remains uncertain about classifying the 
serious adverse event, the sponsor should not exclude the relatedness; the event should be classified 
as “possible” and the reporting not be delayed. 
 
Particular attention shall be given to the causality evaluation of unanticipated serious adverse events. 
The occurrence of unanticipated events related could suggest that the clinical investigation places 
subjects at increased risk of harm than was to be expected beforehand. The site should determine and 
record if the AE was anticipated or unanticipated.   If the risks for entering the study described in the 
informed consent / clinical brochure / clinical protocol or risk analysis reflect the nature, severity or 
degree of incidence of the AE, then it was anticipated.  If not, then the AE is unanticipated.  
 
12.8.2 Reporting Requirements 
 
The following events are considered reportable events: 

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a) any serious adverse event that has a causal relationship with the investigational device, the 
comparator or the investigation procedure or where such causal relationship is reasonably 
possible; 
b) any device deficiency that might have led to a serious adverse event if appropriate action had 
not been taken, intervention had not occurred, or circumstances had been less fortunate; 
c) any new findings in relation to any event referred to in points a) and b). 
 
All causality assessments should be made using the guidance in the section above. Only causality level 
1 (i.e. “not related”) is excluded from reporting. If either the sponsor or the investigator has assigned a 
higher causality level than "not related", the event should be reported. 
 
12.8.3 Reporting Timelines 
The sponsor must report to the CEC and as applicable, to all NCAs where the clinical investigation is 
authorized to start: 
• 
For all reportable events as described in section 6.4 which indicate an imminent risk of death, 
serious injury, or serious illness and that requires prompt remedial action for other 
patients/subjects, users or other persons or a new finding to it: Immediately, but not later than 2 
calendar days after awareness by sponsor of a new reportable event or of new information 
in relation with an already reported event.  
o 
This includes events that are of significant and unexpected nature such that they become 
alarming as a potential public health hazard. It also includes the possibility of multiple 
deaths occurring at short intervals. These concerns may be identified by either the NCA or 
the manufacturer. 
• 
Any other reportable events as described in section 6.4 or a new finding/update to it: 
Immediately, but not later than 7 calendar days following the date of awareness by the 
sponsor of the new reportable event or of new information in relation with an already 
reported event. 
 
 
12.9 List of foreseeable adverse events and anticipated adverse device effects, together with 
their likely incidence, mitigation or treatment  
 
There are currently no adverse device effects associated with the Hemanext RBC Processing System 
reported in the earlier in vivo and pivotal human trial as reported in the Investigator Brochure.  
Hemanext RBC Processing System related potential Adverse Device Effects (including potential 
Serious Adverse Effects) may include, but are not limited to risks related to:  
• 
Lack of sickle cell trait testing of RBC unit before processing and storage in the Hemanext RBC 
Processing System leading to high hemolysis and sickled red blood cells being transfused  
o 
A false negative on sickle trait testing of RBC unit before processing and storage in the 
Hemanext RBC Processing System leading to high hemolysis and sickled red blood cells 
being transfused  
• 
Undetected leak in the HSB inner bag leading to a loss of sterility of the RBC unit. The product 
labeling is for fluid path sterility only.  
• 
Use of a non-indicated additive solution with the Hemanext RBC Processing System leading to 
negatively affected quality of RBCs  
 
The incidence is unknown. Mitigation of associated risk is achieved via continuous pharmacovigilance 
activities conducted during the study.  
 
Well established blood transfusion complications (acute and delayed transfusion related effects) known 
to occur in medical practice using a conventional method of blood processing and storage will be 
considered as expected events. These effects are listed below18: 
 
• 
Transfusion-associated graft versus host disease 

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• 
Transfusion-related acute lung injury (TRALI) 
• 
Post transfusion purpura 
• 
Transfusion-associated circulatory overload (TACO) 
• 
Transfusion-transmitted infection (TTI) 
• 
Allergic reaction 
• 
Transfusion-associated dyspnea (TAD) 
• 
Febrile non-hemolytic transfusion reaction (FNHTR) 
• 
Hypotensive transfusion reaction 
• 
Delayed hemolytic transfusion reaction (DHTR) 
• 
Delayed serologic transfusion reaction (DSTR) 
• 
Acute hemolytic transfusion reaction (AHTR) 
• 
Major cardiac event (MCE) 
• 
Haematoma (bruise) 
• 
Arterial puncture 
• 
Delayed bleeding (re-bleeding) 
• 
Nerve injury/irritation 
• 
Localized infection/inflammation 
• 
Deep venous thrombosis (DVT) 
• 
Arteriovenous fistula 
• 
Compartment syndrome 
• 
Brachial artery pseudo-aneurysm 
• 
Vasovagal reactions  
 
12.10 Assessment, notification and reporting on the use of radiation sources 
Not Applicable. 
 

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13. STATISTICAL METHODS  
13.1 Hypothesis 
Study is not powered so there is no hypothesis in this clinical investigation. 
13.2 Determination of Sample Size  
10 burn patients and 10 patients with haematological malignancies, who require transfusion of red cell 
concentrate and who fulfil all eligibility criteria will be enrolled in this clinical investigation at Haukeland 
University Hospital. 
 
A total of twenty patients will be sufficient to assess preliminary safety as the rate of transfusion related 
adverse events is usually low and if unexpected adverse events (any type or grade) should occur, this 
will be identified. 
 
13.3 Statistical criteria of termination of the investigation  
There are no statistical criteria for the termination of the investigation. 
 
13.4 Planned Analyses  
A descriptive analysis will be performed on all quantitative data: means and standard deviations will be 
calculated for quantitative data, medians and interquartile intervals for discrete data, performance and 
qualitative variables. A listing of all AEs will be provided. 
 
13.4.1 Datasets to be analysed, analysis populations 
Data from all patients will be included in the analysis. This includes data from patients who withdraw or 
drop out of the study up to and including their last visit. 
13.4.2 Primary Analysis 
This clinical investigation is not powered to support a quantitative analysis of the primary endpoint. 
 
13.4.3 Secondary Analyses 
The analysis of quantitative secondary endpoints will be limited to descriptive statistics. 
 
13.4.4 Interim analyses 
There will be no interim analysis of the study endpoints.  
 
13.4.5 Deviation(s) from the original statistical plan  
All deviations from the statistical plan will be reported and if necessary the statistical plan will be updated. 
 
13.5 Handling of missing data and drop-outs  
Investigators will attempt to contact any patients who received a transfusion during the investigation and 
who subsequently dropped out of the study in order to ensure that they did not experience any adverse 
events either in the 7 days (+/- 1) following their transfusion, or beyond 7 days (+/-1) until their following 
transfusion or 28 days post-transfusion, whichever comes first. Any patients who drop out of the 
investigation before receiving a transfusion will be replaced in order to meet the sample size 
requirements.  
 
 

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14. QUALITY ASSURANCE AND CONTROL  
All participant data relating to the study will be recorded on printed or electronic CRF unless transmitted 
to the sponsor or designee electronically (eg, laboratory data).  The investigator is responsible for 
verifying that data entries are accurate and correct by physically or electronically signing the CRF. 
The investigator must maintain accurate documentation (source data) that supports the information 
entered in the CRF. 
The investigator must ensure that the CRFs are securely stored at the study site in encrypted 
electronic and/or paper form and are password protected or secured in a locked room to prevent 
access by unauthorized third parties. 
The investigator must permit study related monitoring, audits, ethics committee review, and regulatory 
agency inspections and provide direct access to source data documents. This verification may also 
occur after study completion. It is important that the investigator(s) and their relevant personnel are 
available during the monitoring visits and possible audits or inspections and that sufficient time is 
devoted to the process. 
Monitoring details describing strategy, methods, responsibilities, and requirements, including handling 
of noncompliance issues and monitoring techniques, are provided in the monitoring plan.  
The sponsor or designee is responsible for the data management of this study, including quality 
checking of the data. 
Study monitors will perform ongoing source data verification to confirm that data entered into the CRF 
by authorized site personnel are accurate, complete, and verifiable from source documents; that the 
safety and rights of participants are being protected; and that the study is being conducted in 
accordance with the currently approved protocol and any other study agreements, ISO 14155:2020, 
ICH GCP, and all applicable regulatory requirements. 
The investigator(s) will notify the sponsor immediately of any regulatory inspection notification in 
relation to the study. Furthermore, the investigator will cooperate with the sponsor to prepare the 
investigator site for the inspection and will allow the sponsor, whenever feasible, to be present during 
the inspection.  The investigator site and investigator will promptly resolve any discrepancies that are 
identified between the study data and the participant's medical records. The investigator will promptly 
provide copies of the inspection findings to the sponsor or its agent.  Before response submission to 
the regulatory authorities, the investigator will provide the sponsor or its agents with an opportunity to 
review and comment on responses to any such findings. 
 
14.1 Data handling and record keeping / archiving  
Records and documents pertaining to the conduct of this study must be retained by the investigator for 
15 years after study completion unless local regulations or institutional policies require a longer retention 
period. No records may be destroyed during the retention period without the written approval of the 
sponsor. No records may be transferred to another location or party without written notification to the 
sponsor. The investigator must ensure that the records continue to be stored securely for as long as 
they are maintained. 
When participant data are to be deleted, the investigator will ensure that all copies of such data are 
promptly and irrevocably deleted from all systems. 
 
14.1.1 Case Report Forms  
All original source data will be contained in original laboratory printouts, site laboratory notebooks, site 
data sheets and/or study-specific source documents. Data transmittal to the Sponsor will be 
accomplished using paper Case Report Forms (CRFs). Original source data will not be entered directly 
on the CRFs. Original data is to be transcribed from source data records to the CRFs by site study staff. 
Data entered onto the CRFs will then be verified against the source data during Sponsor on-site 
monitoring visits. At the study site visits the verified and corrected CRFs must be reviewed and 

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electronically signed by the respective Principal Investigator to finalize the data. Investigative site study 
data and records for this protocol are subject to monitoring or inspection by the Sponsor, and notified 
body. 
 
14.1.2 Specification of source data and source documents  
Source documents provide evidence for the existence of the participant and substantiate the integrity 
of the data collected. Source documents are filed at the investigator site. 
Data reported on the CRF or entered in the CRF that are from source documents must be consistent 
with the source documents or the discrepancies must be explained. The investigator may need to 
request previous medical records or transfer records, depending on the study. Also, current medical 
records must be available. 
 
14.1.3 Archiving of essential clinical investigation documents 
See section 14.1. 
 
14.2 Data management  
For all subjects enrolled in the study, site staff will promptly complete and allow Hemanext and/or its 
designees' access to all case report forms (CRFs) required for the study in the form supplied by the 
Sponsor or its designee. Site staff will not be required to disclose information in CRFs which would 
permit identification of a subject enrolled in, or a candidate for, the study. CRFs will be provided to 
Hemanext or its designees in a medium specified by Hemanext or its designee. At the request of 
Hemanext or its designees, sites will promptly correct any errors and/or omissions to the CRFs for the 
study and will make available to the Sponsor and/or its designees the corrected CRFs and supporting 
records for further verification. Investigator agrees to sign/e-sign a statement in each subject’s study 
records or CRF attesting to his/her review of the CRF and verifying that the information included on 
such form is accurate and includes the treatment, care, and events surrounding such subject’s 
involvement in the study.  
 
Sites will retain organized subject, laboratory, and study device inventory records relating to the study 
for the period of time required by applicable federal law or regulation. The site will not destroy such 
records without giving the Sponsor prior written notice and the opportunity to further store such records, 
at the Sponsor’s cost and expense. Case Report Forms will be retained for a minimal period of 15 years 
after completion of the study. Clinical records kept by the Sponsor will be held in locked cabinet. 
 
14.2.1 Data Management System  
Refer to Data Management Plan. 
 
14.2.2 Data security, access and back-up  
Refer to Data Management Plan. 
 
14.2.3 Analysis and archiving 
Refer to Data Management Plan. 
14.2.4 Electronic and central data validation  
Refer to Data Management Plan. 
 

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14.3 Monitoring  
Monitoring will be conducted by the sponsor or delegate according to clinical monitoring SOPs to assure 
that the protocol is followed, any adverse events are reported, data collected are scientifically sound, 
and that the study is conducted in compliance with ICH Good Clinical Practice, ISO, and MDR 
guidelines. On-site monitoring visits will occur at study initiation, during the study performance as 
needed (minimum one interim visit) and at the study close. 
 
On-site monitoring visits will take place at each center at study initiation, during the course of the study 
(as long as there are patients in follow up at the site) at the frequency defined in the monitoring plan, 
and for the final visit at the close of the study. The initiation visit is intended to provide an opportunity 
for the monitor to review the Investigational Plan with the Investigators and to ensure that the 
Investigators:  
1. have appropriate training, facilities, patient load, time, and willingness to comply with study 
requirements;  
2. have the approval of the supervising CEC for the Investigational Plan;  
3. have all study documentation and required records on site; and  
4. assume responsibility for the investigation at their center.  
 
Visits during the study are intended to assess Investigators’ adherence to the Investigational Plan, 
maintenance of records, reports and investigational devices, and review of source documents for 
accuracy, completeness, and legibility. During these study visits, the monitor is required to assess the 
progress of the study toward meeting study objectives, and to identify any concerns that stem from 
observations of device performance and/or review of the Investigator’s patient records, study 
management documents, and informed consent documents, and to ensure accountability of all 
patients that have been treated under the study.  
 
The monitor’s final on-site visit at completion of the study is intended to assure that all the data have 
been properly completed and to have a closing meeting with the Investigators and their staff members. 
Reports of the on-site visits will be made by the monitor and should include resolution of concerns, 
completion of appropriate follow-up activities, completion of assigned tasks, and any necessary 
corrective actions. At the close of the study, the monitor will prepare a final report. 
 
14.4 Audits and Inspections  
The sponsor retains the right to audit any investigational site for the duration of this clinical investigation. 
All investigators do guarantee access to their site and source data for monitors, auditors, or inspectors 
of the competent administrative authority. 
14.5 Confidentiality, Data Protection  
All parties will comply with all applicable laws, including laws regarding the implementation of 
organizational and technical measures to ensure protection of participant data. 
Participants’ personal data will be stored at the study site in encrypted electronic and/or paper form 
and will be password protected or secured in a locked room to ensure that only authorized study staff 
have access. The study site will implement appropriate technical and organizational measures to 
ensure that the personal data can be recovered in the event of disaster. In the event of a potential 
personal data breach, the study site will be responsible for determining whether a personal data 
breach has in fact occurred and, if so, providing breach notifications as required by law. 
To protect the rights and freedoms of participants with regard to the processing of personal data, 
participants will be assigned a single, participant-specific numerical code.  Any participant records or 
data sets that are transferred to the sponsor will contain the numerical code; participant names will not 
be transferred. All other identifiable data transferred to the sponsor will be identified by this single, 
participant-specific code.  The study site will maintain a confidential list of participants who participated 
in the study, linking each participant’s numerical code to his or her actual identity and medical record 
identification. In case of data transfer, the sponsor will protect the confidentiality of participants’ 
personal data consistent with the clinical study agreement and applicable privacy laws. 
 
 

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14.6 Storage of biological material and related health data  
Not applicable.  
No biological material and/or related health data from the participants will be stored for the purpose of 
this clinical investigation. 
 
 
 

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15. PUBLICATION AND DISSEMINATION POLICY  
The results of this study may be published or presented at scientific meetings by the investigator after 
publication of the overall study results or 1 year after the end of the study (or study termination), 
whichever comes first.  
The investigator agrees to refer to the primary publication in any subsequent publications, such as 
secondary manuscripts, and submits all manuscripts or abstracts to the sponsor 30 days before 
submission.  This allows the sponsor to protect proprietary information and to provide comments and 
the investigator will, on request, remove any previously undisclosed confidential information before 
disclosure, except for any study or Hemanext intervention related information necessary for the 
appropriate scientific presentation or understanding of the study results. 
For all publications relating to the study, the investigator will comply with recognized ethical standards 
concerning publications and authorship, including those established by the International Committee of 
Medical Journal Editors. 
The sponsor will comply with the requirements for publication of the overall study results covering all 
investigator sites. 
Authorship of publications for the overall study results will be determined by mutual agreement and in 
line with International Committee of Medical Journal Editors authorship requirements.  
If publication is addressed in the clinical study agreement, the publication policy set out in this section 
will not apply. 
 
 

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16. FUNDING AND SUPPORT  
16.1 Funding  
As the sponsor of the study, Hemanext, Inc. will provide all the funding for this investigation. 
 
16.2 Other Support  
Not applicable. 
17. INSURANCE  
Insurance will be provided by the Sponsor.  A copy of the certificate is filed in each investigation site file 
and the sponsor’s Trial Master File.   
18. REFERENCES  
1. Müller MM, Geisen C, Zacharowski K, et al. Transfusion of Packed Red Cells: Indications, 
Triggers and Adverse Events. Dtsch Arztebl Int 2015; 112 (29-30): 507-17; quiz 518. 
2. Yoshida T, Prudent M, D’Alessandro A. Red blood cell storage lesion: causes and potential 
clinical consequences. Blood Transfus 2019;17(1):27-52.  
3. D'Alessandro A, Reisz JA, Zhang Y, et al. Effects of aged stored autologous red blood cells 
on human plasma metabolome. Blood Adv 2019; 3 (6): 884-896.  
4. Zimring JC. Established and theoretical factors to consider in assessing the red cell storage 
lesion. Blood. 2015 Apr 2;125(14):2185-90. 
5. Yoshida T, AuBuchon JP, Tryzelaar L, Foster KY, Bitensky MW. Extended storage of red 
blood cells under anaerobic conditions. Vox Sang 2007;92(1):22–31. 
6. Brouard D, Landry P, Ducas E, et al. Red Blood Cells Anaerobic Storage with Hemanext 
Processing System. Vox Sang 2018; 113: 153. 
7. Dumont LJ, Yoshida T, AuBuchon JP. Anaerobic Hypoxic storage of red blood cells in a 
novel additive solution improves in vivo recovery. Transfusion (Paris) 2009; 49 (3): 458–64.  
8. Yoshida T, Shevkoplyas SS. Anaerobic storage of red blood cells. Blood Transfus Trasfus 
Sangue 2010; 8 (4): 220–36. 
9. Zolla L, D’Alessandro A. An efficient apparatus for rapid deoxygenation of erythrocyte 
concentrates for alternative banking strategies. J Blood Transfus 2013; 2013: 896537. 
10. D’Amici GM, Rinalducci S, Zolla L. Proteomic analysis of RBC membrane protein degradation 
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19. APPENDICES 
19.1 Investigator Brochure 
Document provided separately. 
 
 
19.2 Hemanext Storage Bag (HSB) labelling 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
19.3 Hemanext ONE Instructions for Use 
 
               IFU Reference: LBL-194-0057 revision E01 
 
 
 
EXCLUSIVELY FOR 
CLINICAL 
INVESTIGATIONS 
Sponsor : Hemanext Inc. 
Clinical 
Investigation 
reference
: 
CLIN-0012 
Principal 
Investigator
: 
Dr 
Stian 
Almeland, Aukeland University Hospital, 
Bergen (Norway) 

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