Senescence, Frailty, and Mesenchymal Stem Cell Functionality in Chronic Kidney Disease: Effect of Senolytic Agents
Phase: PHASE2
Conditions: Chronic Kidney Disease
Sponsor: Mayo Clinic

 
 
Senescence, Frailty, and 
Mesenchymal Stem Cell 
Functionality in Chronic Kidney 
Disease: Effect of Senolytic 
Agents 
 
NCT02848131 
 
April 19, 2019 

Senescence and Frailty in CKD 
15-005843 
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Revised 04/19/2019 
 
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SENESCENCE, FRAILTY, AND MESENCHYMAL STEM CELL 
FUNCTIONALITY IN CHRONIC KIDNEY DISEASE: EFFECT OF 
SENOLYTIC AGENTS 
 
 
 
 
Regulatory Sponsor: 
LaTonya Hickson, MD 
Department of Nephrology and Hypertension 
Mayo Clinic 
200 First Street Southwest 
Rochester, Minnesota 55905 
507-284-3594 
Study Products: 
Sprycel® (dasatinib) and Quercetin 
Protocol Number: (IRBe) 
15-005843 
IND Number: 
127789 
 
 
 
 
 
 
Initial version: 
09/02/2015 (Version 1.0) 
Revised: 
11/05/2015 (Version 1.1) 
Revised: 
04/21/2016 (Version 2.0) 
Revised: 
08/12/2016 (Version 3.0) 
Revised: 
06/15/2017 (Version 4.0) 
Revised: 
08/08/2017 (Version 5.0) 
Revised: 
 
   08/23/2018 (Version 6.0) 
Revised: 
 
   12/17/2018 (Version 7.0) 
Revised: 
 
   04/19/2019 (Version 8.0)

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Table of Contents 
1 
INTRODUCTION ............................................................................................................................................. 6 
1.1 
BACKGROUND ................................................................................................................................................................................... 6 
1.2 
INVESTIGATIONAL AGENT ............................................................................................................................................................. 8 
1.2.1 
Sprycel® (dasatinib) ............................................................................................................................. 8 
1.2.2 
Quercetin .............................................................................................................................................. 8 
1.3 
PRECLINICAL DATA ......................................................................................................................................................................... 9 
1.4 
CLINICAL DATA TO DATE ........................................................................................................................................................... 10 
1.5 
DOSE RATIONALE AND RISK/BENEFITS ................................................................................................................................. 12 
2 
STUDY OBJECTIVES ................................................................................................................................... 16 
3 
STUDY DESIGN ............................................................................................................................................. 18 
3.1 
GENERAL DESIGN .......................................................................................................................................................................... 18 
3.2 
PRIMARY STUDY ENDPOINTS ..................................................................................................................................................... 19 
3.3 
SECONDARY STUDY ENDPOINTS............................................................................................................................................... 19 
3.4 
PRIMARY SAFETY ENDPOINTS ................................................................................................................................................... 20 
4 
SUBJECT SELECTION ENROLLMENT AND WITHDRAWAL ........................................................... 20 
4.1 
INCLUSION CRITERIA .................................................................................................................................................................... 20 
4.2 
EXCLUSION CRITERIA .................................................................................................................................................................. 20 
4.3 
SUBJECT RECRUITMENT, ENROLLMENT AND SCREENING ................................................................................................ 21 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ........................................................................................................................................ 21 
4.4.1 
When and How to Withdraw Subjects ................................................................................................. 21 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects .................................................................... 23 
5 
STUDY DRUGS .............................................................................................................................................. 23 
5.1 
DESCRIPTION .................................................................................................................................................................................. 23 
5.2 
TREATMENT REGIMEN ................................................................................................................................................................. 23 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ....................................................................................... 24 
5.4 
SUBJECT COMPLIANCE MONITORING ...................................................................................................................................... 24 
5.5 
PRIOR AND CONCOMITANT THERAPY ..................................................................................................................................... 24 
5.6 
MASKING/BLINDING OF STUDY ................................................................................................................................................ 24 
5.7 
RECEIVING, PACKAGING, STORAGE, DISPENSING AND RETURN .................................................................................... 25 
5.7.1 
Receipt of Drug Supplies .................................................................................................................... 25 
5.7.2 
Packaging ........................................................................................................................................... 25 
5.7.3 
Storage ................................................................................................................................................ 25 
5.7.4 
Dispensing of Study Drug ................................................................................................................... 25 
5.7.5 
Return or Destruction of Study Drug .................................................................................................. 25 
6 
STUDY PROCEDURES ................................................................................................................................. 25 
6.1 
VISIT 1 – SCREENING AND ELIGIBILITY .................................................................................................................................. 25 
6.2 
VISIT 2 – ENROLLMENT TIME ZERO ........................................................................................................................................ 26 
6.3 
STUDY DAYS 1, 2 AND 3 – INVESTIGATIONAL PRODUCT ADMINISTRATION ............................................................... 26 
6.4 
VISIT 3 – STUDY DAY 14 (+/- 3 DAYS) ........................................................................................................... 26 
6.5 
VISIT 4 – FOLLOW-UP VISIT AT 4 MONTHS (+/-2 WEEKS) ............................................................................... 26 
6.6 
FOLLOW-UP AT 12 MONTHS (+/-2 MONTHS) ................................................................................................... 27 
7 
STATISTICAL PLAN .................................................................................................................................... 29 
8 
SAFETY AND ADVERSE EVENTS ............................................................................................................ 30 
8.1 
DEFINITIONS ................................................................................................................................................................................... 30 
8.2 
RECORDING OF ADVERSE EVENTS ........................................................................................................................................... 32 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .......................................................... 32 

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8.3.1 
Investigator reporting: notifying the Mayo IRB .................................................................................. 32 
8.3.2 
Sponsor-Investigator reporting: Notifying the FDA ........................................................................... 33 
8.4 
STOPPING RULES............................................................................................................................................................................ 33 
8.5 
MEDICAL MONITORING ............................................................................................................................................................... 34 
8.5.1 
Data and Safety Monitoring Board or Data Safety Monitoring Plan ................................................. 34 
9 
DATA HANDLING AND RECORD KEEPING ......................................................................................... 34 
9.1 
CONFIDENTIALITY ......................................................................................................................................................................... 34 
9.2 
SOURCE DOCUMENTS ................................................................................................................................................................... 34 
9.3 
CASE REPORT FORMS ................................................................................................................................................................... 34 
9.4 
RECORDS RETENTION .................................................................................................................................................................. 35 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ...................................................................... 35 
10.1 
STUDY MONITORING PLAN ................................................................................................................................................... 35 
10.2 
AUDITING AND INSPECTING ................................................................................................................................................. 36 
11 
ETHICAL CONSIDERATIONS ................................................................................................................... 36 
12 
STUDY FINANCES ........................................................................................................................................ 36 
12.1 
FUNDING SOURCE .................................................................................................................................................................... 36 
12.2 
CONFLICT OF INTEREST ......................................................................................................................................................... 36 
12.3 
SUBJECT STIPENDS OR PAYMENTS ..................................................................................................................................... 36 
13 
PUBLICATION PLAN ................................................................................................................................... 37 
14 
REFERENCES ................................................................................................................................................ 38 
 
 
List of Tables 
Table 1 Study Summary ............................................................................................................................................... 5 
 
 
Table of Figures 
Figure 1: Rationale: Schematic illustration of a preconditioning process to optimize opportunities for future 
autologous stem cell transplantation with mesenchymal stem cells (MSC) from patients with chronic kidney disease. 
......................................................................................................................................................................        7 
Figure 2: MSC obtained from obese pre-diabetic pigs show increased senescence, demonstrated by H2AX 
upregulation and decreased telomerase expression by quantitative PCR. * P<0.05, ** P<0.01 vs. Lean. ................... 9 
Figure 3: Newly identified senolytic drugs (dasatinib and quercetin) reduce the viability (ATPLite) of senescent 
preadipocytes (comparable to MSC)............................................................................................................................. 9 
Figure 4: MSC function improves with clearance of senescent cells. MSCs were isolated from inguinal white 
adipose tissue of 27-month old mice that had been treated with 3 doses of senolytics (1x/month). Key markers of 
adipogenesis were more robustly expressed in MSC from dasatinib and quercetin (gray bars, n=3) than in vehicle 
(white bars, n=4) treated mice. *P<0.05 ..................................................................................................................... 10 
Figure 5: Effect of dasatinib on preadipocytes (also known as mesenchymal stem cells) and HUVEC ..................... 13 
Figure 6: Effect of quercetin on preadipocytes (also known as mesenchymal stem cells) and HUVEC .................... 13 
Figure 7: Effect of quercetin on preadipocytes (also known as mesenchymal stem cells) and HUVEC .................... 14 
Figure 8: Combination of dasatinib with quercetin (D+Q) removes senescent cells induced by chemotherapy ......... 14 
Figure 9: Senescent cell clearance ameliorates impairment of running endurance due to chemotherapy ................... 15 
Figure 10: Diagram of Study Events ........................................................................................................................... 19 

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LIST OF ABBREVIATIONS 
 
AE 
Adverse Event/Adverse Experience 
CFR 
Code of Federal Regulations 
CKD 
Chronic Kidney Disease 
CRF 
Case Report Form 
DN 
Diabetic Nephropathy 
DSMB 
Data and Safety Monitoring Board 
eGFR 
Estimated glomerular filtration rate 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
MSC 
Mesenchymal Stem Cell 
PHI 
Protected Health Information 
PI 
Principal Investigator 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SOP 
Standard Operating Procedure 

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Table 1 Study Summary 
 
Title 
Senescence, Frailty, and Mesenchymal Stem Cell Functionality in 
Chronic Kidney Disease: Effect of Senolytic Agents 
Running Title 
Senescence and Frailty in CKD 
Protocol Number 
15-005843 
Phase 
Phase II 
Methodology 
Single blind with blinding on the study analyses, open label, 
randomized study. 
Overall Study 
Duration 
18 months 
Subject Participation 
Duration 
12 months 
Single or Multi-Site 
Single Site Study 
Objectives 
To compare the effect of senolytic drugs on cellular senescence, 
physical ability or frailty, and adipose tissue-derived MSC functionality 
in patients with chronic kidney disease. 
Number of Subjects 
30 
Diagnosis and Main 
Inclusion Criteria 
Chronic kidney disease, diabetes mellitus 
Study Product, Dose, 
Route, Regimen and 
Duration 
This study will involve a single 3-day oral treatment regimen with 
dasatinib 100 mg daily and quercetin 1000 mg total daily 
Statistical 
Methodology 
For the analyses, categorical data will be described by counts and 
percents and quantitative data by means and standard deviations. 
Power calculations were based on senescence by SA-β-galactoside 
measurement which has a mean of 5% (i.e., 5% of MSCs have the SA- 
β-gal marker) in healthy adult and is 3-4 fold higher in DN kidney 
tissue. In addition, we will explore the relationship between patient 
laboratory studies (primarily creatinine, proteinuria, blood glucose, 
hemoglobin A1c), vital measurements (e.g., BMI), frailty index score, 
and senescence (or MSC function) using linear regression. 

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1 
Introduction 
This document is a protocol for a human research study. This study will be carried out in 
accordance with the applicable United States government regulations and Mayo Clinic research 
policies and procedures. 
 
1.1 
Background 
As the global epidemic of obesity and diabetes mellitus spreads, an exponential rise in incident 
chronic kidney disease (CKD) is predicted, leaving healthcare systems overwhelmed 
worldwide1-3. In 2012, 29.1 million people (9.3% of the population) were living with diabetes in 
the U.S., with estimated costs of $249 billion 4. Diabetes is the most common cause of end stage 
renal disease (ESRD), a costly condition with high morbidity and mortality5. Moreover, a frailty 
phenotype, often regarded as distinct clinical syndrome of physiologic vulnerability to stress, is 
highly prevalent in the CKD population6-8. As recently highlighted in a systematic review, frailty 
in CKD is associated with high risk for adverse events6,8-11. Hence, containing the high cost and 
heightened cardiovascular morbidity of the CKD population is key and novel efforts to minimize 
the progression to ESRD must be rigorously pursued. 
 
CKD, particularly diabetic nephropathy (DN), is characterized by vascular damage resulting 
from chronic sterile inflammation, increased reactive oxygen species generation, advanced 
glycation end product accumulation, steatosis, insulin resistance, and altered renin-angiotensin- 
aldosterone system (RAAS) activation. At present, there is no effective intervention to 
ameliorate progression to ESRD beyond that of RAAS blockade, healthy lifestyle modifications, 
and optimal diabetes and blood pressure control2,12-20. In the diabetic kidney, intrinsic 
regenerative capacity is limited and unable to prevent the development of chronic 
glomerulosclerosis and tubulointerstitial fibrosis. However, recent advances in regenerative 
medicine applying mesenchymal stem cell (MSC) transplantation offer hope for DN and 
several other kidney diseases21-24. MSCs are non-embryonic stem cells with anti-fibrotic, anti- 
inflammatory, and pro-angiogenic paracrine activity25-27. In preclinical studies, MSC reparative 
properties reduce glomerulosclerosis and microalbuminuria, and improve kidney function in 
DN20,28-38. There are no ongoing clinical trials applying MSC for DN in the U.S. However, 
results from clinical trials using stem cell therapy for type 1 and 2 diabetes mellitus indicate 
improved glycemia and safety of the approach39-42. 
 
To minimize risk of alloimmunization, autologous (rather than allogeneic) MSC transplantation 
is often preferred. However, despite encouraging results of preclinical trials, patient-associated 
risk factors appear to alter the biologic characteristics of MSC and reduce their reparative 
ability43-45. Common characteristics in DN such as older age, uremia, frailty, and obesity may 
impair functionality of MSC thereby limiting the efficacy of autologous MSC transplantation. 
Diabetes is a major risk factor for frailty and impaired MSC function, and functional 
impairment has previously been described in MSC isolated from diabetic patients 44-49. 
 
An important cause underpinning MSC dysfunction is a milieu of increased cellular senescence, 
an irreversible cell cycle arrest caused by potentially oncogenic, metabolic, or other insults 50-53. 
Affected cells develop a senescence-associated secretory phenotype (SASP), generating 
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species, which impair neighboring cell function and alter tissue structure 53-56.  Patients with 
diabetes have increased markers of senescence and inflammatory cytokines in fat and kidney 
tissues47,57-60. Hence, increased senescent cell burden in DN may substantially compromise MSC 
function and become a barrier to cellular therapy. Our exciting new data reveal that cellular 
senescence may be treatable with drugs, which do not require in-vitro cell manipulation61. 
We recently identified and validated a new class of senolytic drugs that selectively eliminate 
senescent cells62. Our preliminary data show that in pre-diabetic animal models, which exhibit 
increased senescence, eradicating senescent cells by senolytic treatment improves stem cell 
function. In addition, clearance of the senescent cell burden in mice with doxorubicin-induced 
senescence was associated with functional improvement in running endurance therein modifying 
the frailty profile 61. Given these findings, we aim to examine senolytic therapy as a potential in 
vivo preconditioning method to improve mesenchymal stem cell function (Figure 1), minimize 
the burden of cellular senescence, and optimize frailty parameters in patients with CKD. 
 
Figure 1: Rationale: Schematic illustration of a preconditioning process to optimize opportunities for future 
autologous stem cell transplantation with mesenchymal stem cells (MSC) from patients with chronic kidney disease. 
In planning for cellular-based therapy for CKD (or DN), patients with increased senescence 
burden or impaired MSC function would be offered a pre-conditioning protocol with senolytic 
drugs to improve MSC function and the microenvironment, thereby allowing for autologous 
transplantation. Moreover, removal of a high senescent cell burden in the body may allow for 
positive changes in kidney function and bodily physical ability (reduced frailty). 
 
The proposed studies will be the first of its kind which will compare cellular senescence, frailty, and MSC 
function in CKD across a range of estimated glomerular filtration rate (eGFR), and examine the effect of 
senolytic agents on CKD-MSC senescence and function both in vitro and in vivo. Additionally, we will 
examine the effect on frailty markers and cellular senescence (in the skin) before and after senolytic 

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therapy.  Our overall goal is to change the trajectory of kidney disease. The early step in this 
mission is to characterize and optimize the functional properties of MSC and their 
microenvironment in CKD, to allow these patients to benefit from future enrollment in 
clinical trials using stem cell transplantation. In doing so, we will investigate an innovative 
approach for preconditioning MSC as a critical first step toward the application of cellular therapy 
for CKD. These studies will advance the knowledge of the effects of cellular senescence, frailty, 
and MSC functionality in CKD.  In addition, they will help develop pre-screening protocols to 
optimize enrollment in trials using autologous MSC transplantation for CKD. 
 
1.2 
Investigational Agent 
An investigational product is defined as a pharmaceutical form of an active substance or placebo 
being tested or used as a reference in a clinical study, including products already with a 
marketing authorization but used or assembled (formulated or packaged) differently than the 
authorized form, or used for an unauthorized indication, or when used to gain further information 
about the authorized form. The investigational product(s) will be stored in a secure area 
according to local regulations. It is the responsibility of the investigator to ensure that 
investigational product is only dispensed to study subjects. The investigational product(s) will be 
dispensed only by authorized personnel according to local regulations. In this protocol, 
investigational products are Sprycel® (dasatinib), and quercetin. 
 
1.2.1 Sprycel® (dasatinib) 
Sprycel® (dasatinib) is an FDA approved product (NDA #021986). SPRYCEL is a kinase 
inhibitor indicated for the treatment of: 
• newly diagnosed adults with Philadelphia chromosome-positive (Ph+) chronic myeloid 
leukemia (CML) in chronic phase. The trial is ongoing and further data will be required 
to determine long-term outcome. 
• adults with chronic, accelerated, or myeloid or lymphoid blast phase Ph+ CML with 
resistance or intolerance to prior therapy including imatinib. 
• adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) 
with resistance or intolerance to prior therapy. 
Commercially available dasatinib will be purchased for the purposes of this trial. Dasatinib will 
be supplied as 100 mg tablet white to off-white, biconvex, oval, film- coated with “BMS 100” 
debossed on one side and “852” on the other side. 
 
1.2.2 Quercetin 
Quercetin is a flavonoid present in many fruits, vegetables, and grains and is also used as an 
ingredient in supplements, beverages, or various types of foods. Typical dietary intakes are 
between 5 mg and 40 mg per day, but intakes of 200-500 mg/day are possible with high 
consumption of fruits and vegetables, especially when the peel is consumed. Quercetin has been 
safely used in amounts up to 500 mg twice daily for up to 8 weeks. Up to date, no reports of 
significant toxicity have been reported, and weight of the current evidence from multiple in vitro 
studies demonstrates safety of this product as a food additive. Our anticipation of any risks of 
toxicity in CKD patients which will receive this drug for only three days is <1%. Quercetin 
phytosome dehydrate capsules equating to 1000 mg total daily dosage will be administered for 3 
consecutive days orally for the CKD patients randomized to the Intervention group. This will be 
obtained commercially from the Thorne research company. 

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Quercetin will be supplied as quercetin phytosome (sophora japonica concentrate (leaf) / 
phosphatidylcholine complex from Sunflower) 250 mg by Thorne Research. Quercetin 
Phytosome is a “00” hypromellose (vegetarian cellulose) capsule filled with a pale yellow 
powder containing 250 mg quercetin phytosome. Microcrystalline cellulose, leucine, and silicon 
dioxide are added as manufacturing aids. 
 
1.3 
Preclinical Data 
Insulin resistance in obese hypertensive pigs is associated with increased MSC senescence. 
Similar to findings in diabetic patients44,45, our preliminary data in obese hypertensive pigs, 
which develop insulin resistance, suggest that pre-diabetes may contribute to premature 
senescence of adipose-derived MSC (Figure 2). 
 
Figure 2: MSC obtained from obese pre-diabetic pigs show increased senescence, demonstrated by H2AX 
upregulation and decreased telomerase expression by quantitative PCR. * P<0.05, ** P<0.01 vs. Lean. 
Relevance: These data show increased senescence in disease models of obesity and hypertension. 
As kidney function declines, superimposition of a ‘uremic state’ may further impair MSC 
function, thereby limiting the reparative capacity of MSCs and serving as a barrier to autologous 
transplantation in patients with advanced DN. 
 
Senolytic drugs clear senescent cells and improve MSC function 
 
A. Senolytic drugs clear senescent cells. 
After screening 46 agents that target gene products which protect senescent cells from apoptosis 
in vitro, we recently identified 2 agents, dasatinib and quercetin, which are effective in 
selectively clearing senescent cells (Figure 3). 
 
Figure 3: Newly identified senolytic drugs (dasatinib and quercetin) reduce the viability (ATPLite) of senescent 

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preadipocytes (comparable to MSC). 
 
This landmark work was recently published61, and these drugs will be available for our pilot 
studies testing senolytic agents in DN-MSC. Further evidence is found in our preliminary in vivo 
studies of dasatinib and quercetin in skin biopsies from old, diabetic female Rhesus monkeys. 
Studies revealed a reduction in the expression of p16, a reliable marker of senescent cell burden 
(from 54.8 to 45.1 arbitrary units; P<0.009; T test) as early as 5 days after 3 daily doses of 
dasatinib and quercetin. In murine models, this effect was sustained for several weeks. 
 
B. MSC function improves with clearance of senescent cells. 
In preliminary studies, we examined function of MSC from old mice after senolytic treatment 
(oral quercetin and dasatinib, 10 weeks). Gene expression (quantitative PCR) of key 
adipogenesis markers, including CEBPa and PPARγ, was found to be increased in the senolytic- 
treated mice versus vehicle-treated mice, Figure 4. 
 
Figure 4: MSC function improves with clearance of senescent cells. MSCs were isolated from inguinal white 
adipose tissue of 27-month old mice that had been treated with 3 doses of senolytics (1x/month). Key markers of 
adipogenesis were more robustly expressed in MSC from dasatinib and quercetin (gray bars, n=3) than in vehicle 
(white bars, n=4) treated mice. *P<0.05 
 
Given that CEBPa and PPARγ are both necessary for insulin sensitivity to develop in the 
maturation of preadipocytes63, these data show that senolytic treatment improves the function of 
these progenitor cells by enhancing their ability to undergo transdifferentiation. 
 
Relevance: These novel studies provide the framework for preconditioning adipose-derived 
MSC with senolytic drugs. Our observations that 1) senolytic drugs selectively eradicate 
senescent cells, 2) clearance of senescent cells is evident within 5 days of senolytic treatment and 
persists for several weeks in animal models, and 3) impairment in MSC function is reversible 
when treated with senolytics in vitro, all strongly support the hypotheses for the AIMS in the 
proposed study. 
 
1.4 
Clinical Data to Date 
The senolytic drugs used in this study include dasatinib and quercetin. Dasatinib has previously 
been approved for the treatment of chronic myeloid leukemia (CML) by the FDA. This proposal 

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outlines a new indication for use and will be provided in conjunction with the dietary supplement 
quercetin for a 3-day period. 
To our knowledge, there are no published studies utilizing dasatinib or quercetin or the 
combination of both drugs in the chronic kidney disease (CKD) population independent of a 
diagnosis of CML. Dasatinib is a tyrosine kinase inhibitor used as an oral daily treatment for 
CML with fewer side effects and improved survival compared to older treatment agents for this 
disease64. Dasatinib is generally well-tolerated with the more common adverse effects consisting 
of rash, abdominal pain, diarrhea, nausea, myelosuppression, fluid retention, and headache. 
Fortunately, one recent publication by Yilmaz et al65 conducted a historical cohort review of 468 
newly diagnosed patients with chronic-phase chronic myeloid leukemia at MD Anderson who 
were treated long-term with tyrosine kinase inhibitors (imatinib, dasatinib, and nilotinib). The 
primary goal was to examine the incidence of changes in kidney function over time. Among 
this study cohort, 99 of 468 patients received dasatinib dosed at 100 mg daily or 50 mg twice 
daily for more than 3 months and were followed for a median of 39 months.  Among the 
dasatinib treated patients, only one of 99 patients developed acute kidney injury defined as a rise 
in serum creatinine of 0.3 mg/dL. Among the 93 dasatinib-treated patients with normal baseline 
kidney function, the mean estimated glomerular filtration rate (eGFR) initially declined and then 
stabilized after 4 years. Among the 6 dasatinib-treated patients with CKD (eGFR <60 ml/min) at 
baseline, there were no significant changes in eGFR over time within this small group. The 
overall findings were that long-term dasatinib-treated patients with normal baseline kidney 
function did experience a decline in eGFR but no association was found with development of 
acute kidney injury. Additionally, those with CKD at baseline did not experience any further 
decline in eGFR (for either of the tyrosine kinase inhibitors studied). 
 
Dasatinib has rarely been associated with acute kidney injury among patients treated for 
leukemia.  The injury may occur in the context of tumor lysis syndrome which is of minimal to 
no risk for CKD patients who lack the underlying hematological disease process. Among patients 
treated for leukemia, available case reports also describe a variety of kidney lesions including: 
acute tubular necrosis from adverse effects such as gastroenteritis and nephrotic syndrome from 
thrombotic microangiopathy occurring in patients receiving dasatinib therapy66-68. These events 
generally resolve with interruption of drug therapy and conservative management. Based on a 
case report and review by Wallace et al in the American Journal of Kidney Disease68 a possible 
mechanism for dasatinib-induced kidney injury is through inhibition of the vascular endothelial 
growth factor (VEGF) signaling pathway, a specific tyrosine kinase signaling pathway. 
However, there are no package insert recommended dosing adjustments for either kidney disease 
or reductions in kidney function for patients receiving dasatinib therapy. 
 
Quercetin is a naturally-occurring flavonoid known to inhibit PI3Kinase, other kinases, and 
mTOR pathways. Quercetin is present in many fruits, vegetables, and grains and is also used as 
an ingredient in supplements, beverages, or various types of foods. Quercetin is a supplement 
and not FDA approved for any indication. The primary contraindication/warning for this drug is 
a hypersensitivity to Quercetin. Adverse effects associated with quercetin include emesis, 
dyspnea, and nephrotoxicity or kidney injury. Kidney injury from this drug has not been 
substantiated in recent reports and overall appears safe in clinical application69, and several 
studies involve use of quercetin for its anti-oxidative and anti-apoptotic effects in animal models 
of kidney disease, including diabetic nephropathy (DN). In fact, there are numerous preclinical 
studies in acute kidney injury or DN suggesting that quercetin may reduce oxidative stress and 

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improve kidney function70-82. 
 
1.5 
Dose Rationale and Risk/Benefits 
Drugs that eliminate senescent cells are known as “senolytic(s)”. We discovered senolytics that 
selectively eliminate senescent cells including tyrosine kinase inhibitors (TKI). Dasatinib is a 
TKI that is currently used for certain cancer treatments and has been approved for treatment of 
chronic myeloid leukemia (CML). Dasatinib initially induces senescence followed by necrosis in 
cancer cells. In a recent study evaluating the effect of dasatinib against thyroid cancer cell lines  
in vitro and a xenograft model in vivo, dasatinib-treated cells (BHP2-7 and Cal62) exhibited a 
characteristic clumped appearance on biopsy and most of these cells were noted to be senescent 
using a SA-β-Galactosidase “SABG” assay. In this study, the average number of senescent cells 
per high powered field (hpf) were: BHP2-7, control 0/hpf; BHP2-7, dasatinib 20/hpf; Cal62, 
control 0/hpf; Cal62, dasatinib 25/hpf. When these senescent cells were followed, they were 
noted to become necrotic after 10 days of dasatinib treatment. 
 
Senescent cell eradication (or reduction) by activating a drug-inducible “suicide” gene can delay 
multiple age-related phenotypes in genetically-modified progeroid mice. We screened 46 
agents/drugs that could theoretically induce apoptosis preferentially of senescent cells in vitro. 
Then we evaluated these agents and different combinations to determine those agents that are 
most effective at eliminating senescent cells61. Dasatinib preferentially reduced viability and 
caused cell death in senescent human preadipocytes (also known as mesenchymal stem cells or 
MSCs), but was much less effective on senescent human umbilical vein cells (HUVEC) (Figure 
5). After 3 days of exposure, proliferating preadipocytes increased by 2-5 fold in number 
compared to day 0 in the presence of dasatinib. The viability of non-dividing senescent 
preadipocytes from the same subjects decreased by 30-40% in the presence of dasatinib, 
demonstrating selective reduction. 
 
The second agent that we discovered as a promising senolytic drug was quercetin, a naturally 
occurring flavonoid known to inhibit PI3Kinase, other kinases, and mTOR pathways. In contrast 
to dasatinib, at low concentrations quercetin reduced the viability and caused cell death of 
senescent HUVECs to a greater extent than proliferating cells, but was less effective on 
preadipocytes (Figure 6). The combination of dasatinib and quercetin [D+Q] afforded selective 
killing of both senescent preadipocytes and endothelial cells (Figure 7 and Figure 8). By day 3, 
the viability of non-dividing senescent preadipocytes exposed to both these agents was reduced 
by ~70% compared to day 0, while non-senescent, proliferating cells had increased by 2-4 fold, 
suggesting that the combination of dasatinib and quercetin selectively targets a broader range of 
senescent cell types than either agent alone, hence forming the basis of our hypothesis for the 
proposed study. This combination of senolytics (D+Q) was shown not only to be helpful in 
decreasing senescent cell burden, but we also observed functional improvement in running 
endurance in mice with doxorubicin-induced senescence (Figure 9). We also found that D+Q 
alleviated age-related cardiac and vascular dysfunction, improved gait in mice disabled by 
exposing a leg to ionizing radiation, and delayed frailty, neurological dysfunction, and 
osteoporosis in mice with an accelerated aging syndrome61. 

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Figure 5: Effect of dasatinib on preadipocytes (also known as mesenchymal stem cells) and HUVEC 
 
Figure 6: Effect of quercetin on preadipocytes (also known as mesenchymal stem cells) and HUVEC 

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Figure 7: Effect of quercetin on preadipocytes (also known as mesenchymal stem cells) and HUVEC. 
 
 
Figure 8: Combination of dasatinib with quercetin (D+Q) removes senescent cells induced by chemotherapy. 
Senescence was induced by doxorubicin 10mg/kg in 5 month old p16-3MR mice. After 10 days, 
mice were given vehicle (DOXO), ganciclovir (GCV), which activates the thymidylate kinase 
“suicide” gene in p16-expressing senescent cells, or our pilot senolytic compounds (D+Q). After 
another 5 days, animals were imaged for luminescence (B; quantified in A; N=9 mice/ group). C: 
Skin biopsies were collected pre- and post-drug treatment (control, GCV, or D+Q). p16 mRNA 
values (RT-PCR) are % p16 expression post-treatment vs. pre-treatment (each animal is 
normalized to itself; N=4/group). 

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Figure 9: Senescent cell clearance ameliorates impairment of running endurance due to chemotherapy. 
Doxorubicin induces widespread cellular senescence. Treadmill running endurance was tested in 
5 month old p16-3MR mice that had been treated 15 days before with vehicle (Control) or 
doxorubicin to induce senescence. Ten days later, the mice treated with doxorubicin were given 
either vehicle (DOXO) or D+Q. Five days after that, treadmill testing was done. Despite only a 
single treatment with D+Q 5 days before, exercise endurance improved (D&Q half-life is <12 
hrs; N=4; T tests). 
 
Justification of the selection of an intervention’s dose, frequency and administration: 
Two drugs, dasatinib and quercetin, will be utilized as “senolytic agents” in the intervention arm 
of the study: 
 
To our knowledge, dasatinib has not been previously used in the management of chronic kidney 
disease (CKD), alteration of frailty markers, or for preconditioning of mesenchymal stem cells 
(MSC). Dasatinib has been used clinically for the treatment of cancers. Based on our preclinical 
experience with 46 agents/drugs examined, the combination of dasatinib and quercetin induces 
apoptosis of senescent cells in vitro with minimal effect on non-senescent or healthy cells61. 
Removal of these senescent cells has broad potential implications including optimization of 
impaired MSC function, improvement in the frailty phenotype parameters, and improvement in 
kidney function in patients with CKD. 
 
Particularly, in this study we will examine the effects of senolytics which have immense  
potential as a preconditioning treatment for MSC. This would serve as a critical first step 
toward the application of cellular therapy for CKD. As an off-target effect, removal of highly 
abundant senescent cells in the CKD kidney, may allow for functional improvement of 
neighboring tubule cells and structures therein allowing for enhancement in kidney function.  
This finding alone may provide an un-tapped opportunity to alter the trajectory of kidney failure. 
Frailty, generally described as a distinct biological syndrome of decreased reserve and resistance 
to stressors (illness, surgery) which results from cumulative declines across multiple physiologic 
systems, is associated with increased risk for mortality, morbidity, disability, and health care 

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utilization.  This  phenotype  is  common  in  the  CKD  population,  particularly  patients  with 
diabetes; therefore an improvement in frailty phenotype may lead to improved survival, quality  
of life, and healthcare expenditures. 
 
Acknowledging the potential benefits gained from using dasatinib and quercetin, the risks of use 
of these drugs in combination for 3 days are likely to be minimal in relation to the anticipated 
benefits and the knowledge that may be gained from these clinical investigations. 
 
2 
Study Objectives 
Our preliminary data reveal increased MSC senescence in pre-diabetic animal models. 
Importantly, we recently discovered and successfully demonstrated the utility of senolytic drugs 
that selectively eliminate senescent cells in other disease models, and demonstrated in animal 
models that eradicating senescent cells improves stem cell function. Our hypothesis underlying 
the proposed studies is that adipose tissue-derived MSC obtained from patients with DN 
show increased senescence and decreased functionality, which can be ameliorated, both in 
vitro and in vivo, using drugs that clear senescent cells. This hypothesis will be pursued in 3 
primary specific aims: 
 
Primary Aims: 
Aim 1: To compare cellular senescence and functionality in adipose tissue-derived MSC from 
patients with DN (diabetic nephropathy) [estimated glomerular filtration rate (eGFR) 15-60 
mL/min/1.73m2] to MSC from age- and gender- matched controls. MSC senescence will be 
assessed by specific markers of senescence. MSC functionality will be assessed by (a) 
multilineage differentiation potential, (b) proliferation, migration, and tube-formation capacity, 
and (c) paracrine anti-inflammatory and pro-angiogenic activities. 
• Hypothesis 1a: MSC senescence and dysfunction are increased in DN compared to 
healthy controls. 
• Hypothesis 1b: The proportion of senescent cells in patients with DN correlates with 
impairments in MSC function. 
Aim 2: To determine the reversibility of DN-MSC dysfunction utilizing incubation with 
senolytic agents in vitro. 
• Hypothesis 2: Incubation of MSC obtained from DN patients with senolytic agents will 
decrease the fraction of senescent MSC and improve their function relative to MSC from 
healthy controls. 
Aim 3: To examine the effect of senolytic agents on MSC function in a pilot study of patients 
with DN (eGFR 15-60 mL/min/1.73m2). MSC senescence and function will be measured at 
baseline and day 14 in both DN patients treated or untreated with senolytic agents. 
• Hypothesis 3: DN patients treated with senolytic agents will have a decrease in the 
fraction of senescent MSC and alleviation of MSC dysfunction. 
Secondary Aims: 
Aim 4: To examine the effect of senolytic agents on markers of frailty (frailty phenotype) in a 
pilot study of study of patients with DN (eGFR 15-60 mL/min/1.73m2). Frailty index will be 
determined at baseline, day 14, and month 4 in DN patients treated or untreated with senolytic 
agents. 
• Hypothesis 4: DN patients treated with senolytic agents will have an improvement in the 
frailty phenotype at 14 days and 4 months compared to baseline examination. 
 

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Aim 5: To examine the effect of senolytic agents on eGFR in a pilot study of study of patients 
with DN (eGFR 15-60 mL/min/1.73m2). eGFR will be measured at baseline, day 14, month 4 
and 12 in DN patients treated or untreated with senolytic agents. 
• Hypothesis 5: DN patients treated with senolytic agents will have an improvement in the 
eGFR at 14 days and 4 months compared to baseline examination. 
 
Aim 6: To assess the safety and tolerability of a single 3-day treatment regimen with dasatinib 
100 mg daily and quercetin 1000 mg total daily in subjects with DN-CKD. 
 
Aim 7: To examine the molecular characteristics of MSC (or DN-MSC) before and after 
senolytic therapy by using high throughput RNA sequencing and semi-automated real time 
quantitative polymerase chain reaction (qPCR) platform with gene biomarkers for proliferation, 
survival, quiescence, senescence, differentiation, metabolic activity. 
These novel studies will advance the knowledge of the effects of cellular senescence on MSC 
functionality and physical ability or frailty, and help develop pre-selection protocols to optimize 
enrollment in trials using autologous MSC transplantation for DN and CKD. Furthermore, the 
proposed studies explore an innovative approach for preconditioning MSC and aid in developing 
a completely novel therapeutic strategy to delay the progression of CKD. 
 
MSC from patients enrolled in AIM 3 (Senolytic study) will be sent to Dr. Andre van Wijnen’s 
lab for RNA sequencing.  Samples will be studied before and after senolytic intervention. 
The molecular characteristics of MSCs will be examined using high throughput RNA sequencing 
and semi-automated real time quantitative polymerase chain reaction (qPCR) platform with gene 
biomarkers for proliferation, survival, quiescence, senescence, differentiation, metabolic activity 
(1. before & after senolytics drug therapy and 2. by GFR groupings). 
 
Primary Objectives 
To assess the efficacy of a single 3-day treatment regimen with dasatinib and quercetin (senolytic 
drugs) on clearing senescent adipose-derived MSC in patients with CKD. 
 
To assess the efficacy of a single 3-day treatment regimen with dasatinib and quercetin (senolytic 
drugs) on improving adipose-derived MSC functionality in patients with CKD. 
 
Secondary Objective 
To assess the short-term effect of a single 3-day treatment regimen with dasatinib and quercetin 
(senolytic drugs) on frailty index score in patients with CKD. 
 
To assess the short-term effect of a single 3-day treatment regimen with dasatinib and quercetin 
(senolytic drugs) on kidney function in patients with CKD. 
 
To assess the safety and tolerability of a single 3-day treatment regimen with dasatinib 100 mg 
daily and quercetin 1000 mg total daily in subjects with CKD. 
 
 
 
 
 

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3 
Study Design 
 
3.1 
General Design 
Subjects will be screened at outpatient visits in the nephrology, hypertension, diabetes, family 
medicine and internal medicine clinic visit appointments at Mayo Clinic. To increase community 
engagement and minority enrollment, we will expand recruitment into the region by providing 
Mayo-approved recruitment materials in the community (library, churches, public areas, 
community-sponsored health seminars). Other forms of advertisement may include: radio and/or 
newspaper advertisements, website postings, podcast interviews of the principal investigator, etc. 
Interested, qualified subjects will be consented and offered participation in this trial. In this initial 
proof of concept study, we will evaluate 30 subjects (20 Intervention and 10Non-Intervention). 
Once consent has been obtained baseline values will be established and subjects in the 
intervention group will receive a single 3-day course of dasatinib plus quercetin (senolytic 
agents). The non-intervention group will be observed for the study duration. Subjects will be 
followed for a total of 12 months. At enrollment/screening baseline laboratory tests will include 
measurements of kidney function, diabetes and cholesterol, inflammatory markers. Following 
randomization, patients will undergo an abdominal fat biopsy for harvesting of mesenchymal 
stem cells and a 6-mm punch skin biopsy for assessment of senescence markers at time zero and 
day 14. Blood and urine tests will be obtained at day -7 to day 0, day 14, month 4 and month 12 
(by medical record review). Comprehensive examinations performed at the day 0 visit will also 
consist of screening for lifestyle factors (smoking, alcohol, obesity, physical activity), and 
cardiovascular risk assessment. Frailty phenotyping through creation of a frailty index score will 
also be conducted at visits (day 0, day 14, month 4). If screening/eligibility tests were performed 
clinically up to 7 days prior to enrollment visit (Day 0), then subjects will undergo modified 
testing to include only those tests not previously completed. 
 
Subjects will be screened at outpatient visits in the nephrology, hypertension, diabetes, family 
medicine and internal medicine clinic appointments at Mayo Clinic. To increase community 
engagement and minority enrollment, we will expand recruitment into the region by providing 
Mayo-approved recruitment materials in the community (library, churches, public areas, 
community-sponsored health seminars). Other forms of advertisement may include: radio and/or 
newspaper advertisements, website postings, podcast interviews of the principal investigator, etc. 
Due to lack of access to electronic medical records in the non-Mayo Clinic patients, an additional 
telephone or in-person screening interview may be necessary to confirm eligibility prior to the 
formal study screening/enrollment date.  Interested and qualified subjects will be consented and 
offered participation in this trial. Once consent has been obtained baseline values will be 
established and subjects in the intervention group will begin a single 3- day treatment with the 
senolytics, dasatinib and quercetin. 

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Fi g ure 1 0: Dia gra m of St u d y E ve nts 
 
 
* T he 1 2 m o nt h visit will be c o m plete d vi a me dic al rec or d re vie w. S u bjects will be as ke d t o pr o vi de a rele ase 
of i nf or m ati o n s o t h at  w e are o nl y t o re q uest a c o p y t heir l a b or at or y  d at a.  
* If scree ni n g/eli gi bilit y tests w ere perf or me d cli nic all y u p t o 7 d a ys pri or t o e nr oll me nt visit ( D a y 0), t he n 
s u bjects will u n der g o m o difi e d testi n g t o i ncl u de o nl y t h ose tests n ot pre vi o usl y c o m pl ete d.  
 
3. 2  
Pri m ar y St u d y  E n d p oi nts  
T he pri mar y e n d p oi nts i n cl u de: 
 Pr o p orti o n of se nesce nt mese nc h y mal ste m cells (a n d se nes ce nt s ki n cells) prese nt at d a y 
1 4 c o m pare d t o bas eli ne ( da y 0).  
 Mese nc h y mal ste m cell f u ncti o nalit y ( pr oliferati o n, mi grati o n, t u be  f or mati o n), paracri ne 
acti vities (secr eti o n of a n gi o ge nic a n d gr o wt h fact ors), a n d a nti -i nfl a m mat or y acti vities at 
da y 1 4 c o m par e d t o da y 0.  
 
3. 3  
Sec o n d ar y St u d y  E n d p oi nts  
T he sec o n d ar y e n d p oi nts i ncl u de: 
 C ha n ge i n esti mate d gl o mer ular filtrati o n rate fr o m ba seli ne t o peri o d of s h ort-ter m ( 0- 4 
m o nt hs) a n d l o n g-ter m ( 1 2 m o nt hs) f oll o w u p.  
 C ha n ge i n frailt y i n de x sc ore fr o m baseli ne t o da y 1 4.  
 Safet y of c o m bi nati o n t h era p y usi n g das ati ni b a n d q uerceti n.  
 
3. 4  
Pri m ar y S af et y  E n d p oi nts  
Safet y assess me nts are u n derta ke n wit h t he meas ure me nt of safet y la b orat or y tests a n d 

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procedures, vital signs and recording of adverse events 
 
4 Subject Selection Enrollment and Withdrawal 
 
Informed Consent: 
Trained clinical study coordinators will contact subjects, assist in recruitment and carry-through 
of the protocols. Description of the studies and review of the informed consent forms with each 
patient will be conducted in person directly with the clinical coordinators and/or the responsible 
principle and co-investigators involved in the study. Written informed consent will be obtained 
with details of the procedures to be followed, the number of subjects to be included, 
identification of the risks and benefits, and alternative procedures. Subjects will be required to 
give appropriate consent or have an appropriate representative available to do so. 
 
Subject selection: 
Diabetic nephropathy (DN) will be defined clinically as CKD (estimated glomerular filtration 
rate; eGFR 15-60 mL/min/1.73m2) in the setting of diabetes without other overt etiologies of 
CKD beyond concomitant hypertension. 
 
4.1 
Inclusion Criteria 
1. Age 40-80 years 
2. Chronic kidney disease estimated glomerular filtration rate (eGFR) 15-45 
ml/min/1.73m2 
3. Diabetes mellitus and taking diabetes medications 
 
4.2 
Exclusion Criteria 
1. Concomitant glomerulonephritis, 
2. Nephrotic syndrome, 
3. Solid organ transplantation, 
4. Autosomal dominant or recessive polycystic kidney disease, 
5. Known  renovascular disease, 
6. Pregnancy, 
7. Active immunosuppression therapy, 
8. Hemoglobin A1c ≥ 10% at screening, 
9. History of active substance abuse (including alcohol) within the past 2 years, 
10. Current alcohol abuse (>3 alcoholic beverages/day or >21 per week), 
11. Body weight >150 kg or body mass index (BMI) >50 
12. Human immunodeficiency virus infection 
13. Active hepatitis B or C infection 
14. Tyrosine kinase inhibitor therapy 
15. Known hypersensitivity or allergy to dasatinib or quercetin 
16. Inability to give informed consent 
17. Uncontrolled systemic lupus erythematosus 
18. Uncontrolled pleural/pericardial effusions or ascites 
19. New invasive cancer except non-melanoma skin cancers 
20. Invasive fungal or viral infection 

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21. Inability to tolerate oral medications 
22. Total bilirubin>2x upper limit of normal 
23. Subjects taking medications that are sensitive to substrates or substrates with a narrow 
therapeutic range for CYP3A4, CYP2C8, CYP2C9, or CYP2D6 or strong inhibitors or 
inducers of CYP3A4 (e.g. cyclosporine, tacrolimus or sirolimus). If antifungals are 
absolutely necessary from an infectious disease perspective, then they will be allowed 
only if the levels are therapeutic. 
24. Strong inhibitors of CYP3A4. See Appendices 1-3. 
25. Subjects on therapeutic doses of anticoagulants (Warfarin (Coumadin);Rivaroxaban 
(Xarleto);  Apixaban (Eliquis); Dabigatran (Pradaxa, Prazaxa) or Other). 
26. Subjects on antiplatelet agents ((Clopidogrel (Plavix); Dipyridamole + Asprin 
(Aggrenox); Ticagrelor (Brilinta); Prasugrel (Effient); Ticlopidine (Ticlid) or Other) 
who are unable or unwilling to reduce or hold therapy prior to and during the 2-day 
drug dosing. Subjects may continue their previous regimen on day 3. 
27. Subjects on quinolone antibiotic therapy for treatment or for prevention of infections 
within 10 days. 
28. Subjects taking H2-antagonists or proton pump inhibitors and unwilling to discontinue 
therapy for 1 week before and 2 weeks following enrollment. 
29. QTc>450 msec 
30. Presence of any condition that the Investigator believes would put the subject at risk or 
would preclude the patient from successfully completing all aspects of the trial. 
 
*Active immunosuppression therapy may include common systemic drugs such as tacrolimus, 
sirolimus, cyclosporin, rituximab (or other monoclonal antibodies), mycophenolate mofetil. Most 
potential subjects on these medication therapies will be identified through the exclusion criteria 
outlined above. 
 
Involvement of special vulnerable populations: 
We will not involve special vulnerable populations, such as fetuses, neonates, pregnant women, 
children, prisoners, institutionalized individuals, or others who may be considered vulnerable 
populations. 
 
4.3 
Subject Recruitment, Enrollment and Screening 
An accrual feasibility study was performed for patients residing within 150 miles of Rochester, 
MN that were seen at Mayo Clinic within the last 24 months and matched study inclusion 
criteria. We identified 1900 chronic kidney disease (CKD) patients among which 750 patients 
had diabetic nephropathy (DN). With a 20% accrual rate expected for a study that involves fat 
and skin biopsies, we would easily be able to recruit the target patients for the senolytic study 
over the course of the award period. Recruitment sources include: 1) the CKD clinic in which the 
Principal Investigator, Dr. Hickson serves as Co-Director (minimum of 250 CKD Clinic patients 
per quarter), 2) Nephrology clinics, and 3) Endocrine and general/family medicine clinics at 
Mayo Clinic in Rochester. To increase community engagement and minority enrollment, we will 
expand recruitment into the region by providing Mayo-approved recruitment materials in the 
community (library, churches, public areas, community-sponsored health seminars). Other forms 
of advertisement may include: radio and/or newspaper advertisements, website postings, podcast 
interviews of the principal investigator, etc. Due to lack of access to electronic medical records 

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i n t he n o n- Ma y o Cli nic patie nts, a n a d diti o nal tele p h o ne or i n- pers o n scree ni n g i nter vie w m a y be 
necessar y t o c o nfir m eli gi bilit y pri or t o t he f or mal st u d y scree ni n g/e nr oll m e nt date. F urt her 
s u p p ort will c o me fr o m o ur i nstit uti o n’s well-esta blis he d electr o nic a n d S ur ve y Res earc h Ce nter 
cli nical trial recr uit me nt res o urces.  
 
Tr o u bles h o oti n g f or u n met tar gets f or mi n orit y recr uit me nt: 
After 6 - 9 m o nt hs of r ecr uit me nt eff orts we are u ns uccessf ul i n recr uiti n g Africa n A merica ns ( g oal 
3 0 % of s u bjects), t he n w e will ca pitalize o n o ur o n g oi n g c olla b orati ve relati o ns hi p wit h Ma y o 
Cli nic J ac ks o n ville i n J ac ks o n ville, Fl ori da. D u val c o u nt y, Fl ori da has a m or e di verse 
re pres e ntati o n of mi n orities wit h Africa n A merica ns c o m prisi n g 3 0. 3 % of t he p o p ulati o n i n 2 0 1 6. 
I n a d diti o n, we c o nti n ue t o part ner wit h t he U ni versit y of Mi n nes ota/ H e n ne pi n C o u nt y i n 
Mi n nea p olis, Mi n nes ota a n d E m or y U ni versit y i n Atl a nta, Ge or gia f or s uccessf ul, tar gete d 
recr uit me nt of Africa n A merica n s u bjects.  As nee de d, we will a da pt st u d y pr ot oc ols a n d o btai n 
I R B a p pr o v al acc or di n gl y.  Mi n orit y s u bjects recr uite d fr o m off-site sites will be rei m b urse d f or 
airfar e, h otel acc o m m o dati o ns, a n d f o o d u p t o a n all o wa ble ma xi m u m a m o u nt.   
4. 4  
E arl y Wit h dr a w al of S u bjects  
 
4. 4. 1  W he n a n d H o w t o Wit h dr a w S u bjects  
All s u bjects will be assesse d d uri n g t h e 3 da ys of me dicati o n a d mi nistrati o n, da y 1 4 visit, a n d 
s u bse q ue nt st u d y visits.  If a se v ere a d vers e e v e nt ( S A E) occ urs at a n y ti me d uri n g 
a d mi nistrati o n of t he 3 - d a y dr u g re gi me n, a f or m al re vie w will occ ur a n d s u bse q ue nt patie nts 
will be e nr olle d o ne at a ti me usi n g t he sa me re gi me n. If t hree or m ore e ve nts accr u e, t he pil ot 
st u d y will be hel d a n d eit her a p ote ntial d osi n g re gi me n re visite d or disc o nti n uati o n of t he st u d y 
pr ot oc ol will occ ur. Ot her i nter ve nti o ns will be as per t he directi o n of t he F o o d a n d Dr u g 
A d mi nistrati o n a n d Ma y o I nstit uti o nal Re vie w B oar d. 
 
St u d y C o m pleti o n : 
F or eac h s u bject i n t he st u d y, t he e n d of st u d y will be reac he d w h e n treat me nt a n d p ost- treat me nt 
safet y f oll o w- u p p eri o ds ha ve bee n c o m plete d. 
 
S u bject wit h dr a w al : 
A s u bject ma y be wit h dr a w n fr o m t he st u d y pri or t o t hat s u bject c o m pleti n g all of t he st u d y 
relate d pr o ce d ur es. S o me reas o ns ma y i ncl u de: 
 S u bject safet y  iss ues 
 Fail ure of s u bject t o a d here t o pr ot oc ol re q uire me nts 
 Disease  pr o gr essi o n 
 S u bject decisi o n t o wit h dra w fr o m t he st u d y ( wit h dra wal of c o nse nt) 
Wit h dra w n s u bjects ma y n ot ree nter t h e st u d y. 
 
Pre m at ure wit h dr a w al f r o m st u d y : 
S u bjects ma y v ol u ntaril y wit h dra w fr o m t he st u d y f or a n y reas o n at a n y ti me. S u bjects are 
c o nsi dere d wit h dr a w n if t he y state a n i nte nti o n t o wit h dra w f urt h er partici pati o n i n all 
c o m p o ne nts of t he st u d y, die or ar e l ost t o f oll o w- u p f or a n y ot her reas o n. T he i n vesti gat or ma y 
wit h dra w a s u bject fr o m t he st u d y ( wit h o ut re gar d t o t he s u bject’s c o nse nt) if t he y b elie ve t hat 
c o nti n ue d partici pati o n i n t he st u d y w o ul d be c o ntrar y t o t he best i nterests of t he patie nt. 
 

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S u bjects are c o nsi dere d as l ost t o f oll o w- u p if all reas o na ble atte m pts b y t h e i n vesti gat or t o 
c o m m u nicate wit h t he i n di vi d ual fail. T he i n vesti gat or will ta ke pre v e nti ve meas ures t o a v oi d a 
s u bject bei n g l ost t o f oll o w- u p (e. g., d o c u me nt differe nt wa ys of c o ntact s uc h as tele p h o ne 
n u m ber, h o me a d dr ess, e- mail a d dress, pers o n t o be c o ntact e d i n case t h e s u bject ca n n ot be 
reac h e d). If t he s u bject ca n n ot be reac he d, t h e i n vesti gat or will ma ke a reas o na ble eff ort t o 
c o ntact t he s u bject, d o c u me nt all atte m pts a n d e nter t he l oss of f oll o w - u p i nf ormati o n i nt o t he 
Case Re p ort F or m ( C R F). T he f oll o wi n g m et h o ds will be use d: at least t w o tele p h o ne calls will 
be place d t o t he last a vail a ble tele p h o ne n u m b er (eac h call o n differe nt da ys) a n d o ne re gistere d 
letter will be se nt b y p ost t o t he last a vaila ble h o m e a d dress. If t he s u bject is still u nreac ha ble 
after all c o ntact atte m pts liste d a b o ve, he/s he will be c o nsi dere d t o be l ost t o f oll o w - u p. 
 
If pre mat ure wit h dra wal occ urs f or a n y reas o n, t h e reas o n f or pre mat ure wit h dra wal fr o m t he 
st u d y, al o n g wit h w h o m a de t he decisi o n (s u bject, i n vesti gat or) will be rec or de d i n t he C R F. 
 
Re p orti n g of Seri o us A d verse E ve nts a n d U n a ntici p ate d Pr o ble ms  
W he n a n a d vers e e ve nt h as bee n i de ntifie d, t h e st u d y tea m will ta ke a p pr o priate d acti o n 
necessar y t o pr otect t he st u d y  s u bject a n d t h e n c o m plete t he St u d y A d vers e E ve nt W or ks heet a n d 
l o g. T he i n vesti gat or will e val uate t he e ve nt a n d d eter mi ne t he necessar y f oll o w- u p a n d re p orti n g 
re q uire d. 
 
S u bject re pl ace me nt : 
S u bjects wit h dra w n fr o m t he st u d y will be re place d b y n e wl y r ecr uite d s u bj ects meeti n g 
i ncl usi o n criteria matc hi n g si milar baseli ne c haracteristics (a ge, ge n d er, race a n d ki d ne y 
f u ncti o n). 
4. 4. 2  D at a C ollecti o n a n d F oll o w- u p f or Wit h dr a w n  S u bjects  
 F or wit h dra w n s u bjects n ot u n der g oi n g a n y st u d y i nter ve nti o n, n o a d diti o nal f oll o w- u p 
will be  d o ne 
 F or wit h dra w n s u bjects o nl y u n der g oi n g fat bi o ps y: F or safet y m o nit ori n g t ele p h o ne 
c o ntact will be atte m pte d u p t o 1 4 da ys b e y o n d bi o ps y pr oce d ure.  
 F or wit h dra w n s u bjects r ecei vi n g dasati ni b a n d q u erceti n (I nter v e nti o n). F or safet y 
m o nit ori n g tele p h o ne c o ntact will be atte m pte d a n d s u bjects will be e nc o ura ge d t o  ret ur n 
t o c o m plete t he la b orat or y e v al uati o ns at 1 4 da y a n d 4 m o nt h visit. N o f oll o w u p p h o ne 
call nee d e d be y o n d 4 m o nt hs. It will be hi g hl y rec o m me n de d t hat wit h dra w n s u bjec ts 
ret ur n f or cli nical bl o o d ( C B C, creati ni ne) a n d uri ne ( uri nal ysis) st u dies as part of safet y 
m o nit ori n g.  Researc h data will n ot be c ollecte d o n s u bjects after t h e y are wit h dra w n 
fr o m t he st u d y, a n y a d diti o nal e val uati o n will be f or s u bject safet y o nl y. 
 
5  St u d y  Dr u gs  
5. 1  
Descri pti o n  
C o m merciall y a vaila ble dasati ni b will be p urc has e d f or t he p ur p oses of t his trial. Dasati ni b will 
be s u p plie d as 1 0 0 m g t a blet w hite t o off- w hite, bic o n ve x, o val, fil m- c oate d wit h “ B M S 1 0 0” 
de b osse d o n o ne si de a n d “ 8 5 2” o n t he ot her si d e.  
 
Q uerceti n will be s u p plie d as q uerceti n p h yt os o me (s o p h ora ja p o nica c o nce ntrate (leaf) / 
p h os p hati d ylc h oli ne c o m ple x fr o m S u nfl o wer) 2 5 0 m g b y T h or n e Researc h. T his dr u g pr o d u ct 

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will be dispensed through the research pharmacy in child resistant containers. Quercetin 
Phytosome is a “00” hypromellose (vegetarian cellulose) capsule filled with a pale yellow 
powder containing 250 mg quercetin phytosome. Microcrystalline cellulose, leucine, and silicon 
dioxide are added as manufacturing aids. 
 
5.2 
Treatment Regimen 
1) Dasatinib is a tyrosine kinase inhibitor used to treat cancer, particularly Philadelphia 
chromosome-positive (Ph+) chronic myeloid leukemia (CML) or Ph+ acute 
lymphoblastic leukemia (ALL). 
a. Dose: Dasatinib in the form of Sprycel (Bristol Myers Squibb) 100 mg orally  
daily for 3 consecutive days. One (100 mg) tablet will be taken in the morning for 
each of the 3 days. 
2) Quercetin is a naturally-occurring flavonoid known to inhibit PI3Kinase, other kinases, 
and mTOR pathways. Quercetin is present in many fruits, vegetables, and grains and is 
also used as an ingredient in supplements, beverages, or various types of foods. 
a. Dose: Quercetin dehydrate capsules equating to 1000 mg total daily dosage will 
be administered orally for 3 consecutive days. Two (250 mg) capsules will be 
taken each morning and two (250 mg) capsules will be taken in the evening for 
each of the 3 days. 
This protocol is based on current package inserts and recommended dosing regimens, in addition 
to preliminary preclinical studies and recent investigations published in Aging Cell61. There are 
no recommended dosing adjustments for kidney dysfunction. There are no specific 
contraindications to using these drugs. 
 
Dasatinib: 
Dasatinib is currently FDA approved. Precautions include: cardiac adverse events, avoidance of 
use of H2 blockers and proton pump inhibitors (affects dasatinib absorption), fluid retention, 
hemorrhage, myelosuppression, dermatologic reactions, and avoidance in pregnancy/breast 
feeding. The drug interferes with cytochrome P450 and may require drug adjustments to agents 
such as calcineurin inhibitors (See Appendices). Unlike standard treatment regimens for CML 
(lasting several months), this medication will only be administered for 3 days. Elimination half-
life is 3-5 hours in adults. Similarly, in our animal models, drug clearance was observed within 
72 hours. Yet, based on animal studies, senescent cell clearance persists for approximately 2-4 
weeks. 
 
Quercetin: 
Quercetin is a supplement and not FDA approved for any indication. The recommended dose 
ranges from a total of 750-1500 mg per day. The primary contraindication/warning is 
hypersensitivity to Quercetin. Listed drug interactions include: cyclosporine, digoxin, and 
fluoroquinolones. Adverse effects include emesis, dyspnea, and nephrotoxicity. The 
nephrotoxicity has not been substantiated in recent reports, and several studies72-80,83,84 involve 
use of quercetin for its anti-oxidative and anti-apoptotic effects in kidney disease models, 
including DN. 
 
5.3 
Method for Assigning Subjects to Treatment Groups 
Subject randomization will be by chance in a ratio of 14 subjects to the intervention arm and 6 
subjects in the non-intervention arm. 

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5.4 
Subject Compliance Monitoring 
Patient adherence to study treatment will be monitored by drug accountability (pill counts). The 
study coordinator will do pill counts. 
 
5.5 
Prior and Concomitant Therapy 
For the intervention group, drugs listed as part of the exclusion criteria are not permitted during 
the 3-day course of treatment with dasatinib and quercetin. If patients are required to initiate 
these medications within the 3-day period then they will be removed from the study primarily 
due to risk of drug-drug interaction. 
 
5.6 
Masking/Blinding of Study 
In order to minimize the study bias, the laboratories analyzing the collected samples and initial 
data will not have access as to which group the samples came from. 
 
Since this is an open label study the investigator and subject will be aware of which group they 
are in. 
 
5.7 
Receiving, Packaging, Storage, Dispensing and Return 
 
5.7.1 Receipt of Drug Supplies 
The investigational products for this study will be delivered to and managed by the Research 
Pharmacy according to their established standard procedures. 
 
5.7.2 Packaging 
Subjects randomized to the intervention arm will be provided with one bottle containing 3 tablets 
of dasatinib, and one bottle containing 12 capsules of quercetin. The bottles will be prepared and 
dispensed by the Research Pharmacy with appropriate labeling to include a statement that these 
products are for investigational use only. 
 
5.7.3 Storage 
Investigational products should be stored at room temperature 68° to 77°F (20° to 25°C). 
5.7.4 Dispensing of Study Drug 
The study drug is to be used exclusively in the clinical study according to the instructions of this 
protocol and directions for use. The Investigator’s designee is responsible for providing subjects 
with the study drug and instructions for dosing and proper storage of the study drug. Subjects 
will be instructed to return unused product to the research center. 
 
The Investigator’s designee will record the amount of study drug dispensed, date of dispensing 
as well as the amount of drug returned and drug remaining. 
 
5.7.5 Return or Destruction of Study Drug 
At the completion of the study, there will be a final reconciliation of drug shipped, drug 
dispensed, drug returns, and drug remaining. This reconciliation will be logged on the drug 
reconciliation form, signed and dated. Any discrepancies noted will be documented and 
investigated, prior to return or destruction of unused study drug. Drug destroyed on site will be 

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d oc u me nte d i n t he st u d y files. 
 
6  St u d y  Pr oce d ures  
6. 1  
Visit 1 – Scree ni n g a n d  Eli gi bilit y  
Patie nts meeti n g t he e ntr y criteria a n d c o nse nti n g t o partici pate i n t he pr ot o c ol will u n der g o a 
c o m plete p h ysi cal e x a m a n d t he f oll o wi n g l a b orat or y tests:  
 Eli gi bilit y c o nfir m ati o n a n d i nf or me d c o nse nt disc ussi o n a n d d oc u me ntati o n  
 C o m pre he nsi ve E x a m  
 Pre g n a nc y  test 
o  P oi nt of Care test f or all pre me n o pa us al w o m e n  
 Bl o o d Tests  
 S p ot Uri ne Tests  
 2 4 h o ur Uri ne  
 Electr ocar di o gra m  ( E K G) 
 Kar n o vs k y a n d F u ncti o n al Assess me nt Sta gi n g ( F A S T) sc ore 
 S F 3 6 Healt h  S ur ve y 
 Plas ma – uri ne – Cell Bi o ba n k f or f ut ure researc h  
If s cree ni n g/eli gi bilit y tests were perf or me d cli nicall y u p t o 7 da ys pri or t o e nr oll me nt visit ( Da y 
0),  t he n  s u bjects  will  u n der g o  m o difie d  testi n g  t o  i ncl u de  o nl y  t h os e  tests  n ot  pre vi o usl y  
c o m plete d.  
 
6. 2  
Visit 2 – E nr oll me nt Ti me  Zer o  
T his visit will be rec or de d as “ Da y 0 ” a n d will re q uire a visit t o t he researc h ce nter w h ere t he 
f oll o wi n g tests will be perf or me d: 
 Fat  Bi o ps y 
 S ki n Bi o ps y  
 Frailt y  assess me nt  
 I nter val Assess me nt 
 Dis pe nsi n g of 3 d a y s u p pl y of i n vesti gati o nal pr o d uct t o t he I nt er ve nti o n gr o u p o nl y.  
6. 3  
St u d y D a ys 1, 2 a n d 3 – I n vesti g ati o n al Pr o d uct A d mi nistr ati o n  
T he I nter v e nti o n gr o u p will be pr o vi de d wit h das ati ni b + q uerceti n o n da y 1 ( or bef ore). 
Dasati ni b a n d q uer ceti n will be ta ke n f or 3 c o nsec uti ve da ys o nl y. If t he d asati ni b or q uerceti n 
dr u gs are starte d i n t he e ve ni n g, t he n t h e y will be re q uire d t o c o m plet e t he 7 2 h o ur c o urse ( u nless 
A Es occ ur, s ee st o p pi n g r ules), t h us t he s u bjects ma y n ee d t o ta ke dr u g(s) t he f o urt h da y as well. 
S u bjects will be as ke d t o rec or d t h e ti me/ date eac h d ose i s ta ke n i n a dr u g diar y f or m a n d will be 
i nstr ucte d t o ret ur n u n use d pr o d uct a n d t he diar y t o t he researc h ce nter. 
 
6. 4  
Visit 3 – St u d y D a y 1 4 ( +/- 3 d a ys) 
T his visit will be rec or de d as “ da y 1 4”.  A s u m mar y of t he e v e nts d uri n g t his da y are b el o w: 
 I nter val Assess me nt  
 Fat  Bi o ps y 
 S ki n Bi o ps y  
 Frailt y  assess me nt  
 Bl o o d Tests  

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 S p ot Uri ne Tests  
 2 4 h o ur Uri ne  
 Kar n o vs k y a n d F u ncti o n al Assess me nt Sta gi n g ( F A S T) sc ore 
 S F 3 6 Healt h  S ur ve y 
•  Plas ma – Uri ne - Cell Bi o ba n k f or f ut ure researc h 
F or t his visit, a ± 3 da y wi n d o w will be  all o we d.  
6. 5  
Visit 4 – F oll o w- u p Visit at 4 m o nt hs ( +/ - 2 w ee ks)  
T his visit will be rec or de d as “ 4 - m o nt h” visit.  D uri n g t his visit, t he f oll o wi n g tests w o ul d occ ur: 
 I nter val Assess me nt  
 Frailt y  assess me nt  
 Bl o o d Tests  
 S p ot Uri ne Tests  
 2 4 h o ur Uri ne  
 Kar n o vs k y a n d F u ncti o n al Assess me nt Sta gi n g ( F A S T) sc ore 
 S F 3 6 Healt h  S ur ve y 
 Plas ma – Uri ne – Cell  Bi o ba n k f or f ut ure  res earc h F or  t his  visit,  a  ± 2  wee k wi n d o w  will  be 
all o we d. 
 
6. 6  
F oll o w- u p at 1 2 m o nt hs ( +/- 2 m o nt hs)  
T his visit  will be c o m plete d via me dical rec or d vie w. S u bjects will be as ke d t o 
pr o vi de a r elease of i nf or mati o n s o t hat we are a bl e t o re q uest a c o p y of t heir 
la b orat or y dat a. 
F or t his visit, a ± 2 m o nt h wi n d o w will be all o we d. 
 
T a ble 1. Sc he d ule of visits  
 
Scree ni n g/ 
Eli gi bilit y 
D a y -7 t o  
D a y 0  
E nr oll me nt, 
Ti me Zer o  
D a y 
1- R x  
D a y 
2- R x  
D a y 
3- R x  
D a y 1 4 
( +/-3)  
4  
m o nt hs  
1 2  
m o nt hs  
Visits  
[ V 1] 
[ V 2] 
 
 
 
[ V 3] 
[ V 4] 
 
Eli gi bilit y C o nfir m ati o n 
& C o nse nt  
X  
 
 
 
 
 
 
 
C o m pre he nsi ve E x a m (1, 2) 
X( 1 ) 
 
 
 
 
 
 
 
Vit al Si g ns a n d I nter v al 
Assess me nt  
X  
X  
 
 
 
X  
X  
 
Pre g n a nc y Test  
X  
 
 
 
 
 
 
 
F at Bi o ps y ( 2 t ot al) (3) 
 
X  
 
 
 
X  
 
 
S ki n bi o ps y ( 2 t ot al) (4) 
 
X  
 
 
 
X  
 
 
I nter ve nti o n gr o u p 
R X: 
D as ati ni b + Q uerceti n  
 
 
X  
X  
X  
 
 
 
Dr u g Di ar y  
 
 
X  
X  
X  
 
 
 
Bl o o d Tests (5) 
X  
 
 
 
 
X  
X  
X A  
S p ot Uri ne Tests (6) 
X  
 
 
 
 
X  
X  
X A  

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24 hr Urine (7) 
X 
 
 
 
 
X 
X 
XA 
Electrocardiogram 
X 
 
 
 
 
 
 
 
Frailty assessment (3 total) (8) 
 
X 
 
 
 
X 
X 
 
Plasma-Urine-Cell biobank(9) 
X 
 
 
 
 
X 
X 
 
SF 36 QOL 
X 
 
 
 
 
X 
X 
 
Karnofsky& FAST 
Performance 
Assessment 
X 
 
 
 
 
X 
X 
 
A=clinically performed test. 
 
1 If screening/eligibility tests were performed clinically up to 7 days prior to enrollment visit (Day 0), then 
subjects will undergo modified testing to include only those tests not previously completed. 
2 For safety purposes the Study Investigators have the right to screen fail patients. 
3Drug education will occur at screening or Day 0 
 
All chronic kidney disease/diabetic nephropathy patients will undergo routine 
laboratory assessment of kidney function and of potential complications of CKD. 
These laboratory studies (primarily proteinuria, lipid panel, blood glucose, 
hemoglobin A1c) and vital measurements (primarily body mass index (BMI)) 
will be used to determine clinical metabolic parameters which may relate to 
senescence, as previously suggested in DN kidney. 
 
(1) Comprehensive Exam (Initial) 
History assessment of past medical and surgical history. Medication review or 
reconciliation (statin, oral hypoglycemic, insulin, anti-hypertensives, etc). Further 
screening for exclusion criteria. Collection of vital signs including heart rate and blood 
pressure, height/weight, body mass index; BMI. Physical exam consisting of visualization of the 
abdominal wall and assessment of lower extremity edema 
 
(2) Vital Signs and Interval Assessment  
• Interval history assessment of: new medications (since enrollment), recent 
hospitalizations, or treated infection, and Adverse Event Assessment. Collection of vital 
signs including heart rate and blood pressure, height/weight, body mass index; BMI. 
Physical exam consisting of visualization of the abdominal wall and assessment of lower 
extremity edema. 
 
(3) Fat Biopsy 
• Subjects will undergo a subcutaneous fat biopsy (0.5-2 g) by Mayo surgeons using a 1- 
1.5 inch incision in our outpatient surgical suite under sterile conditions. One to two 
dissolvable sutures may be placed to close the incision. The fat tissue will be transferred 
to designated study labs at Mayo Clinic, Rochester, MN. 
 
(4) Skin Biopsy 
• At the same time as the fat biopsy a 6mm punch skin biopsy will be collected by the 
surgeon. The skin tissue will be transferred to designated study labs at Mayo Clinic, 
Rochester, MN. 
 
(5) Blood Tests 
• Kidney function: serum creatinine with estimated glomerular filtration rate (eGFR), 
blood urea nitrogen, and cystatin C. 

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• Bone mineral metabolism: serum calcium, phosphorus, albumin, bicarbonate, parathyroid 
hormone, protein total, sodium, potassium, bilirubin, alkaline phosphatase, and AST. 
• Anemia of renal disease: serum complete blood count, iron and total iron binding 
capacity and ferritin. 
• Diabetes:  Serum glucose, hemoglobin A1c. 
• Inflammatory and cardiovascular disease markers: C-reactive protein, cardiac troponin T, 
tumor necrosis factor-α, and uric acid. 
• Other labs: pregnancy test 
• Lipid Screen: Cholesterol, HDL, and Triglycerides 
• Senescence: Activin A 
(6) Spot Urine Tests 
• Urinalysis with microscopy. 
• Urine protein: creatinine (microalbumin, urine). 
(7) 24 hour urine collection 
• 24 hour Creatinine clearance 
• 24 hour Urine Protein 
 
(8) Frailty Assessment 
• Frailty phenotyping will consist of generation of a frailty index score from 5 measures 
of weakness through grip strength, walking speed, endurance and energy screening, 
unintended weight loss screening, and physical activity level calculations. Appendix 4. 
 
 
(9) Plasma-Urine-Cell Biobank 
• Collection of plasma, cells and urine from subjects will enable us to evaluate and answer 
pertinent questions related to the biology of aging and senescence. Studies utilizing 
these samples will allow us to gain a greater understanding of the pathophysiology of 
accelerated aging and the potential for us to develop new therapies to improve patient 
outcomes. An aliquot of 22 mL plasma will be obtained from each subject at the same 
time that other blood tests are done. The specimen will be kept on ice and immediately 
transported to the plasma bank for processing. In addition, an aliquot of urine up to 100 
mL will be obtained from each subject. 
 
7 Statistical Plan 
For the analyses, categorical data will be described by counts and percents and quantitative 
data by means and standard deviations. 
Study personnel will remain blinded to kidney function and treatment status. A 
statistician, working with the pharmacist at time of analyses, will be un-blinded for 
interim (~50% recruitment) and final analyses. In the case of an adverse event, 
information related to that particular patient will be revealed to the clinician. 
Sample Size and Power 
Power calculations were based on senescence by SA-β-galactoside measurement which has a 

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mea n of 5 % (i. e., 5 % of M S Cs ha ve t he S A- β -gal mar ker) i n h ealt h y a d ult a n d is 3 - 4 f ol d 
hi g her i n D N ki d ne y tiss ue, 5 7, 5 8 T a ble . I n a d diti o n, we will e x pl ore t he relati o ns hi p bet wee n 
patie nt la b orat or y st u dies ( pri maril y creati ni ne, pr otei n uria, bl o o d gl uc os e, he m o gl o bi n A 1c), 
vital meas ure me nts ( e. g., B MI), frailt y i n de x, a n d se nesce n ce ( or M S C f u ncti o n) usi n g li near 
re gressi o n. 
 
T a ble.  
Gr o u ps  
P o w er a n al yses w ere b ase d o n se nesce nce ( S A -β -g al)  
 
 
 
A nal ysis 1  
e G F R 1 5 -6 0 ( n = 1 4  
D N treate d wit h 
se n ol ytics; n = 6 D N 
treate d wit h place b o)  
T he sa m ple size ( n = 3 0; 2 0 se n ol ytic; 1 0 place b o -treate d) will ha ve 9 5 % 
p o wer t o detect a differe nce i n mea ns of 5. 5 % (e g, a pre -se n ol ytic S A B G 
mea n, μ 1, of 1 5 % a n d a p ost -s e n ol ytic μ 2 of 9. 5 %), ass u mi n g a sta n dar d 
de viati o n of differe nces of 5. 0, usi n g a paire d t -test wit h a 0. 0 5 t w o-si de d 
si g nifica nce le vel. 
 
 
 
A nal ysis 
2 
 
W e will e x pl ore t he relati o ns hi p bet wee n la b orat or y st u dies ( pri maril y 
pr otei n uria, L D L c h olester ol, bl o o d gl uc ose, he m o gl o bi n A 1c), vital 
meas ure me nts ( pri maril y B MI), me dicati o n e x p os ure ( metf or mi n, i ns uli n 
d osa ges), frailt y i n de x, a n d se nesce nce ( or M S C f u ncti o n) usi n g li near 
re gressi o n. 
 
Tre at me nt C o m pli a nce  
A d here n ce t o me dicati o n re gi mes will be descri be d i n ter ms of perce nt of me dicati o n ta ke n 
(act ual or re p ort e d) f or d asati ni b a n d q uerceti n a n d c o m pare d b et wee n t h e gr o u ps. 
 
Fe asi bilit y Assess me nt  
We will c o n d uct a feasi bilit y assess me nt at 5 0 % e nr oll me nt t o assess f or a n y det ecta ble c ha n ges 
i n t he treat me nt ar m. 
 
8  S afet y a n d A d verse  E ve nts  
C o m m o n Ter mi n ol o g y Criteria f or A d vers e E ve nts ( C T C A E) is wi del y acce pte d t hr o u g h o ut t he 
ca ncer a n d H S C T c o m m u nit y as t he sta n d ar d classificati o n a n d se verit y gra di n g scale f or 
a d verse e ve nts i n ca n cer t hera p y cli nical trials a n d ot her o nc ol o g y setti n gs. T he Nati o nal Ca ncer 
I nstit ute p u blis he d t he C o m m o n Ter mi n ol o g y Criteria f or A d v erse E ve nts ( C T C A E) versi o n 4. 0 
o n Ma y 2 8, 2 0 0 9 ( v 4. 0 3: J u ne 1 4, 2 0 1 0). T he t o xicities i n t he i nter ve nti o n gr o u p will be assesse d 
b y t his scale. T h e 1 9 6 pa ge d o c u me nt f or C T C A E V 4 ca n be f o u n d o n t his we bsite 
htt p://e vs. nci. ni h. g o v/ft p 1/ C T C A E/ C T C A E _ 4. 0 3 _ 2 0 1 0- 0 6- 1 4 _ Q uic k Refere nce _ 5 x 7. p df  
(accesse d 7/ 7/ 2 0 1 5) 
 
8. 1  
Defi niti o ns  
U n a ntici p ate d Pr o ble ms I n v ol vi n g R is k t o S u bjects or Ot hers ( U PI R T S O) 
A n y u n a ntici pate d pr o ble m or a d verse e ve nt t hat meets t he f oll o wi n g t hree criteria:  
 Seri o us : Seri o us pr o ble ms or e ve nts t hat res ults i n si g nifica nt h ar m, ( w hic h ma y b e 
p h ysical, ps yc h ol o gi cal, fi na ncial, s ocial, ec o n o mic, or le gal) or i ncrease d ris k f or t he 
s u bject or ot hers (i ncl u di n g i n di vi d uals w h o are n ot researc h s u bjects). T h ese i ncl u de: ( 1) 
deat h; ( 2) life t hr eate ni n g a d verse e x perie nce; ( 3) h os pitalizati o n - i n patie nt, ne w, or 

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pr ol o n ge d; ( 4) disa bilit y/i nca pacit y - p ersiste nt or si g nifica nt; ( 5) birt h defect/a n o mal y; ( 6) 
breac h of c o nfi d e ntialit y a n d ( 7) ot her pr o ble ms, e ve nts, or ne w i nf or m ati o n (i.e. 
p u blicati o ns, D S M B re p orts, i nteri m fi n di n gs, pr o d uct la beli n g c ha n ge) t h at i n t he o pi ni o n 
of t he l ocal i n vesti gat or ma y a d vers el y affect t he ri g hts, safet y, or w elfare of t he s u bjects 
or ot hers, or s u bsta ntiall y c o m pr o mise t he res earc h data, A N D  
•  U na ntici pate d: (i.e. u n e x pecte d) pr o ble ms or e v e nts are t h ose t hat are n ot alrea d y 
descri be d as p ote ntial ris ks i n t he pr ot oc ol, c o nse nt d oc u me nt, n ot liste d i n t he 
I n v esti gat or’s Br oc h ure, or n ot part of a n u n d erl yi n g diseas e. A pr o bl e m or e ve nt is 
" u na ntici pat e d" w he n it was u nf oreseea ble at t he ti me of its occ urre n ce. A pr o ble m  or 
e ve nt is " u na ntici pate d" w he n it occ urs at a n i ncrease d fre q ue n c y or at a n i ncreas e d 
se verit y t ha n e x pecte d, A N D  
 Relate d: A pr o ble m or e v e nt is "rel ate d" if it is p ossi bl y relat e d t o t he res earc h  pr o ce d ures.  
 
A d verse E ve nt  
A n u nt o war d or u n d esira ble e x perie nce ass ociate d wit h t he use of a me dical pr o d uct (i.e. dr u g, 
de vice, bi ol o gic) i n a p atie nt or resear c h s u bject.  
Seri o us A d verse E ve nt  
A d verse e ve nts ar e classifie d as seri o us or n o n -seri o us. Seri o us pr o ble ms/e ve nts ca n be well 
defi ne d a n d i ncl u d e; 
 deat h  
 life t hreate ni n g a d vers e e x perie nce  
 h os pitalizati o n  
 i n patie nt, ne w, or pr ol o n ge d; disa bilit y/i nca p acit y  
 persiste nt or si g nifi ca nt birt h  defect/a n o mal y  
 
a n d/ or per pr ot o c ol ma y be pr o ble ms/e ve nts t hat i n t he o pi ni o n of t he s p o ns or- i n vesti gat or ma y 
ha ve a d v ersel y affecte d t he ri g hts, s afet y, o r welfare of t he s u bjects or ot hers, or s u bsta ntiall y 
c o m pr o mise d t he res ear c h data.  
 
All a d verse e ve nts t hat d o n ot meet a n y of t he criteria f or s eri o us, s h o ul d b e re gar de d as n o n- 
seri o us a d verse e v e nts. 
 
A d verse E ve nt R e p orti n g Peri o d  
F or t his st u d y, t he st u d y treat me nt f oll o w- u p p eri o d is defi ne d as 1 2 m o nt hs. T he a d verse e v e nt 
re p orti n g peri o d e n ds w h e n t he s u bject c o m pletes t he st u d y ( 1 2 m o nt hs). 
 
Pree xisti n g C o n diti o n 
A pree xisti n g c o n diti o n is o ne t hat is prese nt at t h e start of t he st u d y. A pree xisti n g c o n diti o n 
s h o ul d be rec or de d as a n a d verse e ve nt if t he fre q u e nc y, i nte nsit y, or t he c h aract er of t he 
c o n diti o n w orse ns d uri n g t he st u d y peri o d. 
 
I n t he C K D a n d dia b etes patie nt p o p ulati o n, s y m pt o ms ass ociate d wit h ure mia or dia betes ma y 
be prese nt at baseli ne. T h ese ma y i ncl u de: na us ea, v o miti n g, diarr hea, pr urit us, ras h, c hr o nic 
pai n, h y p o gl yce mic reacti o ns, a n d hea dac hes. We a ntici pate t hat i n t his patie nt p o p ulati o n t hese 
ma y b e e x acer b ate d wit h ma n y n e w dr u gs i nitiate d f or cli nical or researc h p ur p oses. If it is 

Se nesce nce a n d Frailt y i n C K D 
1 5 -0 0 5 8 4 3  
V ersi o n 8. 0 
Re vise d 0 4/ 1 9/ 2 0 1 9  
 
P a ge 3 2  of 4 5 
 
deter mi ne d b y t he PI t hat t hese s y m pt o ms were prese nt pri or t o i nitiati o n of t he dr u gs, t h e y will 
n ot be c ollecte d as a d verse e ve nts.  
 
Ge ner al P h ysic al E x a mi n ati o n Fi n di n gs 
At scree ni n g, a n y cli nicall y si g nifica nt a b n or malit y s h o ul d be re c or de d as a pree xisti n g 
c o n diti o n. At t he e n d of t he st u d y, a n y ne w cli nicall y si g nifi ca nt fi n di n gs/a b n or malities t hat 
meet t he defi niti o n of a n a d verse e ve nt m ust als o be rec or de d a n d d oc u me nte d as a n a d v erse 
e ve nt.  
 
P ost -st u d y A d verse E ve nt 
All u nres ol ve d a d verse e ve nts s h o ul d be f oll o we d b y t he s p o ns or-i n vesti gat or u ntil t he e ve nts are 
res ol ve d, t he s u bject is l ost t o f oll o w- u p, or t he a d verse e v e nt is ot her wise e x plai ne d. At t he last 
sc he d ule d visit, t he s p o ns or-i n vesti gat or s h o ul d i nstr uct eac h s u bj ect t o re p ort, t o t he s p o ns or- 
i n vesti gat or, a n y s u bse q u e nt e ve nt(s) t hat t he s u bj ect, or t he s u bject’s pers o nal p h ysicia n, 
belie ves mi g ht r eas o na bl y be relate d t o p artici pati o n i n t his st u d y.  
 
A b n or m al L a b or at or y V al ues 
T he f oll o wi n g cli nical la b orat or y a b n or malit y s h o ul d be d oc u me nte d as a n a d verse e ve nt if …  
 
1.  Ac ute ki d ne y i nj ur y o n c hr o nic ki d ne y disease i n t he I nter v e nti o n gr o u p: 
•  Rise i n ser u m creati ni ne > 0. 3 m g/ d L wit hi n 1 4 da ys after e ntr y i n t he st u d y 
•  D o u bli n g of ser u m creati ni ne 
2.  Ne w o nset ne p hr otic s y n dr o me ( h y p oal b u mi ne mi a, d ysli pi de mia, ne w o ns et ne p hr otic 
ra n ge pr ot ei n uria, e d e ma, li pi d uria) i n t he I nt er ve nti o n gr o u p. 
H os pit aliz ati o n, Pr ol o n ge d H os pit aliz ati o n or S ur ger y 
A n y a d vers e e ve nt t hat r es ults i n h os pitalizati o n or pr ol o n ge d h os pitalizati o n s h o ul d be 
d oc u me nte d a n d r e p orte d as a seri o us a d v erse e ve nt u nless s pecificall y i nstr ucte d ot her wise i n 
t his pr ot oc ol. A n y c o n diti o n res p o nsi ble f or s ur ger y s h o ul d be d o c u me nte d as a n a d verse e v e nt 
if t he c o n diti o n meets t he criteria f or a n a d vers e e v e nt. 
 
T he f oll o wi n g h os pitalizati o ns will n ot be c o nsi dere d S A E f or t his st u d y: 
 a visit t o t he e mer ge nc y de part me nt or ot her h os pital de part me nt < 2 4 h o urs, t hat d oes n ot 
res ult i n a d missi o n ( u nless c o nsi dere d a n i m p orta nt me dical or life-t hreate ni n g e v e nt)  
 electi ve s ur ger y, pla n ne d pri or t o si g ni n g c o ns e nt  
 a d missi o ns as per pr ot oc ol f or a pla n ne d m e dical/s ur gical pr oce d ure  
 r o uti ne healt h assess me nt re q uiri n g a d missi o n f or baseli ne/tre n di n g of healt h stat us (e. g. 
r o uti ne ma m m o gra m)  
 me dical or s ur gical a d missi o n ot her t ha n t o re me d y ill healt h a n d pla n n e d pri or t o e ntr y 
i nt o t he st u d y. A p pr o priate d oc u me ntati o n is re q uire d i n t hese cases  
 
8. 2  
Rec or di n g of A d verse  E ve nts  
At eac h c o ntact wit h t he s u bject, t he st u d y tea m m ust see k i nf or mati o n o n a d verse e v e nts b y 
s pecific q uesti o ni n g a n d, as a p pr o priat e, b y e x a mi nati o n. I nf or mati o n o n all a d verse e ve nts 
s h o ul d be rec or de d i m me diatel y i n t he s o urce d o c u me nt, a n d als o i n t he a p pr o priate a d v erse 
e ve nt secti o n of t he case re p ort f or m ( C R F) or i n a se parat e a d verse e v e nt w or ks heet. All clearl y 
relate d si g ns, s y m pt o ms, a n d a b n or mal dia g n ostic, la b orat or y or pr oce d ure res ults s h o ul d 
rec or d e d i n t he s o urce d o c u me nt. 

Se nesce nce a n d Frailt y i n C K D 
1 5 -0 0 5 8 4 3  
V ersi o n 8. 0 
Re vise d 0 4/ 1 9/ 2 0 1 9  
 
P a ge 3 3  of 4 5 
 
 
All a d verse e ve nts occ urri n g d uri n g t he st u d y peri o d m ust be rec or d e d. T he cli nical c o urse of 
eac h e ve nt s h o ul d be f oll o we d u ntil res ol uti o n, sta bilizati o n, or u ntil it has bee n ulti matel y 
deter mi ne d t hat t he st u d y treat me nt or partici pati o n is n ot t he pr o ba ble ca us e. Seri o us a d verse 
e ve nts t hat ar e still o n g oi n g at t he e n d of t he st u d y peri o d m ust be f oll o we d u p, t o deter mi ne t he 
fi nal o utc o me. A n y seri o us a d verse e ve nt t hat occ urs after t h e st u d y p eri o d a n d is c o nsi dere d t o 
be at least p ossi bl y relate d t o t he st u d y treat me nt or st u d y partici pati o n s h o ul d be rec or de d a n d 
re p orte d i m me diatel y. 
 
8. 3  
Re p orti n g of Se ri o us A d verse E ve nts a n d U n a ntici p ate d  Pr o ble ms  
W he n a n a d vers e e ve nt h as bee n i de ntifie d, t h e st u d y tea m will ta ke a p pr o priate d acti o n 
necessar y t o pr otect t he st u d y partici p a nt a n d t he n c o m plete t he St u d y A d v erse E ve nt W or ks heet 
a n d l o g. T h e s p o ns or-i n v e sti gat or will e val uate t h e e ve nt a n d d eter mi ne t h e necessar y f oll o w- u p 
a n d re p orti n g r e q uire d. 
 
8. 3. 1  I n vesti g at or re p orti n g: n otif yi n g t he M a y o I R B 
T he I n vesti gat or will re p ort t o t he Ma y o I R B a n y U PI R T S Os a n d N o n- U PI R T S Os acc or di n g t o 
t he Ma y o I R B P olic y a n d Pr oce d ures.  
 
I nf or mati o n c ollect e d o n t he a d vers e e ve nt w or ks h eet (a n d e ntere d i n t he researc h d ata bas e): 
 S u bject  i de ntifier: 
 T he date t he a d vers e e ve nt  occ urre d:  
 Descri pti o n of t he a d v ers e e ve nt:  
 Relati o ns hi p of t he a d verse e ve nt t o t he researc h  dr u g  
 If t he a d v erse e ve nt was e x pecte d:  
 Gra de a n d  attri b uti o n 
 T he se verit y of t h e a d verse e ve nt: ( use a ta ble t o d efi ne se v erit y s cale  1- 5) 
 If a n y i nter v e nti o n was necessar y:  
 Res ol uti o n: ( was t he i nci de nt res ol ve d s p o nta ne o usl y, or after disc o nti n ui n g treat me nt) 
 D ate of  Res ol uti o n: 
 
T he i n vesti gat or will re vi e w all a d verse e v e nt re p orts t o deter mi ne if s pecific re p orts nee d t o be 
ma de t o t he I R B a n d F D A. T he i n vesti gat or will si g n a n d d ate t he a d v erse e ve nt re p ort w he n it 
is re vie we d. F or t his pr ot oc ol, o nl y directl y relate d S A Es/ U PI R T S Os will be re p ort e d t o t he 
I R B. 
 
8. 3. 2  S p o ns or -I n vesti g at or re p orti n g: N otif yi n g t he F D A  
T he s p o ns or-i n vesti gat or will re p ort t o t he F D A all u ne x pecte d, seri o us s us p ecte d a d v erse 
reacti o ns acc or di n g t o t h e re q uir e d I N D Safet y Re p orti n g ti meli nes, f or mats a n d re q uire m e nts. 
 
U ne x pecte d fatal or life t hreate ni n g s us pecte d a d v erse reacti o ns w h ere t here is e vi de nce t o 
s u g gest a ca us al relati o ns hi p bet wee n t he st u d y dr u g/ place b o a n d t he a d verse e ve nt, will be 
re p orte d as a seri o us s us p ecte d a d v erse reacti o n. T his will be re p orte d t o t he F D A o n F D A F or m 
3 5 0 0 A, n o later t ha n 7 cale n dar da ys after t h e s p o ns or- i n vesti gat or’s i nitial recei pt of t h e 
i nf or mati o n a b o ut t he e v e nt. 
 
Ot her u ne x pecte d seri o us s us pecte d a d v erse reacti o ns w here t here is e vi de n ce t o s u g gest a ca usal 

Se nesce nce a n d Frailt y i n C K D 
1 5 -0 0 5 8 4 3  
V ersi o n 8. 0 
Re vise d 0 4/ 1 9/ 2 0 1 9  
 
P a ge 3 4  of 4 5 
 
relati o ns hi p bet wee n t h e st u d y dr u g/ place b o a n d t he a d vers e e v e nt, will be re p orte d as a seri o us 
s us pecte d a d v erse reacti o n. T his will be re p orte d t o t he F D A o n F D A F or m 3 5 0 0 A, n o later t ha n 
1 5 cale n dar da ys after t h e s p o ns or-i n v esti gat or’s i nitial recei pt of t he i nf or mati o n a b o ut t he 
e ve nt.  
 
A n y cli nicall y i m p orta nt i ncreas e i n t h e rate of seri o us s us pecte d a d verse reacti o ns o ver t h ose 
liste d i n t he pr ot o c ol or pr o d uct i nsert will be re p orte d as a seri o us s us p ecte d a d verse reacti o n. 
T his will be re p orte d t o t he F D A o n F D A F or m 3 5 0 0 A n o later t ha n 1 5 cal e n dar d a ys after t he 
s p o ns or-i n vesti gat or’s i nitial recei pt of t he i nf or mati o n a b o ut t he e ve nt. 
 
Fi n di n gs fr o m ot her st u di es i n h u ma n or a ni mals t hat s u g gest a si g nifi ca nt ris k i n h u ma ns 
e x p ose d t o t he dr u g will be re p ort e d. T his will be re p orte d t o t he F D A o n F D A F or m 3 5 0 0 A, n o 
later t ha n 1 5 cale n dar da ys after t he s p o ns or-i n vesti gat ors i nitial recei pt of t he i nf or mati o n a b o ut 
t he e ve nt. 
 
8. 4  
St o p pi n g  R ules  
All patie nts will be assesse d  d uri n g t he 3 da ys of dr u g a d mi nistrati o n a n d d uri n g t he d a y 1 4 visit. 
If a se ver e a d vers e e ve nt occ urs at a n y ti me d uri n g a d mi nistrati o n of t he 3-da y dr u g re gi me n, a 
f or mal re vie w will occ ur a n d s u bse q ue nt patie nts will be e nr olle d o ne at a ti me usi n g t he sa me 
re gi me n. If t hr ee or m or e e ve nts accr ue, t he pil ot st u d y will be hel d a n d eit her a p ote ntial d osi n g 
re gi me n re visite d or disc o nti n uati o n of t he st u d y pr ot oc ol will occ ur. Ot her i nter ve nti o ns will be 
as per t he dir ecti o n of t he F D A a n d M a y o I R B. 
 
8. 5  
Me dic al  M o nit ori n g  
It is t he r es p o nsi bilit y of t he Pri nci pal I n vesti gat or t o o versee t he s afet y of t he st u d y at his/ her 
site. T his safet y m o nit ori n g will i ncl u de caref ul assess me nt a n d a p pr o priate re p orti n g of a d v erse 
e ve nts as n ote d a b o v e, as well as t he c o ns tr ucti o n a n d i m ple me ntati o n of a site data a n d safet y- 
m o nit ori n g pla n (see secti o n 1 0 “ St u d y M o nit ori n g, A u diti n g, a n d I ns p ecti n g”). Me dical 
m o nit ori n g will i ncl u de a re g ular assess me nt of t h e n u m ber a n d t y pe of seri o us a d verse e ve nts. 
 
8. 5. 1  D at a a n d S af et y M o nit ori n g B o ar d or D at a S afet y M o nit ori n g Pl a n  
T here will n ot be a f or mal D S M B h o we ver we will ha ve a D S M P a n d t he PI will m o nit or. 
 
9  D at a H a n dli n g a n d Rec or d  Kee pi n g  
9. 1  
C o nfi de nti alit y  
I nf or mati o n a b o ut st u d y s u bjects will be ke pt c o nfi de ntial a n d ma na ge d acc or di n g t o t he 
re q uire me nts of t h e Healt h I ns ura nce P orta bilit y a n d Acc o u nta bilit y Act of 1 9 9 6 ( HI P A A). 
T h ose re g ulati o ns re q uire a si g ne d s u bj ect a ut h orizati o n i nf or mi n g t he s u bject of t he f oll o wi n g: 
 W hat pr otecte d healt h i nf or mati o n ( P HI) will be c ollecte d fr o m s u bjects i n t his  st u d y 
 W h o will ha ve access t o t hat i nf or mati o n a n d w h y  
 W h o will use or discl ose t hat i nf or mati o n 
 T he ri g hts of a r esearc h s u bject t o re v o ke t heir a ut h orizati o n f or use of t heir P HI.  
I n t he e ve nt t hat a s u bj ect re v o kes a ut h orizati o n t o c ollect or use P HI, t he i n vesti gat or, b y 
re g ulati o n, retai ns t he a bilit y t o use all i nf or mati o n c ollecte d pri or t o t he re v ocati o n of s u bject 
a ut h orizati o n. F or s u bjects t hat ha ve re v o k e d a ut h orizati o n t o c ollect or use P HI, atte m pts 
s h o ul d be ma de t o o btai n per missi o n t o c ollect at least vital stat us (l o n g ter m s ur vi val stat us t hat 

Senescence and Frailty in CKD 
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the subject is alive) at the end of their scheduled study period. 
 
9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents. Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ 
diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories, and at medico-technical departments involved 
in the clinical trial. 
 
9.3 
Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study. Case 
reports in the form of completed checklists will be kept to assure inclusion/exclusion criteria and 
review of adverse events/toxicity. All data requested on the CRF must be recorded; data will be 
entered directly into REDCap. All missing data must be explained. If a space on the CRF is left 
blank because the procedure was not done or the question was not asked, write “N/D”.  If the 
item is not applicable to the individual case, write “N/A”. All entries should be printed legibly in 
black ink. If any entry error has been made, to correct such an error, draw a single straight line 
through the incorrect entry and enter the correct data above it. All such changes must be initialed 
and dated.  Do not erase or use “white-out” for errors.  For clarification of illegible or uncertain 
entries, print the clarification above the item, then initial and date it. If the reason for the 
correction is not clear or needs additional explanation, neatly include the details to justify the 
correction. 
 
Data Management 
The data will be housed in both hard copy case report forms (CRFs) and eCRFs through a 
system called REDCap. 
 
Data Security and Confidentiality 
Source documents and CRFs and original consents will be stored in secured locations. All data 
will be entered into a password protected, limited access database. Individually-identifiable 
patient history and medical record information will be stored in a database under coded 
accession numbers. Clinical  laboratory values are stored in the electronic medical record 
system, requiring protected password access. These data are monitored regularly for access and 
a formal policy regarding protection of personal privacy is in place throughout each institution. 
The key to identification of  subjects will be maintained in a secure office environment under 
the direction of the principal investigators. 
 
Data Quality Assurance 
Manual and computerized quality checks will occur during data collection and analyses and any 
discrepancies will require Case Report Form (CRF) review and validation of correct data. 
 
9.4 
Records Retention 
The principle investigator will maintain records and essential documents related to the conduct 

Se nesce nce a n d Frailt y i n C K D 
1 5 -0 0 5 8 4 3  
V ersi o n 8. 0 
Re vise d 0 4/ 1 9/ 2 0 1 9  
 
P a ge 3 6  of 4 5 
 
of t he st u d y. T h ese will i ncl u de s u bject case hist ories a n d re g ul at or y d oc u me nts. T he 
i n vesti gat or will ret ai n t he s pecifie d rec or ds a n d re p orts f or; 
 U p t o 2 years after us e of t he dr u g; or, u ntil 2 years after s hi p me nt a n d d eli ver y of t he 
dr u g f or i n vesti gati o nal use is disc o nti n ue d a n d t he F D A h as bee n s o n otifie d. Or 
w hic he ver is  l o n ger. 
•  2. As o utli ne d i n t he Ma y o Cli nic Researc h P olic y Ma n ual – “ Rete nti o n of a n d Access  t o 
Researc h Data P olic y” htt p:// ma y o c o nte nt. m a y o.e d u/researc h - p olic y/ M S S _ 6 6 9 7 1 7 T he 
s pecifie d r ec or ds a n d re p orts are o utli ne d i n t he M a y o Cli nic Researc h P oli c y M a n ual – 
“ Rete nti o n of a n d A ccess t o Researc h Data P olic y”  
htt p:/ / ma y o c o nte nt. ma y o.e d u/researc h- p olic y/ M S S _ 6 6 9 7 1 7 
 
1 0  St u d y M o nit ori n g, A u diti n g, a n d  I ns pecti n g 
1 0. 1  St u d y M o nit ori n g  Pl a n  
T he i n vesti gat or will all ocate a de q uat e ti me f or s u c h m o nit ori n g acti vities. T he I n vesti gat or will 
als o e ns ure t h at t he m o nit or or ot her c o m p lia nce or q ualit y ass ura n ce re vie wer is gi ve n access t o 
all t he st u d y-r elate d d o c u me nts a n d st u d y relate d facilities (e. g. p har m ac y, dia g n ostic la b orat or y, 
etc.), a n d h as a de q u ate s p ace t o c o n d u ct t he m o nit ori n g visit. 
 
As a ser vice t o t he s p o ns or- i n vesti gat or, t his st u d y ma y b e m o nit ore d d uri n g t he c o n d uct of t he 
trial b y staff fr o m t he M a y o Cli nic Office of Res earc h Re g ulat or y S u p p ort. Cli nical trial 
m o nit ori n g ma y i ncl u de r e vie w of t he st u d y d oc u me nts a n d data ge n erat e d t hr o u g h o ut t he 
d urati o n of t he st u d y t o h el p e ns ure t he v ali dit y a n d i nte grit y of t he d ata al o n g wit h t he  
pr otecti o n of h u ma n r esearc h s u bjects. T his will assist s p o ns or- i n vesti gat ors i n c o m pl yi n g wit h 
F o o d a n d Dr u g A d mi nistrati o n re g ulati o ns. 
 
1 0. 2  A u diti n g a n d  I ns pecti n g 
T he i n vesti gat or will  per mit st u d y -relate d m o nit ori n g, a u dits, a n d i ns pecti o ns b y t he I R B, t he 
s p o ns or, a n d g o ver n me nt re g ulat or y a ge ncies, of all st u d y relate d d o c u me nts (e. g. s o urce 
d oc u me nts, re g ulat or y d o c u me nts, data c ollecti o n i nstr u me nts, st u d y data etc.). T he i n vesti ga t or 
will e ns ure t he ca pa bilit y f or i ns pecti o ns of a p plica ble st u d y- relat e d facilities (e. g. p har mac y, 
dia g n ostic la b orat or y, et c.). 
 
Partici pati o n as a n i n vesti gat or i n t his st u d y i m plies acce pta nce of p ote ntial i ns pecti o n b y 
g o ver n me nt re g ul at or y a ut h orities a n d a p plica ble c o m plia nce offices.  
 
1 1  Et hic al C o nsi der ati o ns  
T his st u d y is t o be c o n d u cte d acc or di n g t o U nite d States g o ver n me nt re g ulati o ns a n d 
I nstit uti o nal researc h p oli cies a n d pr o ce d ures. 
 
T his pr ot oc ol a n d a n y a m e n d me nts will be s u b mitte d t o a pr o perl y c o nstit ute d l ocal I nstit uti o nal 
Re vie w B o ar d (I R B), i n a gree m e nt wit h l ocal le gal prescri pti o ns, f or f or m al a p pr o val of t h e 
st u d y. T he d ecisi o n of t h e I R B c o ncer ni n g t h e c o n d uct of t he st u d y will be ma de i n writi n g t o 
t he s p o ns or-i n vesti gat or bef ore c o m me nce me nt of t his st u d y. 
 
All s u bjects f or t his st u d y will be pr o vi de d a c o ns e nt f or m descri bi n g t his st u d y a n d pr o vi di n g 
s ufficie nt i nf or mati o n f or s u bjects t o ma ke a n i nf or me d decisi o n a b o ut t heir partici pati o n i n t his 

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study. This consent form will be submitted with the protocol for review and approval by the IRB 
for the study. The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed 
by the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent. 
 
12 Study Finances 
12.1 Funding Source 
This study is financed through a grant from the 2015 DOM Research Career Development 
Award and provided by the National Institute of Health (NIH). 
 
12.2 Conflict of Interest 
Any study team member who has a conflict of interest with this study (patent ownership, 
royalties, or financial gain greater than the minimum allowable by their institution, etc.) must 
have the conflict reviewed by a properly constituted Conflict of Interest Committee with a 
Committee-sanctioned conflict management plan that has been reviewed and approved by the 
study sponsor-investigator prior to participation in this study. 
 
12.3 Subject Stipends or Payments 
Subject remuneration will consist of $175 for each fat+skin biopsy performed and an 
additional $75 if they complete the four month visit. If subject screen fails during first 
visit and does not undergo a fat/skin biopsy, remuneration will consist of $75. Subjects 
will receive parking passes for the time involved with completing the study visits or taxi 
reimbursement to attend study visits with the exception of month 12.  Subjects will be 
directed where to park in order to receive the parking passes. In addition, subjects will be 
provided a Mayo pen for participation in the study. 
 
Minority subjects recruited from off-site sites will be reimbursed for airfare, hotel 
accommodations, and food up to an allowable maximum amount as follows: Mileage per driven 
mile: Your reimbursement for travel is calculated on the actual round trip miles you travel from 
your home address to the Mayo Clinic and back as determined by a web-based mileage calculator 
(e.g. ,MapQuest). This distance will be documented in the subjects study file. They will receive 
reimbursement at the current IRS determined rate. Flight costs to and from the nearest airport to 
Rochester International Airport or MSP. Shuttle service or cab service from the airport (RST or 
MSP) to Mayo Clinic. Overnight hotel accommodations up to $150.00 dollars per night for max 2 
night stay. Airport parking costs at your home airport. Meal per diem of $75.00 dollars.   
 
Please see Patient Contact Material: Travel Information for details.  
 
13 Publication Plan 
 
The principle investigator, Dr. Hickson, holds the primary responsibility for publication of the 
results of the study. 
 
We will register with ClinicalTrials.gov prior to subject recruitment and enrollment. We will 
post results to ClinicalTrials.gov within 12 months of final data collection for the primary 

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outcome. 

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Fitoterapia. 2011;82:920-926. 
 
Appendices 
 
Appendix 1. Strong Inhibitors of CYP3A4 
Boceprevir 
Clarithromycin 
Conivaptan 
Indinavir 
Itraconazole 
Ketoconazole 
Lopinavir/ritonavir 
Nefazodone 
Nelfinavir 
Posaconazole 
Ritonavir 
Saquinavir 
Telaprevir 
Telithromycin 
Voriconazole 
 
Appendix 2. Strong inducers of CYP3A4 
Carbamazepine 
Phenytoin 
Rifampin 
St. John’s wort 
 
Appendix 3. Major or sensitive substrates of CYP2C8, CYP2C9, CYP2D6 and CYP3A4 
 
Sensitive substrate 
Substrate 
with 
narrow 
therapeutic range 
CYP2C8 
Repaglinide 
Paclitaxel 
CYP2C9 
Celecoxib 
Warfarin, phenytoin 
CYP3A 
Alfentanil, 
aprepitant, 
budesonide, 
buspirone,
conivaptan, 
darifenacin, 
darunavir, 
dasatinib,
dronedarone, 
eletriptan, 
eplerenone, 
everolimus,
felodipine, indinavir, fluticasone, lopinavir, lovastatin,
lurasidone, 
maraviroc, 
midazolam, 
nisoldipine,
quetiapine, 
saquinavir, 
sildenafil, 
simvastatin,
sirolimus,     tolvaptan,   tipranavir, 
triazolam, vardenafil 
Alfentanil, 
cyclosporine, 
dihydroergotamine, 
ergotamine,  
fentanyl, 
pimozide, 
quinidine, 
sirolimus, tacrolimus, 

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CYP2D6 
Atomoxetine, 
desipramine, 
dextromethorphan, 
metoprolol, 
nebivolol, 
perphenazine, 
tolterodine, 
venlafaxine 
Thioridazine 
Sensitive CYP substrates refer to drugs whose plasma AUC values have been shown to increase 
5-fold or higher when co-administered with a known CYP inhibitor. 
CYP substrates with narrow therapeutic range refers to drugs whose exposure-response 
relationship indicates that small increases in their exposure levels by the concomitant use of CYP 
inhibitors may lead to serious safety concerns (e.g., Torsades de Pointes). 
 
Appendix 4: Frailty Phenotyping 
The following tests will be administered to determine frailty phenotyping (index) using the 
following criteria: 
 
• Weakness: Grip strength of the dominant hand will be tested using a Jamar electronic 
hand held dynamometer. Three serial measurements will be taken and the mean 
calculated. Strength measurements will be normalized by gender and body mass index. 
Weakness will be defined as grip strength in the lowest 20th percentile of a community 
dwelling population of adults 65 years and older. 
 
• Slow Walking Speed: Time to walk 5 meters will be measured using a handheld 
ultrasonic measuring device. Subjects will be instructed to walk at their usual 
comfortable pace. Walking aids such as canes and walkers may be used if needed. Three 
separate trials will be collected. Subjects will meet the slow walking speed criteria if the 
average time to walk the 5-meter course is ≥ 6 seconds. 
 
• Poor Endurance and energy:  Is indicated by self-report of exhaustion.  Subjects will be 
asked two questions from the Center for Epidemiological Studies Depression Scale 
(CES-D): 1) I felt that everything I did was an effort, and 2) I could not get going. 
Subjects who answer “a moderate amount of time (3-4 days)” or “most of the time (5-7 
days)” to either of the statements will be categorized as meeting the exhaustion criteria of 
the frailty scale. 
 
• Unintended Weight Loss: Subjects will be asked if they have unintentionally lost ≥ 10 
pounds in the prior year.  An affirmative response fulfills this criterion. 
 
• Low Physical Activity Level: A weighted score of kilocalories expended per week will 
be calculated at baseline using the Physical Activity Scale for the Elderly (PASE).  This 
is an easily administered and scored instrument that measures the level of physical 
activity in individuals aged 65 or older.  The PASE is a 10 item instrument which 
assesses the frequency and duration of participation in; 1) leisure activities ( e.g., walking 
outside the home, light, moderate and strenuous sport and recreation), 2) household 
activities ( dusting, washing dishes,  vacuuming, home repairs, lawn work, gardening) 
and 3) work-related activities (e.g., amount of physical activity required on the job). 
Weekly activity level can be converted to equivalent kilocalories of expenditure, and 
individuals reporting a weekly kilocalorie expenditure in the lowest 20th percentile for 
their gender (men, <383 kcal/week; women<270 kcal/week) were classified as having 

Senescence and Frailty in CKD 
15-005843 
Version 8.0 
Revised 04/19/2019 
 
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low physical activity.