Clinical trial NCT02631148
Conditions: Obesity Prediabetic State
Sponsor: Brigham and Women's Hospital
Start date: 2016-01-01; Completion date: 2017-12-31
Enrollment: 12 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
In a 6 week pilot study, 20 individuals with habitual sleep restriction will all be asked to extend their nightly sleep by 1 hour, and will then be randomized 1:1 to nightly controlled-release oral melatonin (2mg) or placebo. The investigators will assess whether sleep extension and nightly melatonin supplementation in the community is a feasible intervention with a beneficial effect on the following chronic kidney disease (CKD) risk factors: systemic and renal specific renin-aldosterone-angiotensin system (RAAS) activation (systemic plasma renin activity, plasma angiotensin II levels, 24-hour urine aldosterone excretion, and renal plasma flow response to captopril); nocturnal blood pressure measured by 24-hour ambulatory blood pressure monitor; central blood pressure measured by pulse wave analysis; and glucose metabolism measured by Minimal Model assessment of insulin resistance and β-cell response to a mixed meal protocol.

Detailed description:
The investigators will recruit individuals from the Boston area who meet the inclusion and exclusion criteria. The investigators will include both men and women and all races and ethnicities. The only exception will be women who are pregnant because certain medications used during the inpatient evaluations (e.g., nitroglycerine), and certain study medications (i.e., captopril) are contraindicated during pregnancy.

Participant Enrollment

Responders to advertisements will be pre-screened by telephone to obtain a body mass index (BMI) estimate and a medical history to gauge potential eligibility. For participants who may be eligible following this phone query, the basic study schema will be described to identify those who remain interested in participation after learning the duration, inpatient requirements, and potential medication use. These individuals will then be invited to attend an outpatient screening visit.

The pilot study is a double-blind, placebo-controlled randomized trial, in which 16 subjects with obesity (body mass index \[BMI\] ≥30 kg/m2), pre-diabetes (hemoglobin A1C \[HbA1C\], 5.7-6.4%), and self-reported short sleep duration (\<7 hours/night) are randomly assigned 1:1 to receive either placebo or 2 mg of controlled-release melatonin, taken orally every evening 1 hour before bed for 6 weeks. All subjects will be asked to extend their sleep time by one hour during the 6 week period between inpatient visits. Endpoints will be measured at both the baseline and 6-week inpatient visits.

Screening Visit: Screening visits will take place at the Brigham and Women's Outpatient Center for Clinical Investigation During the outpatient screen, Dr. McMullan will explain the study in detail, review the consent form, and answer questions. After obtaining written informed consent for participation, a history and physical examination will be performed in order to initially judge eligibility based upon the criteria set out in that section of this record. Participants deemed potentially eligible based upon the screening history and exam will undergo phlebotomy and analysis for HbA1c, serum chemistries and glucose, and complete blood count (CBC) to confirm eligibility using the criteria presented in the table.

Study Procedures Pre-admission: All participants will wear a wrist activity monitor for a total of 8 weeks; 2 weeks prior to the baseline inpatient visit and for the 6 weeks between inpatient visits. Participants will complete a daily sleep log during the 2 weeks preceding each visit. Three days before admission, participants will be placed on a high salt diet by supplementing their usual diet with 150 millimoles (mmol) sodium/day for 3 days using dry bouillon added to food.

Treatment assignments: Prior to admission for the baseline visit, participants will be randomized (1:1) to receive study medication (melatonin 2mg of controlled release formulation or placebo). All participants will be asked to extend their sleep time by one hour during the 6 week period between inpatient visits.

Baseline and Follow-up inpatient visit: Baseline and 6-week inpatient visits will be virtually identical. Each inpatient visit will begin at 4:00PM on Day 0 and end at 4:00 PM on Day 1.

Day 0 - All participants will begin 24 hour urine collection on admission to the Brigham and Women's Hospital Center for Clinical Investigation (CCI) on the evening of day 0. The 24-hour urine collection will be continued overnight (nurses will keep the daytime (8AM to 8PM) and nighttime (8PM to 8AM) urine separate to permit analysis of diurnal variation in urinary analytes). Subjects will fast after 9 pm to ensure a 12-hour fast by the next morning.

Day 1 -At 8 am, central blood pressure and vascular compliance will be assessed, followed at approximately 9 am by measurement of renal specific RAAS activity via para-aminohippurate (PAH) renal plasma flow testing with captopril, and systemic renin-aldosterone-angiotensin system (RAAS) will be measured by plasma renin activity (PRA), plasma angiotensin II (Ang II) and urine aldosterone. Next the participant will receive a mixed meal (10kcal/kg, 45% carbohydrate, 15% protein, 40% fat, 1g/kg glucose) to be consumed in 15 minutes with blood draws at 0, 10, 20, 30, 60, 90 and 120 minutes from the time the meal had begun to be consumed. Plasma glucose, insulin and c-peptide will be measured in all 7 samples of blood. The 24-hour urine collection will conclude at 4 pm on day 1 and will be used to measure 24-hour excretion of sodium and aldosterone. Finally the participant will be fitted with a Spacelabs 90207 ambulatory blood pressure (BP) monitor prior to discharge to be worn for 24-hours.

Follow-up - During the study, participants will be phoned weekly by a study coordinator to assess for compliance and potential side effects. Dr McMullan will call all subjects every 2 weeks to discuss difficulties encountered with their new sleep schedule, to recommend improvements and encourage compliance with the protocol.

Parameters Measured: At the inpatient visits, the following measurements will be made:

Renal Specific renin-aldosterone-angiotensin system (RAAS) - The activity of the local kidney RAAS can be measured by examining the change in effective renal plasma flow (RPF) after oral captopril while in high sodium balance. Effective RPF is measured as clearance of para-aminohippuric acid (PAH), because PAH is cleared solely and nearly entirely by the kidney. The protocol to measure PAH clearance is performed with the participant supine.

Systemic renin-aldosterone-angiotensin system (RAAS) - plasma renin activity (PRA) and angiotensin II (Ang II) levels will be measured on the first morning blood draw.

Central Blood Pressure - Will be measured using pulse wave analysis using the SphygmoCor system (AtCor Medical, West Ryde, New South Wales, Australia), which measures central blood pressure and arterial stiffness.

Glucose metabolism - Will be evaluated by applying the Oral Minimal Model method to the results of a 2 hour 7- measurement, mixed meal tolerance test.2 Subject will be given breakfast in the form of a mixed meal (10kcal/kg, 45% carbohydrate, 15% protein, 40% fat, 1g/kg glucose) which must be consumed within 15 minutes with glucose, insulin and c-peptide measured from arterialized blood drawn at 0, 10, 20, 30, 60, 90 and 120 minutes from start of meal. From the glucose, insulin and c-peptide measurements calculation of insulin sensitivity (reciprocal of insulin resistance) and β-cell responsivity will be calculated.

Data Collection:

This study will collect demographic information (age, self-described race and ethnicity, sex), and physical data (height, weight, screening blood pressure). Blood and urine samples will be analyzed for various biomarkers to collect the data necessary to carry out the specific aims, as described in the section above. All of these data will be recorded in association with a study identification (ID) number, and kept as secure excel files by the statistician and programmer. The only individually identifiable private data that will be collected are names, addresses, and contact phone numbers so that participants can be screened with follow-up phone calls, and they will be admitted to the inpatient CCI under their name. This personal information, however, will not be associated with the results obtained from the various tests performed, as the latter will be associated with a study ID number. The file linking the study ID number and the personally identifiable information will be kept by the Principal Investigator in a secure location and will not be violated unless it becomes medically necessary to contact a participant on the basis of one of their lab screening tests (e.g., elevated liver function tests).

Arms: arm 1: Circadin, controlled release melatonin tablet 2mg by mouth each day before bedtime for 6 weeks arm 2: Placebo tablet identical to Circadin by mouth each day before bedtime for 6 weeks
Interventions: intervention 1: Melatonin intervention 2: Placebo
Intervention descriptions: intervention 1: 2mg controlled release melatonin tablet intervention 2: placebo tablet identical to circadin

Protocol documents:
Prot_SAP_000.pdf: 
NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 1  
 
Effects of Melatonin Supplementation on Renal Physiology in a Habitual Sleep 
Restricted Population. 
NCT02631148 
02/06/2018 
 
 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 2  
 
 
Background and Significance 
In the developed world changes to lifestyle and work practices have diminished the amount of nightly 
sleep many people obtain and altered the times workers are required to be awake.1,2 Both phenomena act 
to desynchronize an individual’s metabolic and physical demands against the internal physiological 
circadian rhythms controlled by external circadian cues and the central and peripheral circadian 
pacemakers.3,4 Evidence that this is detrimental comes from epidemiological studies demonstrating short 
sleep duration, fragmented sleep, and shift work are all associated with increased incidence of diabetes, 
cardiovascular disease and overall mortality, probably via as yet undetermined derangements in 
circadian regulated physiology.5-9  Many of the kidney’s physiological functions follow diurnal 
periodicity with 13% of the protein coding genes expressed in the kidney following a circadian 
pattern.4,10-16 Coordination of the periodicity of these processes in the kidney allows anticipation of the 
metabolic and physiological workload expected of the kidney throughout a 24-hour cycle.  
Sleep measurements and renal function: Preliminary evidence suggests that disruption of the sleep-wake 
cycle promotes the development of four major chronic kidney disease (CKD) risk factors: hypertension, 
diabetes, obesity and increased renin–angiotensin–aldosterone system activation (RAAS), thereby 
leading to a more rapid decline in glomerular filtration rate (GFR) and increased proteinuria (Figure 1). 
Individuals who report sleep duration 5 hours or less per night are 20% more likely to develop 
hypertension than those sleeping 7 hours per night.17 Similarly, in detailed polysomnography (PSG) 
studies, elderly men with reduced duration of “restorative” or “deep” slow wave sleep (SWS or stage N3 
sleep) had an increased risk of incident hypertension18. In a study of 6,834 adults, those who slept 6 or 
fewer hours per night were 1.7 times more likely to develop proteinuria than individuals who slept for 7 
hours per night19 and in a small cross-sectional study of industrial employees, rotating shift workers had a 
higher prevalence of proteinuria relative to daytime only workers20. We have preliminary data showing 
that short self reported sleep duration is associated with a more rapid decline in renal function 
independent of blood pressure and other factors (see, Preliminary Studies).  
Sleep disruption and mechanisms for CKD: Decreased sleep duration, de-synchronization of sleep time, 
or fragmentation of sleep may cause renal damage through increased blood pressure (BP) and activation 
of RAAS,10,11,21-23 impaired glucose homeostasis,6,24 and endothelial dysfunction,25,26 all established risk 
factors for development of CKD.27 Several studies have now demonstrated that acute (1-3 weeks) sleep 
deprivation increases insulin resistance, decreases pancreatic β islet cell function, and chronic sleep 
deprivation is a risk factor for development of diabetes.6,24,28 Similarly, short self-reported sleep duration 
and reduced measured SWS are associated with an increased risk of hypertension.17,18 Meanwhile, 
extension of sleep duration by 1 hour per night for 6 weeks has been found in small studies to decreased 
fasting insulin levels and brachial BP, suggesting sleep duration is a modifiable risk factor for CKD.29,30 
However it was not clear if decreased fasting insulin levels were due to pancreatic β islet function or 
improved insulin sensitivity. 
Changes in sleep patterns are expected to change the 24 hour periodicity of the RAAS.10,11,22,29,31 Of 
particular interest is the effect on 24-hour aldosterone secretion. Beyond the physiological control of 
sodium retention, aldosterone has detrimental effects on kidney function, stimulating expression of PAI-1 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 3  
 
and TGF-β, which promote renal fibrosis, endothelial dysfunction, and altered response of vascular 
smooth muscle cells to catecholamines.32-36  However, data on the effects of circadian disruption on 
aldosterone are conflicting. In a small short-term study involving subjects on continuous enteral feeding, 
one night of sleep deprivation decreased serum aldosterone over 24 hours.22 In contrast, a long-term study 
found that subjects on a fixed sodium diet for up to 205 days had increased (as opposed to decreased) 24-
hour urinary aldosterone excretion on days of shift work with associated increase sodium retention and 
blood pressure.31 These discrepant results may have been due to difference in potassium intake, which 
was higher during days of shift work in the long-term study, and could have affected aldosterone 
production.5,31   
Preliminary Work: Disruption of the diurnal regulation of several physiological processes, including, BP, 
activity of the RAAS, and glycemic control, may lead to increased risk for CKD.  For the past 3 years I 
have investigated the association of circadian rhythms with cardiometabolic risk factors and disease in a 
series of epidemiological analysis (described below). I have also gained extensive experience in the 
performance of inpatient physiological studies in the context of randomized control trials which have 
involved measurement of renal specific RAAS activity using para-aminohippurate (PAH), blood pressure 
measured with 24-hour ambulatory monitoring, pulse wave analysis, and glucose regulation with 
glycemic clamps. During my fellowship I have demonstrated competence in the statistical and clinical 
study methods required for successful completion of the proposed study. 
While others have shown that exposure to light at night during shift work depresses nocturnal melatonin 
secretion (the chief hormonal output from the central circadian pacemaker),37,38 we have found that 
individuals with decreased nocturnal melatonin secretion at baseline have a significantly increased risk of 
later developing type 2 diabetes39,40 and cardiovascular disease (unpublished work), both important risk 
factors for the development of CKD (Table 1). 
 
 
 
 
Less nocturnal BP dipping is related to poor sleep efficiency41 and short sleep duration.42 We therefore 
analyzed the association of decreased nocturnal dipping with incident CKD among individuals recruited 
from the Jackson Heart Study and found that decreased dipping was associated with an increased risk of 
incident CKD (Table 2)43. 
 
 
 
 
Table 1: Odds Ratio for incident type 2 diabetes and myocardial infarction according to nocturnal 
melatonin secretion 
 
 
Odds Ratio (per decrease in log [urine melatonin/creatinine]) 
 
Type 2 diabetes 
Myocardial infarction 
Crude 
1.36 (1.14-1.61) 
1.51 (1.16-1.96) 
Adjusted 
1.48 (1.11-1.98) 
1.69 (1.14-2.51) 
Table 2: Odds Ratio of incident CKD according to nocturnal dipping 
 
Nocturnal dipping (per 10% of awake SBP) 
Unadjusted (N = 603) 
0.58 (0.42 – 0.79) 
Adjusted (N = 408) 
0.55 (0.32 – 0.96) 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 4  
 
These results, in addition to work by others (see, Background and Significance) suggest that changes in an 
individual’s sleep-wake cycle lead to disruption of normal diurnal regulation of physiological processes, 
potentially promoting the development of CKD. Thus, we analyzed the association of short self-reported 
sleep duration with longitudinal changes in eGFR among women enrolled in the Nurses’ Health Study 
and demonstrated that individuals who had lower sleep duration had faster declines in eGFR and higher 
odds of albuminuria (unpublished results, Tables 3&4), further supporting the hypothesis that circadian 
disruption is detrimental to renal function. 
 
 
 
 
 
 
 
Together, these studies suggest that sleep disruption and reduced nocturnal melatonin secretion are risk 
factors for incident CKD. While animal studies have demonstrated the reno-protective effect of sleep 
regulation and supplemental melatonin in preventing renal fibrosis, this has not been studied in humans. 
However, two small studies have demonstrated that increasing sleep duration among individuals with 
reduced sleep duration has beneficial effects on some CKD risk factors. In a study of 16 healthy 
individuals with habitual sleep < 7hours per night, for example, participants were asked to extend their 
sleep by one hour per night for 6 weeks.30 Achieved sleep duration increased by 49 minutes/night and 
participants had decreased insulin levels and increased insulin sensitivity indicating a beneficial metabolic 
effect from sleep extension. Similarly, a small open label study of 36 individuals with diabetes with 
insomnia, found that controlled release melatonin improved sleep efficiency (time spent in bed asleep), 
sleep latency (time taken to fall asleep) and reduced HBA1c from 9.1 to 8.5% over 5 months.44 
This preliminary evidence suggests the importance of both duration and neurophysiological 
characteristics of sleep and sleep timing on renal function similar to what has been found for a range of 
metabolic functions. It also motivates us to perform carefully controlled experiments to investigate the 
mechanisms by which sleep-wake cycle disruption may lead to a more rapid decline in renal function and 
if correction of commonly occurring sleep disorders, such as chronic sleep restriction, is beneficial in 
ameliorating CKD risk factors. 
 
 
 
Table 3: Odds ratio for eGFR decrease of ≥25% over 10 years by self-reported sleep duration 
Sleep duration 
Unadjusted 
Adjusted 
≤5 hours 
1.64 (1.14-2.37) 
1.54 (1.05-2.27) 
6 hours 
1.23 (1.03-1.46) 
1.17 (0.97-1.41) 
7-8 hours (ref) 
1.0 (ref) 
1.0 (ref) 
9 hours 
0.89 (0.59-1.34) 
0.73 (0.47-1.14) 
≥10 hours 
1.38 (0.45-4.25) 
1.00 (0.31-3.19) 
Table 4: Odds ratio of albuminuria (UACR>30mg/g) by self-reported sleep duration 
Sleep duration 
Unadjusted 
Adjusted 
≤5 hours 
2.31 (1.42-3.79) 
2.12 (1.26-3.55) 
6 hours 
1.36 (1.02-1.81) 
1.30 (0.96-1.76) 
7-8 hours (ref) 
1.0 (ref) 
1.0 (ref) 
9 hours 
1.00 (0.51-1.93) 
0.86 (0.42-1.76) 
≥10 hours 
2.15 (0.48-9.59) 
1.33 (0.26-6.74) 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 5  
 
Specific Aims  
 In health, many of the kidney’s physiological functions follow diurnal periodicity synchronized to the 
sleep-wake cycle.4,10-15 This periodicity affects transcription of solute transporters,4 excretion of sodium 
and calcium,12,13 blood pressure, renal blood flow, and glomerular filtration rate (GFR), which are all 
increased during the day.15 In contrast, the activity of the renin-angiotensin-aldosterone system (RAAS) is 
increased during the night. 10,11 Coordination of the periodicity of these processes in the kidney allows 
anticipation of the metabolic and physiological workload expected of the kidney throughout a 24-hour 
cycle. 
 
Preliminary evidence suggests that disruption of the sleep-wake cycle is a potential risk factor for the 
development of chronic kidney disease (CKD). Animals with genetic disruption of circadian rhythms 
develop renal fibrosis, preventable by strictly controlling light-dark periodicity to restore circadian 
rhythm.45 Human studies also suggest that disruption of the sleep wake cycle, whether by sleep 
restriction, or circadian de-synchronization (from shift work), may produce renal damage. In a study of 
6,834 adults, those who slept 6 or fewer hours per night were 1.7 times more likely to develop proteinuria 
than individuals who slept for 7 hours per night.19  In a small cross-sectional study of industrial 
employees, rotating shift workers had a higher prevalence of proteinuria relative to daytime only 
workers.20 We have preliminary evidence that decreased sleep duration is associated with a more rapid 
decline in renal function. Decreased sleep duration, de-synchronization of sleep time, or fragmentation of 
sleep may cause renal damage through increased RAAS activation, increased nocturnal blood 
pressure,10,11,21-23 impaired glucose homeostasis,6,24 increased sympathetic outflow,46,47 systemic 
inflammation,48,49 and endothelial dysfunction25,26 all established risk factors for development of CKD.27 
 
Melatonin, a hormone secreted by the pineal gland mainly during the night, may be a critical mediator 
between circadian disruption and renal injury. Specifically, perturbations of the sleep-wake cycle lead to 
reduced nocturnal melatonin secretion,50-54 which in animals studies is reversibly linked to renal fibrosis27 
and in humans with important risk factors for kidney disease including increased risk for incident 
hypertension,55 type 2 diabetes,39 and cardiovascular disease.27,56 Supplemental melatonin prevents kidney 
injury in animal models of acute and chronic kidney disease.57-59 Systemically, melatonin reduces 
sympathetic outflow to the cardiovascular system while regulating aldosterone production.60-63  
 
We hypothesize that disruption of the sleep-wake cycle by sleep restriction increases risk for CKD, 
potentially via an increase in aldosterone secretion and reduction of nocturnal melatonin secretion with its 
pleiotropic effects on blood pressure, glucose metabolism, and endothelial function. We also hypothesize 
that correction of circadian disruption in high-risk, habitually sleep-restricted individuals by sleep 
extension or by melatonin supplementation using a controlled-release formulation administered at 
bedtime can reduce overall risk for CKD. These hypotheses give rise to the following specific aim: 
 
1. Sleep extension and melatonin supplementation and CKD risk factors   
In a 6 week pilot study, 20 individuals with habitual sleep restriction will all be asked to extend their 
nightly sleep by 1 hour, and will then be randomized 1:1 to nightly controlled-release oral melatonin 
(2mg) or placebo. We will assess whether sleep extension and nightly melatonin supplementation in 
the community is a feasible intervention with a beneficial effect on the following CKD risk factors: 
systemic and renal specific RAAS activation (systemic plasma renin activity, plasma angiotensin II 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 6  
 
levels, 24-hour urine aldosterone excretion, and renal plasma flow response to captopril); nocturnal 
blood pressure measured by 24-hour ambulatory blood pressure monitor; central blood pressure 
measured by pulse wave analysis; and glucose metabolism measured by Minimal Model assessment 
of insulin resistance and β-cell response to a mixed meal protocol.  
 
Subject Selection 
An obese, pre-diabetic, pre-hypertensive population with habitual sleep restriction is ideally suited for a 
study of the effects of sleep extension and melatonin on CKD risk factors. We have shown that obesity 
and insulin resistance are associated with reduced endogenous melatonin secretion. 39,64  Obesity pre-
disposes individuals to aldosterone mediated inflammation and endothelial dysfunction. Thus, measures 
that reduce aldosterone secretion in these individuals may be particularly beneficial.10,23,65  
We will recruit individuals from the Boston area who meet the inclusion and exclusion criteria listed in 
Table 5. Recruitment will take place through several venues.  First, we will recruit from those who have 
already completed our MODERATE randomized trial (N>200 who have completed so far).  The vast 
majority these individuals still reside in Boston.  MODERATE participants have provided consent to be 
re-contacted for future studies.  We will use the MODERATE database to identify individuals who may 
be eligible for our study, and contact them directly to invite them to participate.   
 
Second, we will simultaneously attempt to enroll study participants who fulfill the age and BMI 
requirements using routine media outlets in the local community and also online advertising.  These 
include:  (1) billboards placed in Boston mass-transit buses and subways; (2) advertisements in local print 
media, such as the Boston Metro and the Boston Globe; (3) online advertisement with websites such as 
Craig’s List and Oodle (these sites have been productive sources for recruitment in the past).   
Third, we will use recruitment opportunities provided through Partners, such as Partners RSVP, and 
ClinicalTrials@Partners.   
We will include both men and women and all races and ethnicities. The only exception will be women 
who are pregnant because certain medications used during the inpatient evaluations (e.g., nitroglycerine), 
and certain study medications (i.e., captopril) are contraindicated during pregnancy. 
Table 5. Eligibility Criteria 
Inclusion Criteria 
• 
BMI ≥ 30 kg/m2                                                                  
• 
Age ≥18 years 
• 
HbA1c 5.7-6.4%                                                   
• 
Self reported sleep <7 hours per night 
Exclusion Criteria 
• 
Current or prior history of diabetes mellitus                      
• 
Use of hypoglycemic meds or random serum glucose ≥ 
200 mg/dL               
• 
Estimated GFR <60 mL/min/1.73m2 
• 
Inability to extend sleep by 1 hour per night                      
• 
Pregnant or breast-feeding 
• 
Preexisting lung disease requiring oxygen                         


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 7  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subject Enrollment 
 
Responders to advertisements will be pre-screened by telephone to obtain a BMI estimate and a medical 
history to gauge potential eligibility (Table 5). For those who may be eligible following this phone query, 
the basic study schema (Figure 1) will be described to identify those who remain interested in 
participation after learning the duration, inpatient requirements, and potential medication use.  These 
individuals will then be invited to attend an outpatient screening visit. 
 
We anticipate that the sex and race/ethnicity breakdown of subjects enrolled into EMC-PILOT will be 
similar to that which we have experienced in the MODERATE trial. Thus far in the MODERATE trial, 
enrolled subjects are 63% female, 28% black, 7% more than one race, and 13% Hispanic.  
 
The pilot study is a double-blind, placebo-controlled randomized trial, in which 16 subjects with obesity 
(BMI≥30 kg/m2), pre-diabetes (HbA1C, 5.7-6.4%), and self-reported short sleep duration (<7 hours/night) 
are randomly assigned 1:1 to receive either placebo or 2 mg of controlled-release melatonin, taken orally 
every evening 1 hour before bed for 6 weeks. All subjects will be asked to extend their sleep time by 
one hour during the 6 week period between inpatient visits. Endpoints will be measured at both the 
baseline and 6-week inpatient visits. 
• 
Preexisting CVD 
• 
Active or uncontrolled psychotic disorder           
• 
Active or uncontrolled bipolar illness 
• 
Active malignancy within the prior 5 years                      
• 
Use of  antihypertensive meds 
• 
Hepatic impairment                                                      
• 
Job requires rotating night shifts 
• 
Bariatric surgery within the prior 12 months                     
• 
Use of hypnotic meds 
• 
Hematocrit <36%(women) or <41% (men)                        
• 
Use of natural sleep aids 
• 
Known allergy/intolerance of ACE inhibitors                    
• 
History of stroke 
• 
Recent (within 2 weeks of study) or upcoming travel 
across time zones                                                                
• 
Known obstructive sleep apnea or use of continuous 
positive airway pressure 
• 
Insomnia 
• 
Known allergy to melatonin 
• 
Hypertension Type 1 or 2 (BP >150/90) 
• 
Lactose Intolerance 
• 
Autoimmune Disease 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 8  
 
Figure 1: Schema for pilot study with sleep extension and nightly melatonin as treatments. 
 
 
Screening Visit: Screening visits will take place at the Brigham and Women’s Outpatient Center for 
Clinical Investigation (CCI; 221 Longwood Avenue).  During the outpatient screen, Dr. McMullan  
will explain the study in detail, review the consent form, and answer questions. After obtaining 
written informed consent for participation, a history and physical examination will be performed in order  
initially judge eligibility based upon the criteria set out in Table 5. Those individuals deemed potentially  
eligible based upon the screening history and exam will undergo phlebotomy and analysis for HbA1c, 
serum chemistries and glucose, and CBC to confirm eligibility using the criteria presented in the table.  
 
Study Procedures 
Pre-admission: All participants will wear a wrist activity monitor for a total of 8 weeks; 2 weeks prior to 
the baseline inpatient visit and for the 6 weeks between inpatient visits, Figure 2. They will complete a 
daily sleep log during the 2 weeks preceding the baseline visit and 6 weeks preceding second visit. Three 
days before admission, participants will be placed on a high salt diet by supplementing their usual diet 
with 150 mmol sodium/day for 3 days using dry bouillon added to food. All participants will also be 
asked to do a 24 hour diet recall for the day before admission. 
 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 9  
 
Treatment assignments: Prior to admission for the baseline visit, subjects will be randomized (1:1) to 
receive study medication (melatonin 2mg of controlled release formulation or placebo). All subjects will 
be asked to extend their sleep time by one hour during the 6 week period between inpatient visits. 
 
Baseline and Follow-up inpatient visit: Baseline and 6-week inpatient visits will be virtually identical. 
Each inpatient visit will begin at 4:00PM on Day 0 and end at 4:00PM on Day 1, Figure 2.  
 
Figure 2: Schema for inpatient visit studies at 6-week visit. 
 
 
 
Day 0 — We will complete two 12-hour urine collections for each subject. All subjects will begin the first 
12-hour urine collection at their home at 7:00AM on day 0 of admission to the Brigham and Women’s 
Hospital Center for Clinical Investigation (CCI). The first 12-hour urine collection will be ended at 
7:00PM that evening. The second 12-hour collection will begin and continued overnight until 7:00AM on 
day 1.  The nurses will keep the daytime (7AM to 7PM) and nighttime (7PM to 7AM) urine separate to 
permit analysis of diurnal variation in urinary analytes. Subjects will fast after 9 pm to ensure a 12-hour 
fast by the next morning. 
Day 1 — The second 12-hour urine collection will conclude at 7:00AM on day 1 and will be used to 
measure excretion of sodium and aldosterone. At 8:00AM, central blood pressure and vascular 
compliance will be assessed, followed at approximately 9:00AM by measurement of renal specific RAAS 
activity via para-aminohippurate (PAH) renal plasma flow testing with captopril, and systemic RAAS 
will be measured by plasma renin activity (PRA), angiotensin II (Ang II) and urine aldosterone. Next the 
subject will receive a mixed meal (10kcal/kg, 45% carbohydrate, 15% protein, 40% fat, 1g/kg glucose) to 
be consumed in 15 minutes with blood draws at 0, 10, 20, 30, 60, 90 and 120 minutes from the time the 
meal had begun to be consumed. The mixed meal will achieve glucose of 1g/kg by using specific amounts 
of a Trutol drink; the amounts are based on the subject’s weight, Table 6. Plasma glucose, insulin and c-
peptide will be measured in all 7 samples of blood. Finally the participant will be fitted with a Spacelabs 
90207 ambulatory BP monitor prior to discharge to be worn for 24-hours. 
 
Wrist actigraphy day -42 to 0 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 10  
 
Table 6. Sample Mixed Meal based on 180 lb participant 
Food Description 
Amount 
Measure 
Energy 
Glucose (g) 
Protein (%) 
Fat 
(%) 
Carbohydrate (%) 
Whole milk, Hood  
70 
gram 
44.49 
21.05 
47.37 
31.58 
Egg, whole  
117 
gram 
174.33 
34.45 
62.18 
3.37 
Butter  
7 
gram 
50.19 
0.46 
99.5 
0.03 
SF peanuts, dry roasted  
30 
    gram 
175.5 
15.09 
71.2 
13.71 
Turkey sausage 
30 
gram 
46.68 
42.56 
53.85 
3.59 
Trutol, glucose drink 
323 
gram 
327.52 
81.72 
0 
0 
100 
Total 
818.71 
81.72 
14.18 
40.78 
45.04 
 
Follow-up — During the study, subjects will be phoned weekly by a study coordinator to assess for 
compliance and potential side effects. Dr McMullan will call all subjects every 2 weeks to discuss 
difficulties encountered with their new sleep schedule, to recommend improvements and encourage 
compliance with the protocol. 
 
Parameters Measured:  At the inpatient visits, the following measurements will be made: 
Renal Specific RAAS — The activity of the local kidney RAAS can be measured by examining the change 
in effective renal plasma flow (RPF) after oral captopril while in high sodium balance. Effective RPF is 
measured as clearance of para-aminohippuric acid, because PAH is cleared solely and nearly entirely by 
the kidney. The protocol to measure PAH clearance is performed with the participant supine, Figure 5.
 
Systemic RAAS — PRA and ang II levels will be measured on the first morning blood draw.  
Central Blood Pressure — Will be measured using pulse wave analysis using the SphygmoCor system 
(AtCor Medical, West Ryde, NSW, Australia), which measures central blood pressure and arterial 
stiffness. 
Glucose metabolism — Will be evaluated by applying the Oral Minimal Model method to the results of a 
2 hour 7- measurement, mixed meal tolerance test.2 Subject will be given breakfast in the form of a mixed 
meal (10kcal/kg, 45% carbohydrate, 15% protein, 40% fat, 1g/kg glucose) which must be consumed 
within 15 minutes with glucose, insulin and c-peptide measured from arterialized blood drawn at 0, 10, 
20, 30, 60, 90 and 120 minutes from start of meal. Glucose will be measured using a YSI glucose 
analyzer (CV <2%) for rapid measurement (YSI, Inc, Yellow Springs, OH), insulin will be measured with 
a radioimmunoassay (CV=10%) and c-peptide will be measured using an electrochemiluminescence 
Effe
Efferent arteriole 
Normal  (RAS down regulation) 
HIGH SALT 
ACE-I (RAS blockade) 
Renal Plasma Flow ↔ 
Efferent arteriole Efferent arteriole 
Abnormal  (RAS up regulation) 
HIGH SALT 
ACE-I (RAS blockade) 
Renal Plasma Flow ↑ 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 11  
 
immunoassay(CV=12%). From the glucose, insulin and c-peptide measurements calculation of insulin 
sensitivity (reciprocal of insulin resistance) and β-cell responsitivity will be calculated.   
 
 
Drugs to be used: 
Captopril - The 25mg oral dose of captopril used during the renal specific RAAS measurement.   
Severe hypotensive reactions to a single dose of captopril are very uncommon in our experience among 
those we’ve studied who were free from pre-existing HTN, particularly in high sodium balance; 
nevertheless, participants will undergo constant monitoring during the RPF study, and the study will be 
stopped if the BP following captopril falls below 90 mmHg systolic or 50 mmHg diastolic, at which point 
the participant will receive medical treatment from the attending physician.  Captopril may also be 
associated with angioedema, but typically occurs after repeated doses and even so the risk is <1%.  
Controlled release melatonin (Circadin®) - The 2 mg controlled-release formulation of melatonin has been 
studied previously in diabetic subjects and improves sleep duration44. Pharmacokinetic data suggests that 
this dose of melatonin achieves nocturnal serum melatonin levels at or above physiological concentrations 
among healthy volunteers and is therefore adequate to replete nocturnal melatonin in individuals who 
have relatively low endogenous secretion 67. The tolerability of controlled-release melatonin has been 
widely studied68-71. In the largest series, 791 subjects were evaluated for 3 weeks in a randomized 
placebo-controlled trial; adverse event rates were 0.8% with melatonin and 0.6% with placebo. After 3 
weeks, 711 subjects were re-randomized for an additional 26 weeks; during this prolonged period, the 
incidence of adverse events was 0.6% and 0.7% in melatonin and placebo arms, respectively69. In a 
separate, smaller open label study of controlled-release melatonin, the most common adverse events 
attributed to melatonin were dizziness and headache70. Controlled-release melatonin was found to have no 
effect on psychomotor function or memory in adults relative to placebo71. 
 
Devices to be used: 
Central Aortic Blood Pressure Measurement –Studies of central aortic blood pressure will be performed 
while the subject is supine and fasting, prior to blood draw. The SphygmoCor XCEL PWA device is a 
portable machine that will be used to measure central aortic blood pressure. A thin pillow is placed under 
the arm to align the arm with the heart. A blood pressure cuff is placed on the patient’s arm, over the 
brachial artery. The SphygmoCor XCEL system takes the subject’s brachial systolic and diastolic 
pressure, and then captures the subject’s brachial waveform. The brachial waveform is then analyzed by 
the SphygmoCor Brachial GTF to provide a Central aortic waveform and Central blood pressure 
measurements. The entire procedure will take approximately 10 minutes to perform. Coded data is 
automatically stored via the SphygmoCor EXCEL System and will be downloaded onto a secure research 
computer for storage and analysis. 
Ambulatory blood pressure monitor – The device, the SPACELABS Inc. 90207, consists of a 4.5” x 3.4“ 
x 1.1” box weighing 12 oz. that is usually worn on the belt or pant/skirt-line, and a chord that connects the 
box underneath the clothing to the cuff which is worn on the upper arm.  Multiple cuffs of various sizes 
(small 17-26 cm, standard 24-32 cm, large 32-42 cm, and extra large 38-50 cm) will be available and the 
appropriate cuff for each participant will be utilized.  Once affixed, the device is switched on and the 
study coordinator will manually initiate two or three readings so that the participant may become 
accustomed to how the monitor works/feels before he/she leaves the CCI.  The monitor will be pre-


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 12  
 
programmed to record the BP every 30 minutes during the day and every 60 minutes at night.  
Instructions to participants will include removal of the device before bathing/showering to keep the 
device dry.  At the end of the 24hr monitoring period, the participant will switch off the device and mail it 
back to the study coordinator in a pre-paid mailer (which will be provided prior to CCI discharge).  Once 
received, the study coordinator will download the data using SPACELABS Inc. 92506 Report 
Management System (a PC-compatible Interface).   
 
Data Collection: 
This study will collect demographic information (age, self-described race and ethnicity, sex), and physical 
data (height, weight, screening blood pressure). Blood and urine samples will be analyzed for various 
biomarkers to collect the data necessary to carry out the specific aims, as described in the section above 
Parameters Measured. All of these data will be recorded in association with a study ID number, and kept 
as secure excel files by the statistician and programmer. The only individually identifiable private data 
that will be collected are names, addresses, and contact phone numbers so that participants can be 
screened with follow-up phone calls, and they will be admitted to the inpatient CCI under their name. 
This personal information, however, will not be associated with the results obtained from the various tests 
performed, as the latter will be associated with a study ID number. The file linking the study ID number 
and the personally identifiable information will be kept by the PI in a secure location and will not be 
violated unless it becomes medically necessary to contact a participant on the basis of one of their lab 
screening tests (e.g., elevated liver function tests). 
 
 
Biostatistical analysis 
 
The primary purpose of the trial is to generate pilot data for a larger randomized control trial. 
Therefore we aim to calculate means and standard errors for the parameters as well as estimates of effects 
of sleep extension and melatonin supplementation which will allow accurate power calculations and 
facilitate the design of a larger study. While we suspect we will be underpowered in this study to find 
significant differences in endpoints due to sleep extension or melatonin supplementation we will perform 
statistical analysis on the outcomes as follows. For the main outcomes (renal specific RAAS, BP, 
glycemic control [insulin sensitivity and β-islet cell function]), we can assume a normal approximation 
for the changes in log transformed endpoints and so will use an ANCOVA analysis to compare the 
change in outcome from baseline to 6 week follow-up between melatonin (N=8) and placebo groups 
(N=8) of the study. Finally we will test the interaction of sleep extension and melatonin supplementation 
using multivariable linear regression of the parameter change with predictors which will include treatment 
assignments (sleep extension and melatonin supplementation) and the interaction term sleep extension 
*melatonin supplementation in an analysis of all study participants (N=16). 
For the purposes of this grant we have performed power calculations for sleep extension based on either 
pilot data from obese individuals from our own studies or published results.  
Renal specific RAAS Activity – Based upon published data, we assume that change in renal specific RAAS 
activity (∆RPFcaptopril)  is 46ml/min/1.73m2  in obese individuals, SD 1272, and From these values, we 
estimate that we will have 80% power to detect a change in ∆RPFcaptopril with sleep extension of 15 
ml/min/1.73m2   (33% from baseline) with type I error of 0.05 (two-tailed), Table 7. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 13  
 
Central Blood Pressure – Based on pilot data, we assume a mean central systolic BP of 106 mmHg and 
SD 10 mmHg with a between measurement correlation coefficient 0.89. Thus, for ANCOVA analysis the 
SD is 6.0 for change in BP. From these values, we estimate we will have 80% power to detect a change in 
BP of 8 mmHg due to sleep extension with type I error of 0.05 (two-tailed), Table 7. 
24 hour Ambulatory Blood Pressure – Based on pilot data, we assume a mean 24-hour systolic BP of 
122.8 mmHg and SD of 10.4mmHg with a between-measurement correlation coefficient 0.74. Thus for 
ANCOVA analysis the SD is 5.0 for change in BP. From these values, we estimate that we will have 80% 
power to detect a 6 mmHg change in 24-hour mean SBP due to sleep extension with a type I error rate of 
0.05 (two-tailed). 
Insulin sensitivity –Based on published data, we assume a mean insulin sensitivity of 19.03 
dl/kg/min/pmol/l and SD of 1.38 dl/kg/min/pmol/l and a between-measurement correlation coefficient of 
0.7.2,73 Thus for ANCOVA analysis the SD for change in insulin sensitivity is 1.1 dl/kg/min/pmol/l. From 
these values we estimate that we will have 80% power to detect a change in insulin sensitivity of 1.4 
dl/kg/min/pmol/l due to sleep extension with type I error of 0.05 (two-tailed), Table 7 
β-islet cell responsitivity – Based on published data, we assume a mean β islet cell response (dynamic 
response,ϕd) of 494.88 and SD of 25.16 and a assume a measurement correlation coefficient of 0.7.2,73 . 
Thus for ANCOVA analysis the SD for change in ϕd is 17.68.  From these values we estimate that we will 
have 80% power to detect a change in β islet cell response of 24 due to sleep extension with type I error 
of 0.05 (two-tailed), Table 7.  All power calculation performed with PS power and sample size calculator, 
version 3.0.34. 
Table 7: Comparison of the change in outcome we are powered to detect compared with measured 
changes in outcomes detected in other studies with lifestyle interventions or BMI comparisons. 
Outcome 
Intervention/Comparison 
∆ Measured 
Detectable change in this 
study 
Renal Specific 
RAAS72 
Obese vs overweight 
9ml/min/1.73m2 
15ml/min/1.73m2 
Central  systolic 
BP46 
Diet and exercise 
12 mmHg 
8mmHg 
24hour ABPM47 
Difference in BMI of 
5kg/m2 
3 mmHg 
6mmHg 
Insulin 
Sensitivity22 
Diet and exercise 
19% change 
7% change 
β-islet cell 
function40 
Diet 
20% change 
5% change 
 
 
Risks and Discomforts 
 
Potential complications to participants include: (i) the discomfort from having phlebotomy; (ii) the 
discomfort from having intravenous peripheral catheters placed during CCI admissions; (iii) potential side 
effects from being on a high salt diet for 3 days, such as elevation of BP or hypokalemia; (iv) potential 
side effects from medications administered during the inpatient CCI stays, including drop in BP from oral 
captopril consumption (for the renal plasma flow study (RPF)); (v) side effects from melatonin such as 
allergic reaction, medication interactions, and elevation of liver function tests; and finally (vi) the chance 


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Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 14  
 
of a confidentiality breach such that personal information becomes de-identified and linked to the results 
of the various studies and blood tests.  
i. Phlebotomy: This risk will occur by study design but is minimal. 
ii. Peripheral intravenous catheter placement: This risk will occur by study design but is minimal. 
iii. High salt diet: A high salt diet is common to the US population, and enrolled participants will not have 
pre-existing HTN or hypokalemia; thus, a high salt diet for 3 days is unlikely to cause harm. 
iv. Inpatient procedures: Severe hypotensive reactions to the oral captopril are very uncommon in our 
experience among those we’ve studied who were free from pre-existing HTN; nevertheless, participants 
will undergo constant monitoring during the RPF study, and captopril will not be given if the BP prior to 
scheduled captopril administration is less than 100 mmHg systolic or 60 mmHg diastolic. 
v. Side effects from Melatonin: The tolerability of controlled-release melatonin has been widely studied. 
In the largest series, 791 subjects were evaluated for 3 weeks in a randomized placebo-controlled trial; 
adverse event rates were 0.8% with melatonin and 0.6% with placebo. After 3 weeks, 711 subjects were 
re-randomized for an additional 26 weeks; during this prolonged period, the incidence of adverse events 
was 0.6% and 0.7% in melatonin and placebo arms, respectively. In a separate, smaller open label study 
of controlled-release melatonin, the most common adverse events attributed to melatonin were dizziness 
and headache. Controlled-release melatonin was found to have no effect on psychomotor function or 
memory in adults relative to placebo. 
vi. Breach of confidentiality: This poses a psychological/financial risk, should information about medical 
history, laboratory information, or test results be breached. To guard against this, all recorded data, 
identified by study number only, will be housed separately from the name-address-phone number file of 
participants in the study. Only the principal investigator (or designated assistant) will have need (and 
necessary access) to cross-reference the files, and this will be done only when it is necessary to contact a 
participant for medical reasons, or if the participant is seeking additional information. 
If subjects experience study related adverse events, they will be followed up by the study until the 
symptoms resolve. Depending on severity, this can range from daily to weekly phone calls or possibly 
study visits.  
None of the inpatient studies use radiation and so participants will not be at additional radiation risk from 
enrollment in the study. 
Adequacy of Protection Against Risks 
Overall, as described above, the risks associated with this proposal are either minimal, or else unlikely to 
occur. Informed consent will be obtained from all participants, and all possible protections against risk 
will be employed. 
a. Informed Consent. Our plans for recruitment were outlined in the Research Strategy. Essentially, 
potential participants will be identified though public advertisements and interested individuals will 
initially be screened by telephone to judge potential eligibility. At the screening visit, informed consent 
will be obtained by the PI (Dr. McMullan), or occasionally, by the Co-investigator (Dr. Forman). All 
consent forms will have been pre-approved by the institutional review board at Brigham and Women’s 
Hospital. The process of informed consent will provide potential participants with the following 
information: 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 15  
 
i. Purpose of the study 
ii. Drugs to be administered and the possible use of placebo 
iii. A description of randomization and blinding 
iv. Reasons why the participant may eligible for the study 
v. The number of participants expected to be enrolled 
vi. The funding source for the study 
vii. Duration of the study 
viii. A detailed description of all outpatient and inpatient study protocols and tests to be performed 
ix. Storage of blood samples for possible future use 
x. Circumstances under which participation may be terminated by the investigator 
xi. Procedures for safe and orderly termination if the participant wishes to withdraw 
xii. A detailed explanation of all potential risks, including unforeseen risks, and potential benefits 
xiii. Remuneration 
b. Protections Against Risk. As described above, we will exclude from enrollment individuals who are at 
increased risk for adverse events resulting from study medications. We will screen for side effects of 
study medications weekly, and monitor for biochemical side effects through laboratory screening. 
Individuals who have serious adverse reactions will have study participation terminated. Risk associated 
with the outpatient screening and checkup visits (phlebotomy) is minimal. Risk associated with inpatient 
procedures (the EDD and RPF studies) will be minimized by continuous monitoring by a physician (the 
PI or Co-investigator) and nurse, and – as noted – participants will already be hospital inpatients at that 
time so any serious adverse events can quickly be addressed. No vulnerable populations will be enrolled. 
 
Potential Benefits  
Potential benefit to society: As described in detail in the Study Procedure section, we will perform a 
small pilot study of obese individuals. We plan to enroll a total of 20 individuals into a randomized 
controlled trial. All participants will be adults (age≥18 years), and will be recruited from the Boston area. 
Volunteers will be recruited and screened for inclusion based upon having a BMI≥30 kg/m2, and having 
HbA1C between 5.7 and 6.4%. Other than having these “conditions”, potential participants will be 
expected to otherwise be in general good health, without severe co-morbid conditions as described in the 
Subject Enrollment section. There will be no involvement of special vulnerable populations. After 
randomization, participants will be retained by weekly phone calls; additionally, the duration of this trial 
(6 weeks) is relatively short. Study group assignment will be random, of the 20 participants, 10 will 
receive placebo, and 10 will receive controlled release melatonin (2.0mg of Circadin® nightly for 6 
weeks). The 2 mg controlled-release formulation of melatonin has been studied previously in diabetic 
subjects and improves sleep duration. Pharmacokinetic data suggests that this dose of melatonin achieves 
nocturnal serum melatonin levels at or above physiological concentrations among healthy volunteers and 
is therefore adequate to replete nocturnal melatonin in individuals who have relatively low endogenous 
secretion.  


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 16  
 
The key potential benefit is the knowledge that is gained on potentially modifiable mediators of important 
pathophysiologic mechanisms of disease. The segment of the US population that would meet our study 
criteria is large; specifically, over half of the US adult population is obese, and nearly a quarter of these 
individuals have pre-diabetes. Thus, the results of this study could have profound public health 
implications. 
 
Potential benefit to participants: It is possible that participants will gain direct benefit from these studies. 
First of all, it is possible that individuals who are not randomized to placebo will benefit from treatment. 
On the other hand, because this study is only 12-weeks in duration, these benefits (if present) will likely 
be short-lived. 
Monitoring and quality assurance 
We will submit our data safety monitoring plan (DSMP) to the Brigham and Women’s Hospital 
Institutional Review Board for approval. It is based upon the guidelines set forth by the Brigham and 
Women’s IRB that we have formulated our Safety Monitoring Plan. 
a. Type of DSMP. We plan to implement a fully independent data safety monitoring board (DSMB), 
which will meet every 6 months. The DSMB will have 2 members independent of Drs. McMullan and 
Forman; a statistician and a clinical investigator. The first meeting will be prior to subject enrollment to 
allow agreement on expectations of investigator and DSMB, with review of the study protocol approved 
by IRB. Safety data regarding adverse effects will be presented at each DSMB meeting as will unblinded 
outcome data. At each meeting the DSMB will decide on the continuation of the trial after considering the 
study risk based on the accumulation of adverse events and the futility of the trial based on the outcomes 
data. In addition to the DSMB a committee of investigators, including Drs. McMullan and Forman, as 
well as a research pharmacist will provide safety monitoring on a weekly basis allowing “on-the-spot” 
monitoring for abnormal safety labs or protocol breaches as well as providing decisions regarding 
termination of an individual’s participation. This will allow greater flexibility and speed to react to safety 
issues should they arise. 
b. Data to be reviewed. The safety committee made of investigators will review data pertaining to side 
effects and adverse events.  
ClinicalTrials.gov Requirements 
The principal investigator of this proposal, as the responsible party, will comply with Public Law 110-85 
(FDAAA), and will register this clinical trial on ClinicalTrials.gov. 
 
References: 
1. 
EU. Fifth European Working Conditions Survey. Luxembourg: Publications Office of the European 
Union; 2012 2012. 
2. 
Tsc SL, Wang F, Zhang L, et al. 0174 Preliminary results of shift work and cardiovascular risk 
factors: analysing baseline data of a prospective night shift worker cohort in Shenzhen, China. 
Occupational and environmental medicine. Jun 2014;71 Suppl 1:A81-82. 
3. 
Bixler E. Sleep and society: an epidemiological perspective. Sleep Med. Sep 2009;10 Suppl 1:S3-
6. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 17  
 
4. 
Fine DM, Wasser WG, Estrella MM, et al. APOL1 risk variants predict histopathology and 
progression to ESRD in HIV-related kidney disease. J Am Soc Nephrol. Feb 2012;23(2):343-350. 
5. 
Cai H, Shu XO, Xiang YB, et al. Sleep Duration and Mortality: A Prospective Study of 113 138 
Middle-Aged and Elderly Chinese Men and Women. Sleep. Oct 28 2014. 
6. 
Buxton OM, Cain SW, O'Connor SP, et al. Adverse metabolic consequences in humans of 
prolonged sleep restriction combined with circadian disruption. Sci Transl Med. Apr 
2012;4(129):129ra143. 
7. 
Pan A, Schernhammer ES, Sun Q, Hu FB. Rotating night shift work and risk of type 2 diabetes: 
two prospective cohort studies in women. PLoS Med. Dec 2011;8(12):e1001141. 
8. 
Ford ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled 
cohort risk equations among US adults. Journal of the American Heart Association. Dec 
2014;3(6):e001454. 
9. 
Hermansson J, Gillander Gadin K, Karlsson B, Reuterwall C, Hallqvist J, Knutsson A. Case fatality 
of myocardial infarction among shift workers. International archives of occupational and 
environmental health. Sep 27 2014. 
10. 
Plantinga L, Lee K, Inker LA, et al. Association of sleep-related problems with CKD in the United 
States, 2005-2008. Am J Kidney Dis. Oct 2011;58(4):554-564. 
11. 
Agarwal R, Light RP. Sleep and activity in chronic kidney disease: a longitudinal study. Clin J Am 
Soc Nephrol. Jun 2011;6(6):1258-1265. 
12. 
Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney 
disease in African Americans. Science (New York, N.Y.). Aug 13 2010;329(5993):841-845. 
13. 
Nikolaeva S, Pradervand S, Centeno G, et al. The circadian clock modulates renal sodium 
handling. J Am Soc Nephrol. Jun 2012;23(6):1019-1026. 
14. 
Kopp JB, Nelson GW, Sampath K, et al. APOL1 genetic variants in focal segmental 
glomerulosclerosis and HIV-associated nephropathy. J Am Soc Nephrol. Nov 2011;22(11):2129-
2137. 
15. 
Foster MC, Coresh J, Fornage M, et al. APOL1 variants associate with increased risk of CKD 
among African Americans. J Am Soc Nephrol. Sep 2013;24(9):1484-1491. 
16. 
Zhang R, Lahens NF, Ballance HI, Hughes ME, Hogenesch JB. A circadian gene expression atlas in 
mammals: implications for biology and medicine. Proc Natl Acad Sci U S A. Nov 11 
2014;111(45):16219-16224. 
17. 
Gangwisch JE, Feskanich D, Malaspina D, Shen S, Forman JP. Sleep Duration and Risk for 
Hypertension in Women: Results from The Nurses' Health Study. Am J Hypertens. Apr 2013. 
18. 
Fung MM, Peters K, Redline S, et al. Decreased slow wave sleep increases risk of developing 
hypertension in elderly men. Hypertension. Oct 2011;58(4):596-603. 
19. 
Herzog N, Jauch-Chara K, Hyzy F, et al. Selective slow wave sleep but not rapid eye movement 
sleep suppression impairs morning glucose tolerance in healthy men. 
Psychoneuroendocrinology. Oct 2013;38(10):2075-2082. 
20. 
Madhavan SM, O'Toole JF, Konieczkowski M, Ganesan S, Bruggeman LA, Sedor JR. APOL1 
localization in normal kidney and nondiabetic kidney disease. J Am Soc Nephrol. Nov 
2011;22(11):2119-2128. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 18  
 
21. 
Ito K, Bick AG, Flannick J, et al. Increased burden of cardiovascular disease in carriers of APOL1 
genetic variants. Circulation research. Feb 28 2014;114(5):845-850. 
22. 
Warram JH, Gearin G, Laffel L, Krolewski AS. Effect of duration of type I diabetes on the 
prevalence of stages of diabetic nephropathy defined by urinary albumin/creatinine ratio. J Am 
Soc Nephrol. Jun 1996;7(6):930-937. 
23. 
Mitsiades CS, McMillin D, Kotoula V, et al. Antitumor effects of the proteasome inhibitor 
bortezomib in medullary and anaplastic thyroid carcinoma cells in vitro. J Clin Endocrinol Metab. 
Oct 2006;91(10):4013-4021. 
24. 
Yaggi HK, Araujo AB, McKinlay JB. Sleep duration as a risk factor for the development of type 2 
diabetes. Diabetes Care. Mar 2006;29(3):657-661. 
25. 
Neilan TG, Mongeon FP, Shah RV, et al. Myocardial extracellular volume expansion and the risk 
of recurrent atrial fibrillation after pulmonary vein isolation. JACC. Cardiovascular imaging. Jan 
2014;7(1):1-11. 
26. 
Neilan TG, Shah RV, Abbasi SA, et al. The incidence, pattern, and prognostic value of left 
ventricular myocardial scar by late gadolinium enhancement in patients with atrial fibrillation. J 
Am Coll Cardiol. Dec 10 2013;62(23):2205-2214. 
27. 
Taal MW, Brenner BM. Renal risk scores: progress and prospects. Kidney Int. Jun 
2008;73(11):1216-1219. 
28. 
Buxton OM, Pavlova M, Reid EW, Wang W, Simonson DC, Adler GK. Sleep restriction for 1 week 
reduces insulin sensitivity in healthy men. Diabetes. Sep 2010;59(9):2126-2133. 
29. 
Haack M, Serrador J, Cohen D, Simpson N, Meier-Ewert H, Mullington JM. Increasing sleep 
duration to lower beat-to-beat blood pressure: a pilot study. Journal of sleep research. Jun 
2013;22(3):295-304. 
30. 
Leproult R, Deliens G, Gilson M, Peigneux P. Beneficial Impact of Sleep Extension on Fasting 
Insulin Sensitivity in Adults with Habitual Sleep Restriction. Sleep. Oct 28 2014. 
31. 
Rakova N, Jüttner K, Dahlmann A, et al. Long-Term Space Flight Simulation Reveals Infradian 
Rhythmicity in Human Na+ Balance. Cell metabolism. 2013;17(1):125-131. 
32. 
Brown NJ, Nakamura S, Ma L, et al. Aldosterone modulates plasminogen activator inhibitor-1 
and glomerulosclerosis in vivo. Kidney Int. Sep 2000;58(3):1219-1227. 
33. 
Juknevicius I, Segal Y, Kren S, Lee R, Hostetter TH. Effect of aldosterone on renal transforming 
growth factor-beta. American journal of physiology. Renal physiology. Jun 2004;286(6):F1059-
1062. 
34. 
Ikeda U, Kanbe T, Nakayama I, Kawahara Y, Yokoyama M, Shimada K. Aldosterone inhibits nitric 
oxide synthesis in rat vascular smooth muscle cells induced by interleukin-1 beta. Eur J 
Pharmacol. Jul 18 1995;290(2):69-73. 
35. 
Kornel L, Smoszna-Konaszewska B. Aldosterone (ALDO) increases transmembrane influx of Na+ 
in vascular smooth muscle (VSM) cells through increased synthesis of Na+ channels. Steroids. 
Jan 1995;60(1):114-119. 
36. 
Oberleithner H. Aldosterone makes human endothelium stiff and vulnerable. Kidney Int. May 
2005;67(5):1680-1682. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
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37. 
Bonmati-Carrion MA, Arguelles-Prieto R, Martinez-Madrid MJ, et al. Protecting the Melatonin 
Rhythm through Circadian Healthy Light Exposure. International journal of molecular sciences. 
2014;15(12):23448-23500. 
38. 
Claustrat B, Brun J, Chazot G. The basic physiology and pathophysiology of melatonin. Sleep Med 
Rev. Feb 2005;9(1):11-24. 
39. 
McMullan CJ, Schernhammer ES, Rimm EB, Hu FB, Forman JP. Melatonin secretion and the 
incidence of type 2 diabetes. JAMA. Apr 2013;309(13):1388-1396. 
40. 
McMullan CJ, Curhan GC, Schernhammer ES, Forman JP. Association of nocturnal melatonin 
secretion with insulin resistance in nondiabetic young women. Am J Epidemiol. Jul 15 
2013;178(2):231-238. 
41. 
Ross AJ, Yang H, Larson RA, Carter JR. Sleep efficiency and nocturnal hemodynamic dipping in 
young, normotensive adults. Am J Physiol Regul Integr Comp Physiol. Oct 1 2014;307(7):R888-
892. 
42. 
Borel AL, Benhamou PY, Baguet JP, et al. Short sleep duration is associated with a blood 
pressure nondipping pattern in type 1 diabetes: the DIAPASOM study. Diabetes Care. Sep 
2009;32(9):1713-1715. 
43. 
McMullan CJ, Hickson DA, Taylor HA, Forman JP. Prospective analysis of the association of 
ambulatory blood pressure characteristics with incident chronic kidney disease. J Hypertens. Sep 
2015;33(9):1939-1946. 
44. 
Garfinkel D, Zorin M, Wainstein J, Matas Z, Laudon M, Zisapel N. Efficacy and safety of 
prolonged-release melatonin in insomnia patients with diabetes: a randomized, double-blind, 
crossover study. Diabetes Metab Syndr Obes. 2011;4:307-313. 
45. 
Martino TA, Oudit GY, Herzenberg AM, et al. Circadian rhythm disorganization produces 
profound cardiovascular and renal disease in hamsters. Am J Physiol Regul Integr Comp Physiol. 
May 2008;294(5):R1675-1683. 
46. 
Taylor J. 2013 ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J. Jul 
2013;34(28):2108-2109. 
47. 
Mattix HJ, Hsu CY, Shaykevich S, Curhan G. Use of the albumin/creatinine ratio to detect 
microalbuminuria: implications of sex and race. J Am Soc Nephrol. Apr 2002;13(4):1034-1039. 
48. 
Connell SJ, Hollis S, Tieszen KL, McMurray JR, Dornan TL. Gender and the clinical usefulness of 
the albumin: creatinine ratio. Diabet Med. Jan-Feb 1994;11(1):32-36. 
49. 
Boudjeltia KZ, Faraut B, Esposito MJ, et al. Temporal dissociation between myeloperoxidase 
(MPO)-modified LDL and MPO elevations during chronic sleep restriction and recovery in 
healthy young men. PLoS One. 2011;6(11):e28230. 
50. 
McMullan CJ, Schernhammer ES, Forman JP. Melatonin level and risk for type 2 diabetes--in 
reply. JAMA. Aug 7 2013;310(5):537. 
51. 
Freedman BI, Kopp JB, Langefeld CD, et al. The apolipoprotein L1 (APOL1) gene and nondiabetic 
nephropathy in African Americans. J Am Soc Nephrol. Sep 2010;21(9):1422-1426. 
52. 
Tzur S, Rosset S, Shemer R, et al. Missense mutations in the APOL1 gene are highly associated 
with end stage kidney disease risk previously attributed to the MYH9 gene. Human genetics. Sep 
2010;128(3):345-350. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 20  
 
53. 
Hernández C, Abreu J, Abreu P, Castro A, Jiménez A. Nocturnal melatonin plasma levels in 
patients with OSAS: the effect of CPAP. Eur Respir J. Sep 2007;30(3):496-500. 
54. 
Ulasi, II, Tzur S, Wasser WG, et al. High population frequencies of APOL1 risk variants are 
associated with increased prevalence of non-diabetic chronic kidney disease in the Igbo people 
from south-eastern Nigeria. Nephron. Clinical practice. 2013;123(1-2):123-128. 
55. 
Forman JP, Curhan GC, Schernhammer ES. Urinary melatonin and risk of incident hypertension 
among young women. J Hypertens. Mar 2010;28(3):446-451. 
56. 
Dominguez-Rodriguez A, Abreu-Gonzalez P, Garcia-Gonzalez M, Reiter RJ. Prognostic value of 
nocturnal melatonin levels as a novel marker in patients with ST-segment elevation myocardial 
infarction. Am J Cardiol. Apr 2006;97(8):1162-1164. 
57. 
Ayas NT, White DP, Manson JE, et al. A prospective study of sleep duration and coronary heart 
disease in women. Arch Intern Med. Jan 27 2003;163(2):205-209. 
58. 
Lettieri CJ, Eliasson AH, Andrada T, Khramtsov A, Raphaelson M, Kristo DA. Obstructive sleep 
apnea syndrome: are we missing an at-risk population? Journal of clinical sleep medicine : JCSM : 
official publication of the American Academy of Sleep Medicine. Oct 15 2005;1(4):381-385. 
59. 
Leong WB, Arora T, Jenkinson D, et al. The prevalence and severity of obstructive sleep apnea in 
severe obesity: the impact of ethnicity. Journal of clinical sleep medicine : JCSM : official 
publication of the American Academy of Sleep Medicine. Sep 2013;9(9):853-858. 
60. 
McMullan CJ. HD, Taylor HA, Forman JP. Prospective analysis of the association of ambulatory 
blood pressure characteristics with incident chronic kidney disease. . Journal of Hypertension. 
2015;in press. 
61. 
Ray CA. Melatonin attenuates the sympathetic nerve responses to orthostatic stress in humans. 
J Physiol. Sep 2003;551(Pt 3):1043-1048. 
62. 
Arangino S, Cagnacci A, Angiolucci M, et al. Effects of melatonin on vascular reactivity, 
catecholamine levels, and blood pressure in healthy men. Am J Cardiol. May 1999;83(9):1417-
1419. 
63. 
Cagnacci A, Arangino S, Angiolucci M, Maschio E, Melis GB. Influences of melatonin 
administration on the circulation of women. Am J Physiol. Feb 1998;274(2 Pt 2):R335-338. 
64. 
Matsushita K, Selvin E, Bash LD, Franceschini N, Astor BC, Coresh J. Change in estimated GFR 
associates with coronary heart disease and mortality. J Am Soc Nephrol. Dec 2009;20(12):2617-
2624. 
65. 
Feraco A, Armani A, Mammi C, Fabbri A, Rosano GM, Caprio M. Role of mineralocorticoid 
receptor and renin-angiotensin-aldosterone system in adipocyte dysfunction and obesity. The 
Journal of steroid biochemistry and molecular biology. Sep 2013;137:99-106. 
66. 
Assessment report for Circadin to the European Medicines Agency: European Medicines Agency. 
67. 
Aldhous M, Franey C, Wright J, Arendt J. Plasma concentrations of melatonin in man following 
oral absorption of different preparations. Br J Clin Pharmacol. Apr 1985;19(4):517-521. 
68. 
Lemoine P, Wade AG, Katz A, Nir T, Zisapel N. Efficacy and safety of prolonged-release melatonin 
for insomnia in middle-aged and elderly patients with hypertension: a combined analysis of 
controlled clinical trials. Integr Blood Press Control. 2012;5:9-17. 


NKF Pilot Grant 2015 
Ciaran McMullan, MD, MMSc 
Detailed Protocol: 02.06.18 
Page | 21  
 
69. 
Wade AG, Crawford G, Ford I, et al. Prolonged release melatonin in the treatment of primary 
insomnia: evaluation of the age cut-off for short- and long-term response. Curr Med Res Opin. 
Jan 2011;27(1):87-98. 
70. 
Lemoine P, Garfinkel D, Laudon M, Nir T, Zisapel N. Prolonged-release melatonin for insomnia - 
an open-label long-term study of efficacy, safety, and withdrawal. Ther Clin Risk Manag. 
2011;7:301-311. 
71. 
Lyseng-Williamson KA. Melatonin prolonged release: in the treatment of insomnia in patients 
aged ≥55 years. Drugs Aging. Nov 2012;29(11):911-923. 
72. 
Feldman HI, Appel LJ, Chertow GM, et al. The Chronic Renal Insufficiency Cohort (CRIC) Study: 
Design and Methods. J Am Soc Nephrol. Jul 2003;14(7 Suppl 2):S148-153. 
73. 
McMullan CJ, Yano Y, Bakris GL, Kario K, Phillips RA, Forman JP. Racial impact of diurnal 
variations in blood pressure on cardiovascular events in chronic kidney disease. J Am Soc 
Hypertens. Apr 2015;9(4):299-306.