Clinical trial NCT00773513
Conditions: Chronic Renal Anemia
Sponsor: Hoffmann-La Roche
Start date: 2008-12-12; Completion date: 2017-07-27
Enrollment: 2825 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This 2 arm safety study will compare the outcome with respect to a composite endpoint of all-cause mortality and non-fatal cardiovascular events (myocardial infarction, stroke) in CKD participants either on dialysis or not receiving renal replacement therapy under treatment with methoxy polyethylene glycol-epoetin beta or reference ESAs. Participants will be randomized to receive intravenous (iv) or subcutaneous (sc) methoxy polyethylene glycol-epoetin beta at the following doses: for participants not already receiving ESA treatment, methoxy polyethylene glycol-epoetin beta will be administered at a starting dose of 0.6 micrograms per kilograms every 2 weeks (mcg/kg/2wks) iv or sc; for participants receiving maintenance ESA treatment, iv or sc methoxy polyethylene glycol-epoetin beta will be administered at an initial monthly dose of 120, 200 or 360 micrograms (mcg) depending on the weekly dose of ESA received prior to first methoxy polyethylene glycol-epoetin beta administration. Participants randomized to reference ESA treatment will receive iv or sc ESAs in accordance with their prescribed dosing information.

Detailed description:

Arms: arm 1: Participants will receive reference ESA according to approved label. The approved reference ESA compounds in the study will be darbepoetin alfa, epoetin alfa and epoetin beta. arm 2: Participants not currently being treated with an ESA will receive methoxy polyethylene glycol-epoetin beta iv or sc once every 2 weeks for correction of renal anemia (target Hb 10-12 g/dL). Once corrected and in participants currently being treated with an ESA, methoxy polyethylene glycol-epoetin beta will be administered once monthly.
Interventions: intervention 1: Darbepoetin Alfa intervention 2: Epoetin Alfa intervention 3: Epoetin Beta intervention 4: methoxy polyethylene glycol-epoetin beta
Intervention descriptions: intervention 1: Darbepoetin alfa will be administered as per approved label. intervention 2: Epoetin alfa will be administered as per approved label. intervention 3: Epoetin beta will be administered as per approved label. intervention 4: Participants who are currently not being treated with an ESA will receive methoxy polyethylene glycol-epoetin beta administered at a starting dose of 0.6 mcg/kg body weight once every 2 weeks. Participants who are currently being treated with an ESA will receive methoxy polyethylene glycol-epoetin beta at a dose of 120, 200 or 360 mcg once monthly (based on ESA dose administered in Week -1)

Protocol documents:
Prot_SAP_000.pdf: 
 
Official Title: 
A Randomized, Open Label Study to Assess All-Cause Mortality 
and Cardiovascular Morbidity in Patients with Chronic Kidney 
Disease on Dialysis and Those Not on Renal Replacement 
Therapy Under Treatment with Mircera or Reference ESAs. 
NCT Number: 
NCT00773513 
Document Date: 
Protocol Version D 23-Mar-2015 
 
 
 




PROTOCOL AMENDMENT, VERSION D: 
RATIONALE 
Protocol BH21260 has been amended to prolong the study by approximately 6 years 
because of a lower than anticipated event rate (EMA was informed on 8 May 2014, 
e-CTD seq. 033). 
Additional changes to the protocol are as follows: 
• 
Final visit assessments at study end will be modified to match the primary objective 
of the study to assess cardiovascular morbidity and mortality 
• 
To clarify adverse events reporting on serious adverse event reporting form in the 
electronic Case Report Form 
• 
Update of Appendix 5 with the revised version of the MIRCERA® Educational 
Program for anti-erythropoietin antibody-mediated pure red cell aplasia associated 
with erythropoietin stimulating agent 
• 
Administrative changes in the text of the packaging and labeling 
• 
Administrative changes in the procedures 
• 
Administrative changes in the text in the section of electronic Case Report Form 
because of a change of data capture system. 
 
No other changes have been made.  Substantive new information appears in italics.  
This amendment represents cumulative changes to the original protocol. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 2 


PROTOCOL AMENDMENT, VERSION D: 
SUMMARY OF CHANGES 
PROTOCOL SYNOPSIS 
The protocol synopsis has been updated to reflect the changes to the protocol, where 
applicable. 
SECTION 3.1:  Overview of Study Design and Dosing Regimen
The total length of the study iswas estimated to be 4 years (30 months recruitment and 
18 months of follow-up on treatment after last patient randomized) until the pre-specified 
number of outcome events iswere recorded. Due to an event rate lower than 
anticipated, it is expected that the study will be prolonged by approximately 4-6 
years. 
SECTION 3.1.3:  End of Study 
The study will end when a total of 1264 endpoint events have been recorded. 
Investigators will be informed of the end of study. Each patient remaining in the 
study will have a final visit at this time. The end of the study is defined as the date of the 
last visit of the last patient to complete the study. 
SECTION 5.4.1:  Clinical Assessments during the Treatment Period 
The following clinical information and assessments will be collected/performed during 
the randomized treatment period and at the final visit: 
 Physical examination at the final visit or early withdrawal, including body weight 
determination. 
– Blood pressure: at each study visit, and except at the final visit:, blood pressure will 
be measured before blood sampling using standard local techniques; BP should be 
determined both before and after the dialysis session for HD patients. The same 
technique (e.g., manual assessment, automated reading) should be used throughout 
the entire study for every patient. Blood pressure should be measured in the sitting 
position after at least 5 minutes rest. An appropriate-sized cuff should be used. Both 
systolic and diastolic blood pressures should be recorded. 
SECTION 5.4.2:  Laboratory Assessments Dduring the Treatment pPeriod 
The total volume of blood loss for laboratory assessments will be approximately 
2-4071 mL per visit with safety assessments representing a total of approximately 
112181 mL per year of participation.  
The following laboratory assessments will be performed during the randomized 
treatment period:  
– Hematology: 
– Platelet count at study visit 1, and at monthly visit and at the final visit. 
– Total white blood cell count at study visit 1, and every 3 months and at the final 
visit. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 3 


– Blood chemistry:   
 
– CRP every 3 months and at the final visit. 
– Serum albumin, calcium, phosphorus, potassium at study visit 1, and every 
3 months and at the final visit. 
– Cholesterol, triglycerides, HbA1c, glucose at study visit 1, and once a year and at the 
final visit. 
– 12-lead ECG recording at study visit 1 and at the final visit before dose 
administration. 
SECTION 6.3.2:  Packaging and Labeling of MIRCERA® 
Study medication will be packaged and provided in an open label fashion. It will be 
supplied with either study-specific labels or as commercially available product 
with additional labeling, if required by national legislation. Each syringe will be 
available in an individual blister with a needle for sc or iv administration. The package 
labels will include the following information: protocol number, study drug name, 
strength, lot number, re-tests date/used by (as per local guidelines), patient number, 
administration date and safety precautions for clinical trials. 
SECTION 6.3.4:  Packaging and Labeling of Reference ESAs 
For study centers/countries where reference ESAs will be supplied by Roche, reference 
ESAs will be packed and labeled according to local specifications, in an open fashion. It 
will be supplied with either study-specific labels or as commercially available 
product with additional labeling, if required by national legislation. Each PFS 
will be available blistered in an individual box.  
SECTION 6.5:  Assessment of Compliance 
Theis inventory and dispensing logs must be available for ongoing inspection by the 
Monitor. After injection, all empty blisters of PFS of MIRCERA® or reference ESA will 
be kept in a container or in the medication box and will be made available for the Roche 
Monitor to check at each visit. All supplies, including partially used, expired and unused 
or empty containers and the dispensing logs, must be kept at the study site and returned to 
copies of the inventory and dispensing logs will be retrieved by the Roche Monitor 
periodically and at the end of the study. 
SECTION 6.6:  Destruction of the MIRCERA®/Reference ESAs 
The unused, partially used or expired MIRCERA®/reference ESA PFS provided by the 
Sponsor may be destroyed at the site or at the supplying depot following the current 
Roche and local Standard Operating Procedures as applicable. 
Local or institutional regulations may require immediate destruction of used 
MIRCERA®/reference ESA PFS for safety reasons. In these cases, it may be acceptable 
for investigational site staff to destroy dispensed MIRCERA®/reference ESA PFS 
before a monitoring inspection provided that source document verification is performed 
on the remaining inventory and reconciled against the documentation of quantity shipped, 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 4 


dispensed, returned and destroyed. Written authorization must be obtained from the 
sponsor at study start up before destruction. 
Written documentation of destruction must contain the following: 
– Quantity of MIRCERA®/reference ESA PFS destroyed 
– Date of destruction (date discarded in designated hazardous container for 
destruction) 
– Method of destruction (the site must provide the Sponsor with documentation 
of their institutional policy and procedures for handling and disposing of 
drugs) 
– Name and signature of responsible person [or company] who destroyed discarded 
the investigational products[s] in a hazardous container for destruction 
SECTION 7.1.1:  Clinical AEs 
Clinical AEs encountered during the randomized treatment period and considered as 
serious by the investigator will be recorded on an AE eform of the eCRF (see figure 
in Appendix 1).  
SECTION 7.2.1:  Reporting of Serious Adverse Events [immediately reportable] 
Any clinical AE or abnormal laboratory test value that is serious [as defined in 
Section 7.1.1.3 above] and which occurs during the course of the study, regardless of the 
treatment arm, must be reported to Roche within one working day24 hours of the 
investigator becoming aware of the event [expedited reporting]. The investigator must 
complete the SAE Reporting Form and forward it to the SAE Responsible. 
SECTION 8.2.2:  Sample Size 
Note:  The overall event rate observed during the study is considerably lower 
than that expected at the planning stage.  Changing no other parameters leads to 
an extended study duration; the occurrence of 1264 events has been estimated to 
be approximately 10 years after study start.   
SECTION 15.4:  Electronic Case Report Forms 
Data for this study will be captured via an Electronic Data Capture (EDC) system by 
using eCRFs on a laptop. The data is entered on to the laptop using the off line mode. An 
audit trail will maintain a record of initial entries and changes made; reasons for change; 
time and date of entry; and user name of person authorizing entry or change. The 
investigator will connect on a regular basis, using an analog phone line, and the data will 
be transferred directly to the Roche database. 
eCRFs are to be completed using a Sponsor-designated EDC system.  Sites will 
receive training and have access to a manual for appropriate eCRF completion.  
eCRFs will be submitted electronically to the Sponsor and should be handled in 
accordance with instructions from the Sponsor. 
The investigator should ensure the accuracy, completeness, and timeliness of the data 
reported to the sponsor in the eCRFs and in all required reports. All eCRFs should be 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 5 


completed by designated, trained site staff.  eCRFs should be reviewed and 
electronically signed and dated by the investigator or a designee.  At the end of 
the study, the investigator will receive patient data for his or her site in a 
readable format on a compact disc that must be kept with the study records.  
Acknowledgement of receipt of the compact disc is required. 
TABLE 1:  Schedule of Assessments 
Table 1 has been revised to reflect changes to the protocol. 
APPENDIX 5:  Educational Program For MIRCERA® Anti-erythropoietin-
mediated Pure Red Cell aplasia Associated with Erythropoietin 
Stimulating Agents 
Appendix 5 has been updated with the revised version. 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 6 


 
TABLE OF CONTENTS 
 
1. 
BACKGROUND AND RATIONALE.....................................................................20 
1.1 
Background.............................................................................................20 
1.1.1 
Study Drug..............................................................................................20 
1.2 
Rationale for the Study ...........................................................................21 
2. 
OBJECTIVES...........................................................................................................21 
2.1 
Primary Objective...................................................................................21 
2.2 
Secondary objectives ..............................................................................21 
3. 
STUDY DESIGN .....................................................................................................21 
3.1 
Overview of Study Design and Dosing Regimen...................................21 
3.1.1 
Rationale for Study Design.....................................................................22 
3.1.2 
Rationale for Dose Selection ..................................................................22 
3.1.3 
End of Study ...........................................................................................22 
3.2 
Number of Subjects/ Assignment to Treatment Groups.........................23 
3.3 
Centers ....................................................................................................23 
4. 
STUDY POPULATION...........................................................................................23 
4.1 
Inclusion Criteria ....................................................................................23 
4.2 
Exclusion Criteria ...................................................................................24 
4.3 
Concomitant Medication and Treatment ................................................25 
4.3.1 
Iron Supplementation..............................................................................25 
4.3.2 
Red Blood Cell Transfusions..................................................................26 
4.3.3 
Dialysis ...................................................................................................26 
4.4 
Criteria for Premature Withdrawal .........................................................26 
4.5 
Replacement Policy [Ensuring Adequate Numbers of Evaluable 
Subjects]..................................................................................................27 
4.5.1 
For Subjects ............................................................................................27 
4.5.2 
For Centers..............................................................................................27 
5. 
SCHEDULE OF ASSESSMENTS AND PROCEDURES......................................27 
5.1 
Screening Examination and Eligibility Screening Form ........................29 
5.2 
Procedures for Enrolment of Eligible Subjects.......................................29 
5.3 
Assessments during the Screening Period ..............................................30 
5.3.1 
Clinical Assessments during the Screening Period.................................30 
5.3.2 
Laboratory Assessments during the Screening Period............................30 
5.4 
Assessments during the Treatment Period..............................................31 
5.4.1 
Clinical Assessments during the Treatment Period ................................31 
5.4.2 
Laboratory Assessments during the Treatment Period...........................31 
5.5 
Genomics and Laboratory Biomarkers...................................................32 
5.5.1 
Biomarker Sample Repository (BSR).....................................................32 
6. 
INVESTIGATIONAL MEDICINAL PRODUCT ...................................................33 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 7 


6.1 
Dose and Schedule of MIRCERA® and Comparators...........................33 
6.1.1 
Starting Dose of MIRCERA® and ESA.................................................33 
6.1.1.1 
Patients not currently treated with an ESA.............................................33 
6.1.1.2 
Patients currently treated with an ESA...................................................33 
6.1.2 
Dose Adjustments of MIRCERA® and ESA .........................................34 
6.1.2.1 
Patients Not Currently Treated with an ESA..........................................34 
6.1.2.2 
Patients Treated with an ESA .................................................................34 
6.2 
Preparation and Administration of MIRCERA® 
and Comparator[s] ..................................................................................35 
6.3 
Formulation, Packaging and Labeling....................................................35 
6.3.1 
Formulation of MIRCERA® ..................................................................35 
6.3.2 
Packaging and Labeling of MIRCERA® ...............................................35 
6.3.3 
Formulation of Reference ESAs.............................................................36 
6.3.4 
Packaging and Labeling of Reference ESAs ..........................................36 
6.4 
Blinding and Unblinding ........................................................................36 
6.5 
Assessment of Compliance.....................................................................36 
6.6 
Destruction of the MIRCERA®/Reference ESAs..................................37 
7. 
SAFETY INSTRUCTIONS AND GUIDANCE......................................................37 
7.1 
Adverse Events (AEs) and Laboratory Abnormalities ...........................37 
7.1.1 
Clinical AEs............................................................................................37 
7.1.1.1 
Intensity ..................................................................................................38 
7.1.1.2 
Drug - Adverse event relationship..........................................................38 
7.1.1.3 
Serious Adverse Events [Immediately Reportable to Roche].................38 
7.1.2 
Treatment and Follow-up of AEs ...........................................................39 
7.1.3 
Laboratory Test Abnormalities...............................................................39 
7.1.3.1 
Follow-up of Abnormal Laboratory Test Values....................................39 
7.2 
Handling of Safety Parameters ...............................................................39 
7.2.1 
Reporting of Serious Adverse Events [immediately reportable]............39 
7.2.2 
Pregnancy................................................................................................40 
7.3 
Warnings and Precautions.......................................................................40 
7.4 
Loss of effect...........................................................................................41 
8. 
STATISTICAL CONSIDERATIONS AND ANALYTICAL PLAN......................41 
8.1 
Primary and Secondary Study Endpoints ...............................................41 
8.1.1 
Primary Endpoints ..................................................................................41 
8.1.2 
Secondary Endpoints ..............................................................................41 
8.1.3 
Other Safety Endpoints...........................................................................41 
8.2 
Statistical and Analytical Methods .........................................................42 
8.2.1 
Statistical Model .....................................................................................42 
8.2.1.1 
Primary Endpoint....................................................................................42 
8.2.1.2 
Secondary Endpoints ..............................................................................42 
8.2.2 
Sample Size.............................................................................................42 
8.2.3 
Hypothesis Testing .................................................................................43 
8.2.4 
Analysis Populations...............................................................................44 
8.2.5 
Efficacy Analysis....................................................................................44 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 8 


8.2.5.1 
Interim Analysis......................................................................................44 
8.2.6 
Other Safety Data Analyses....................................................................44 
9. 
DATA COLLECTION, MANAGEMENT AND QUALITY ASSURANCE .........44 
9.1 
Assignment of Preferred Terms and Original Terminology...................45 
10. STUDY COMMITTEES ..........................................................................................45 
10.1 
Steering Committee ................................................................................45 
10.2 
DSMB .....................................................................................................45 
10.3 
Endpoint Committee...............................................................................46 
11. REFERENCES .........................................................................................................47 
12. ETHICAL ASPECTS ...............................................................................................49 
12.1 
Local Regulations/Declaration of Helsinki.............................................49 
12.2 
Informed Consent ...................................................................................49 
12.3 
Independent Ethics Committees/Institutional Review Board.................50 
13. CONDITIONS FOR MODIFYING THE PROTOCOL ..........................................50 
14. CONDITIONS FOR TERMINATING THE STUDY .............................................51 
15. STUDY DOCUMENTATION, ECRFS AND RECORD KEEPING......................51 
15.1 
Investigator's Files / Retention of Documents ........................................51 
15.2 
Source Documents and Background Data ..............................................51 
15.3 
Audits and Inspections............................................................................52 
15.4 
Electronic Case Report Forms ................................................................52 
16. MONITORING THE STUDY..................................................................................52 
17. CONFIDENTIALITY OF TRIAL DOCUMENTS AND SUBJECT 
RECORDS................................................................................................................53 
18. PUBLICATION OF DATA AND PROTECTION OF TRADE SECRETS ...........53 
 
 
 
LIST OF TABLES 
Page 
Table 1 
Schedule of Assessments........................................................................28 
Table 2 
MIRCERA® starting doses (μg/month).................................................33 
 
 
LIST OF FIGURES 
Page 
Figure 1 
Study Design...........................................................................................22 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 9 


 
 
LIST OF APPENDICES 
Page 
Appendix 1 
AEs Categories for Determining Relationship to Test Drug ..................54 
Appendix 2 
ICH Guidelines for Clinical Safety Data Management, Definitions 
and Standards for Expedited Reporting, Topic E2 .................................56 
Appendix 3 
Additional Information on Laboratory/Clinical Assessments ................58 
Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory 
Abnormalities..........................................................................................62 
Appendix 5 
Educational Program For MIRCERA® Anti-erythropoietin-
mediated Pure Red Cell aplasia Associated with Erythropoietin 
Stimulating Agents .................................................................................68 
Appendix 6 
Endpoints Documentation Checklist ......................................................80 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 10 


SYNOPSIS OF POST-AUTHORIZATION SAFETY STUDY 
PROTOCOL BH21260D 
TITLE 
A randomized, controlled, open-label, multi-centre, parallel-group 
study to assess all-cause mortality and cardiovascular morbidity in 
patients with chronic kidney disease on dialysis and those not on 
renal replacement therapy under treatment with MIRCERA® or 
reference ESAs. 
SPONSOR 
Hoffmann-La Roche Ltd 
Global Development  
CLINICAL 
PHASE 
IV 
INDICATION 
Chronic renal anemia  
OBJECTIVES  
Primary:  
to demonstrate non-inferiority of MIRCERA® versus reference 
ESAs in terms of a composite endpoint of all-cause mortality and 
non-fatal cardiovascular events (myocardial infarction (MI), stroke)
Secondary: 
to assess the incidence of anti-erythropoietin antibody-mediated 
pure red cell aplasia (PRCA), gastrointestinal bleeding and 
thromboembolic events  
TRIAL DESIGN 
Randomized, controlled, open-label, multi-centre parallel group, 
non-inferiority study comparing MIRCERA® to other ESAs  
NUMBER OF SUBJECTS 
2800 patients: 1400 patients randomized to MIRCERA®, 1400 
patients randomized to other ESAs 
TARGET POPULATION 
Adult patients ( ≥18 years old) with symptomatic anemia 
associated with CKD (renal anemia) not treated with an ESA 
(20%) or patients with renal anemia on maintenance ESA therapy 
(80%). 
The proportion of patients not on dialysis will be around 20%; 
approximately 76% of patients are expected to be on hemodialysis 
and 4% of patients on peritoneal dialysis. 
LENGTH OF STUDY  
The total length of the study was estimated to be 4 years 
(30 months recruitment and 18 months of follow-up on treatment) 
until the pre-specified number of composite events were 
recorded. Due to an event rate lower than anticipated, it is 
expected that the study will be prolonged by approximately 
4–6 years. 
END OF STUDY 
The study will end when a total of 1264 events of the composite 
endpoint have been recorded.  
INVESTIGATIONAL MEDICINAL 
PRODUCT(S) 
DOSE/ ROUTE/ REGIMEN 
Injectable solution of MIRCERA® 
– 
Patients with renal anemia not treated with an ESA: 0.6 μg/kg 
body weight, administered once every two weeks as iv or sc 
injection.  
– 
Patients with renal anemia who are on maintenance ESA 
therapy: the initial monthly dose of MIRCERA® will be one 
of three starting doses (120, 200 or 360 μg as iv or sc 
injection) based on the weekly dose of ESA administered 
prior to the first MIRCERA® administration. 
MIRCERA® doses will be adjusted to the target Hb levels 
according to approved label. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 11 


COMPARATOR “DRUG”  
DOSE/ ROUTE/ REGIMEN 
Injectable solution of ESAs: darbepoetin alfa (Aranesp®, Nespo®, 
Aranest®), epoetin alfa (Eprex®, Epogen®, Epopen®, Erypo®) 
and epoetin beta (NeoRecormon®, Recormon®). 
The starting dose, dose adjustment, route and regimen of the 
reference ESA should be as per local label. 
ASSESSMENTS OF: 
 
- 
EFFICACY 
N/A 
- 
SAFETY 
Primary endpoint:  
– 
time to composite of all-cause mortality and non-fatal 
cardiovascular events (MI, stroke) 
Secondary endpoints: 
– 
time to the individual components of the composite endpoint: 
the time to death, the time to non-fatal cardiovascular events 
(MI or stroke), the time to MI and the time to stroke 
Other clinical parameters: 
– 
Blood pressure 
– 
Adverse Events (AEs) and  Serious Adverse Events (SAEs) 
Laboratory parameters: 
– 
Iron parameters: serum ferritin, serum iron, serum transferrin 
or total iron-binding capacity (TIBC); calculated transferrin 
saturation (TSAT) or percentage of hypochromic RBCs  
– 
Hematology: hemoglobin (Hb), white blood cell count, 
platelet count 
– 
Blood chemistry: C-reactive protein (CRP), serum albumin, 
calcium, phosphorus, potassium 
– 
Lipids profile (cholesterol, triglycerides)  
– 
Hemoglobin A1c (HbA1c), glucose  
– 
ECG recording  
– 
Anti-erythropoietin antibody determination 
– 
Dialysis adequacy: Kt/V or urea reduction ratio (URR) for 
hemodialysis patients or weekly Kt/V for peritoneal dialysis 
patients. Creatinine clearance (CrCl)/glomerular filtration rate 
[GFR] in patients not on renal replacement therapy.    
- 
PHARMACOKINETICS/
 
PHARMACODYNAMICS  
N/A 
- 
QUALITY OF LIFE/
 
PHARMACOECONOMICS  
N/A 
- 
ROCHE SAMPLE REPOSITORY 
 
All patients who have been enrolled in the study will be asked to 
participate in the Roche Sample Repository Project in countries 
where RSR sampling is to be undertaken.  The RSR project 
involves taking a 9 mL blood sample for pharmacogenetic and 
genetic research.  Taking part in the RSR project is entirely 
optional and is subject to a signature on a separate written 
informed consent.  The RSR study protocol BH21260RG is 
submitted to the concerned Ethic Committee and is available for 
Competent Authority upon request. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 12 


- 
INCLUSION CRITERIA 
1. Written informed consent 
2. Adult patients ( ≥  18 years old) with symptomatic anemia 
associated with CKD (renal anemia) 
3. Patients with renal anemia who are not treated with an ESA: 
– 
Anemia defined as Hb concentration < 11.0 g/dL 
(mean of 2 screening values with at least one day and a 
maximum 2 weeks between measurements) with a 
clinical indication for ESA treatment  
or  
3. Patients with renal anemia who are on maintenance 
ESA therapy:  
– 
If on dialysis: regular long-term hemodialysis  or 
peritoneal dialysis therapy with the same mode of 
dialysis for at least 3 months before screening 
– 
Continuous iv or sc maintenance ESA therapy: 
darbepoetin alfa (Aranesp®, Nespo®, Aranest®), 
epoetin alfa (Eprex®, Epogen®, Epopen®, Erypo®) or 
epoetin beta (NeoRecormon®, Recormon®) 
administered according to approved label of the same 
agent and route of administration for at least 2 months 
before screening 
– 
Hb concentration between 10 and 12 g/dL  (mean of 2 
screening values with at least one day and a maximum of 
2 weeks between measurements) 
4. Patients with adequate iron status defined as: serum ferritin 
above or equal to 100 μg/L or transferrin saturation above or 
equal to 20% (See section 4.4 of the SmPC). 
- 
EXCLUSION CRITERIA 
Contraindications to ESA treatment (See Section 4.3 of SmPC): 
1. Uncontrolled hypertension  
2. Hypersensitivity to the active substance or any of the 
excipients of MIRCERA® and other ESAs 
3. Any other contraindication to ESA therapy 
Conditions known to cause inadequate response to ESA treatment 
or anemia other than symptomatic anemia associated with CKD, 
including (See Section 4.4. of the SmPC): 
4. Hemoglobinopathies (e.g., homozygous sickle-cell disease, 
thalassemia of all types) 
5. Anemia due to hemolysis  
6. Pure red cell aplasia (PRCA)  
 
Other  
7. High likelihood of early withdrawal (e.g. within 1 year) or 
interruption of the study  
8. Pregnancy or breast-feeding  
9. Women 
of 
childbearing 
potential 
without 
effective 
contraception  
10. Administration of another investigational drug within 1 
month before screening or planned during the study period  
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 13 


PROCEDURES (summary):   
The study will be a randomized, controlled, open-label, multi-centre parallel group, non-
inferiority study comparing MIRCERA® to other ESAs (Figure 1). 
Figure 1 
Study Design 
 
After written informed consent is obtained, patients will be screened for eligibility. 
Providing all eligibility criteria are met, patients with renal anemia not treated with an 
ESA will be randomly allocated 1:1 either to MIRCERA® once every two weeks 
(group A) or to a reference ESA treatment (group B) according to label for correction of 
their renal anemia. Once corrected, MIRCERA® patients should be treated with once 
monthly administration. Patients with renal anemia on stable maintenance ESA therapy 
will be randomized 1:1 to continue their current ESA treatment (group B) or to change to 
MIRCERA® treatment (group A) once-monthly. Stratification will be performed by 
treatment setting (correction/maintenance) and baseline CRP category (≤  30 mg/L / 
>30 mg/L). 
Pertinent variables to be documented at baseline include demographic parameters, 
medical history and co-morbidities, co-medications, duration and type of prior ESA, 
type of vascular access for hemodialysis and time since first dialysis. Baseline laboratory 
assessments include hemoglobin values, CRP, other laboratory parameters, dialysis 
adequacy parameters and anti-erythropoietin antibody determination. 
During the study, the participants will be treated according to the usual standard of care 
and current best practice guidelines. The doses of MIRCERA® and reference ESAs 
should be adjusted according to approved label to achieve and maintain the individual 
patient’s Hb levels within the Hb target range (10-12 g/dL). No further intervention will 
be done except for monthly visits at which assessments will be performed as specified in 
the 
protocol. 
Information 
on 
the 
components 
of 
the 
composite 
endpoint 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 14 


(all-cause mortality, myocardial infarction and stroke) and AEs will be collected on an 
ongoing basis and recorded at monthly visits.   
The total length of the study was estimated to be 4 years (30 months recruitment and 
18 months of follow-up on treatment) until the pre-specified number of composite events 
were recorded. Due to an event rate lower than anticipated, it is expected that the 
study will be prolonged by approximately 4–6 years.  
Study oversight will be assured by a steering committee to guide study conduct. 
An independent endpoint adjudication committee will provide a blinded assessment of 
fatal and non-fatal events in the composite endpoint. Suspect events will be recorded by 
the treating personnel in the participating centers, and the relevant information for the 
diagnostic coding of the event will be forwarded to the endpoint committee for blinded 
adjudication. Further details about the role and procedures of the endpoint committee will 
be provided in a separate document, the Endpoint Adjudication Committee charter. 
The suspect events will be adjudicated by blinded committee members, with subsequent 
blinded adjudication in the case of disagreement.  
An independent data and safety monitoring board (DSMB) will review the study data, 
including adjudicated outcomes, and propose continuation or discontinuation of the study 
according to pre-specified rules recorded in the DSMB charter.  
STATISTICAL ANALYSES:   
Primary analysis 
The primary objective is to demonstrate non-inferiority of MIRCERA® versus reference 
ESAs in terms of a composite endpoint of all-cause mortality and non-fatal 
cardiovascular events (MI, stroke), based on a non-inferiority limit of 1.20 for the 
hazard-ratio of the composite endpoint and a one-sided significance level of 0.025. 
The model used for the non-inferiority analyses will be a Cox model on time to event 
with treatment as the independent variable but no co-variables included in the model. 
The analysis will be performed based on the safety population defined as all patients 
randomized who receive at least one dose and had at least one post-dose safety 
assessment. 
Secondary analysis 
In addition to the primary analysis, Kaplan-Meier methods and frequency tables will be 
used to describe the time to the composite endpoint as well as the time to the individual 
components of the composite endpoint for the MIRCERA® versus reference group. 
Other analyses 
The secondary objectives (incidence of anti-erythropoietin antibody-mediated PRCA, 
gastrointestinal bleeding and thromboembolic events), as well as hemoglobin over time 
and dose will be analysed using descriptive statistics and analytical methods such as risk 
ratios, Cox regression and ANOVA methods. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 15 


Demographic and baseline characteristics 
Demographic and baseline characteristics (socio-demographic parameters, medical 
history and co-morbidities, co-medication, laboratory status and dialysis parameters, 
hemoglobin levels, duration and type of prior ESA treatments) will be summarized and 
comparability between treatment groups will be assessed descriptively.  
Sample size 
The stratification will be ensured that 20% of patients will be recruited in the correction 
setting and 80% in the maintenance switch setting. The expected yearly event rate is 
approximately 20%, based on  
– an expected 25% composite endpoint rate (a mortality rate of approximately 16% 
[2, 3] and non-fatal cardiovascular morbidity of approximately 9% [4]) in the 
maintenance setting (80% of patients) 
– a 7% rate for the combined endpoint in the correction setting (20% of patients) 
[CSR BA16738] 
Assuming linear recruitment over 30 months and a follow-up time of 18 months after 
randomization of the last patient, a sample size of 2800 patients, representing 
approximately 7700 patient-years of exposure, would be adequate to observe 1264 events 
of the composite endpoint of death and non-fatal cardiovascular events.  
1264 events are sufficient to ensure 90% power to establish non-inferiority of 
MIRCERA® to comparator ESAs in terms of the composite endpoint based on a 
non inferiority margin of 1.20 and a one-sided significance level of 0.025, assuring that 
the maximum difference between groups at the upper limit of the CI would be 6.1 % for 
the composite endpoint and 3.6% for mortality. 
Duration 
(months) 
NI limit 
(HR) 
Event 
rate per 
year 
No. 
events / 
Nb 
patients 
Expected 
Event 
rate at 
end of 
study (%) 
Highest 
event rate 
based on 
NI limit 
(%) 
Absolute 
/ relative 
difference 
(%) 
Absolute 
and 
relative 
difference 
in deaths 
(%) 
48 
1.2 
0.2 
1264 / 
2800 
45.2 
51.2 
6.1 / 13 
3.6 / 13 
 
Note:  The overall event rate observed during the study is considerably lower 
than that expected at the planning stage.  Changing no other parameters leads to 
an extended study duration; the occurrence of 1264 events has been estimated to 
be approximately 10 years after study start.   
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 16 


References 
1. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, 
Classification, and Stratification. Guideline 4:  Evaluation of GFR. Am J Kidney Dis 
2002, In: http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p5_lab_g4.htm 
(accessed Aug 3rd 2006).  
2. Cheung AK et al. Cardiac diseases in maintenance hemodialysis patients: Results of 
HEMO study.  Kidney Int 2004;65:2380-2389 
3. Excerpts from the USRDS.  2004 Annual Data Report: Atlas of end-stage renal 
disease in the United States.  Am J Kid Dis 2005; 45: Suppl 1 
4. Enkoyan G et al. Effect of dialysis dose and membrane flux in hemodialysis.  
New Engl J Med 2002; 347: 2010-2019 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 17 


GLOSSARY OF ABBREVIATIONS 
AE 
Adverse event 
BP 
Blood pressure 
CI 
Confidence interval 
CKD 
Chronic Kidney Disease 
CRP 
C-reactive protein 
CrCl 
Creatinine clearance 
DCS 
Data collection specification 
DSMB 
Data and Safety Monitoring Board 
dL 
Deciliter 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form(s) 
EDC 
Electronic Data Capture 
eform 
Electronic form (page) 
ESA 
Erythropoiesis-Stimulating Agent 
GFR 
Glomerular Filtration Rate 
Hb 
Hemoglobin 
HD 
Hemodialysis 
ICH 
International Conference on Harmonization 
iDCC 
Independent Data Coordinating Center 
ITT 
Intention-to-treat 
IVRS 
Interactive Voice Response System 
IMP 
Investigational Medicinal Product 
IU 
International Unit 
iv 
Intravenous 
kg 
Kilogram 
L 
Liter 
MDRD 
Modification of Diet in Renal Disease 
μg 
Microgram 
mL 
Milliliter 
μmol 
Micromole 
MI 
Myocardial Infarction 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 18 


GLOSSARY OF ABBREVIATIONS 
min 
Minute 
mmHg 
Millimeters of mercury 
NT-proBNP 
N-terminal pro-brain natriuretic peptide 
PD 
Peritoneal Dialysis 
PFS 
Pre-Filled Syringes 
PRCA 
Pure Red Cell Aplasia 
RBC 
Red Blood Cell 
RSR 
Roche Sample Repository 
SAE 
Serious Adverse Event 
sc 
Subcutaneous 
SmPC 
Summary of product characteristics 
TIBC 
Total iron-binding capacity 
TSAT 
Transferrin saturation 
URR 
Urea Reduction Ratio 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 19 


PART I: STUDY DESIGN AND CONDUCT 
 
1. 
BACKGROUND AND RATIONALE 
1.1 
Background 
An increased incidence of cardiovascular events has been observed at higher hemoglobin 
(Hb) levels in recently published studies of anemia correction in patients with chronic 
kidney disease (CKD) not on dialysis [1, 2]. These studies failed to demonstrate that 
correction of anemia to a target Hb of 13.5 g/dL or higher in patients with chronic kidney 
disease not receiving dialysis reduces the risk of cardiovascular events. One study 
suggested that this degree of correction of Hb level may be associated with an increased 
risk without incremental improvement in quality of life. Taken together, these findings 
suggest caution in the full correction of anemia in patients with chronic kidney disease.  
The global clinical development program for MIRCERA® included 13 Phase I clinical 
pharmacology studies and 10 therapeutic studies comprising four Phase II and 
six Phase III studies in patients with CKD, including patients on dialysis and not on 
dialysis. Administration of MIRCERA® for the treatment of anemia associated with 
CKD was generally well tolerated with no difference in the safety profile in comparison 
to reference erythropoiesis stimulating agents (ESAs) [3, 4].  
Data from phase III correction studies show that the Hb response rates in the 
MIRCERA® group at the end of the correction period were high (93.3% and 97.5% in 
the studies in patients on dialysis and not on dialysis, respectively) and comparable to 
comparators (91.3% and 96.3%, respectively). The median time to response was 43 days 
in the MIRCERA® arm and 29 days in the comparator arm with increases of hemoglobin 
within the first 6 weeks of 0.2 g/dl/week and 0.3 g/dl/week, respectively. 
Four randomized controlled phase III studies were performed in dialysis patients 
currently treated with darbepoetin alfa or epoetin. Patients were randomized to stay on 
their current treatment or to be converted to MIRCERA® in order to achieve stable 
hemoglobin levels. At the evaluation period (week 29-36), the mean and median level of 
hemoglobin in patients treated with MIRCERA® was virtually identical to their baseline 
hemoglobin level. 
1.1.1 
Study Drug 
Methoxy polyethylene glycol-epoetin beta (MIRCERA®) is a covalent conjugate of a 
protein produced by recombinant DNA technology in Chinese Hamster Ovarian cells and 
conjugated to a linear methoxy-polyethylene glycol (PEG). MIRCERA® is a continuous 
erythropoietin receptor activator that shows a different activity at the receptor level 
characterized by a slower association to and faster dissociation from the receptor, 
a reduced specific activity in vitro with an increased activity in vivo, as well as an 
increased half-life, in contrast to erythropoietin. The average molecular mass is 
approximately 60 kDa of which the protein moiety plus the carbohydrate part constitutes 
approximately 30 kDa.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 20 


MIRCERA® stimulates erythropoiesis by interaction with the erythropoietin receptor on 
progenitor cells in the bone marrow. As primary growth factor for erythroid development, 
the natural hormone erythropoietin is produced in the kidney and released into the 
bloodstream in response to hypoxia. In responding to hypoxia, the natural hormone 
erythropoietin interacts with erythroid progenitor cells to increase red cell production. 
The approved reference ESA compounds in the study will be darbepoetin alfa 
(Aranesp®, Nespo®, Aranest®), epoetin alfa (Eprex®, Epogen®, Epopen®, Erypo®) 
and epoetin beta (NeoRecormon®, Recormon®).  
1.2 
Rationale for the Study  
As part of the risk management plan, Roche proposes to gain more experience with 
MIRCERA® administered under clinical practice conditions and according to the 
approved label by performing a non-inferiority study comparing MIRCERA® to other 
ESAs in terms of mortality and cardiovascular morbidity. 
2. 
OBJECTIVES 
2.1 
Primary Objective 
The primary objective is to demonstrate non-inferiority of MIRCERA® versus reference 
ESAs in terms of a composite endpoint of all-cause mortality and non-fatal 
cardiovascular events (myocardial infarction (MI), stroke). 
2.2 
Secondary objectives 
The secondary objectives are to assess the incidence of anti-erythropoietin 
antibody-mediated pure red cell aplasia (PRCA), gastrointestinal bleeding and 
thromboembolic events. 
3. 
STUDY DESIGN 
3.1 
Overview of Study Design and Dosing Regimen   
The study will be a randomized, controlled, open-label, multi-centre parallel group, 
non-inferiority trial comparing MIRCERA® to other ESAs. 
The total length of the study was estimated to be 4 years (30 months recruitment and 
18 months of follow-up on treatment after last patient randomized) until the pre-specified 
number of outcome events were recorded. Due to an event rate lower than 
anticipated, it is expected that the study will be prolonged by approximately 4-6 
years. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 21 


Figure 1 
Study Design 
 
After written informed consent is obtained, patients will be screened for eligibility. 
Providing all eligibility criteria are met, patients with renal anemia not treated with an 
ESA will be randomly allocated 1:1 either to MIRCERA® once every two weeks 
(group A) or to a reference ESA treatment (group B) according to label for correction of 
their renal anemia. Once corrected, MIRCERA® patients should be treated with once 
monthly administration. Patients with renal anemia on stable maintenance ESA therapy 
will be randomized 1:1 to continue their current ESA treatment (group B) or to change to 
MIRCERA® treatment (group A) once-monthly. 
3.1.1 
Rationale for Study Design 
1264 events are sufficient to ensure 90% power to establish non-inferiority of 
MIRCERA® to comparator ESAs in terms of the composite endpoint based on a 
non-inferiority margin of 1.20 and a one-sided significance level of 0.025, assuring that 
the maximum difference between groups at the upper limit of the CI would be 6.1 % for 
the composite endpoint and 3.6% for mortality. 
3.1.2 
Rationale for Dose Selection 
Dosing will be performed as specified in the approved labels. 
3.1.3 
End of Study 
The study will end when a total of 1264 endpoint events have been recorded. 
Investigators will be informed of the end of study. Each patient remaining in the 
study will have a final visit at this time. The end of the study is defined as the date of the 
last visit of the last patient to complete the study. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 22 


3.2 
Number of Subjects/ Assignment to Treatment Groups  
2800 patients, [1400 per treatment arm] will be recruited over a planned recruitment 
period 
of 
30 
months. 
Stratification 
will 
be 
done 
by 
treatment 
setting 
(correction/maintenance) and baseline CRP category (≤ 30 mg/L / > 30 mg/L). 
3.3 
Centers 
Patients will be recruited in approximately 200-250 centers (around 10 patients per site).  
4. 
STUDY POPULATION 
The patient population will consist of adult patients (≥18 years old) with symptomatic 
anemia associated with CKD (renal anemia).  
20 percent of the study population will be patients with renal anemia, who are not treated 
with an ESA and who require correction of anemia. 
The remaining 80 percent of the study population will consist of patients with renal 
anemia who are on maintenance ESA therapy. They will continue their current 
ESA treatment or change to MIRCERA® treatment once-monthly. 
The proportion of patients not on dialysis will be around 20%; approximately 76% of 
patients are expected to be on hemodialysis and 4% of patients on peritoneal dialysis. 
Under no circumstances are patients who enroll in this study permitted to be 
re-randomized to this study and enrolled for a second course of treatment. 
4.1 
Inclusion Criteria 
Patients must fulfill all of the following inclusion criteria to be eligible for 
study enrolment.  
– Written informed consent 
– Adult patients (≥ 18 years old) with symptomatic anemia associated with CKD 
(renal anemia)  
– Patients with renal anemia who are not treated with an ESA: 
o Anemia defined as Hb concentration < 11.0 g/dL (mean of 2 screening 
values with at least one day and a maximum of 2 weeks between 
measurements) with a clinical indication for ESA treatment 
or 
– Patients with renal anemia who are on maintenance ESA therapy:  
o If on dialysis: regular long-term hemodialysis or peritoneal dialysis 
therapy with the same mode of dialysis for at least 3 months 
before screening 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 23 


o Continuous iv or sc maintenance ESA therapy: darbepoetin alfa 
(Aranesp®, Nespo®, Aranest®), epoetin alfa (Eprex®, Epogen®, 
Epopen®, Erypo®) or epoetin beta (NeoRecormon®, Recormon®) 
administered according to approved label of the same agent and route of 
administration for at least 2 months before screening 
o Hb concentration between 10 and 12 g/dL (mean of 2 screening values 
with at least one day and a maximum of 2 weeks between measurements) 
– Patients with adequate iron status defined as: serum ferritin above or equal to 
100 μg/L or transferrin saturation above or equal to 20% (See section 4.4 of the 
SmPC [14]) 
4.2 
Exclusion Criteria 
Contraindications to ESA treatment (See Section 4.3 of SmPC [14]):Uncontrolled 
hypertension  
– Hypersensitivity to the active substance or any of the excipients of MIRCERA® and 
other ESAs 
– Any other contraindication to ESA therapy 
Conditions known to cause inadequate response to ESA treatment or anemia other than 
symptomatic anemia associated with CKD, including (See Section 4.4. of the SmPC [14]): 
– Hemoglobinopathies (e.g., homozygous sickle-cell disease, thalassemia of all types) 
– Anemia due to hemolysis  
– Pure red cell aplasia (PRCA)  
Other: 
– High likelihood of early withdrawal (e.g. within 1 year) or interruption of the study  
– Pregnancy or breast-feeding 
– Women of childbearing potential without effective contraception 
– Administration of another investigational drug within 1 month before screening or 
planned during the study period 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 24 


4.3 
Concomitant Medication and Treatment 
All treatments (medications and medical procedures) are permitted before screening, 
during the screening period and throughout the treatment period except for: 
– Investigational drugs (defined as any material, i.e. placebo or drug, dispensed under 
the provision of a protocol) within 1 month before screening, during screening or the 
treatment periods. Participation in studies testing investigational devices should be 
reported to the sponsor in advance and approved in writing by the sponsor. 
All treatments administered within 3 months before the first screening visit and started or 
stopped at any time during the screening or treatment periods (including those to treat AEs) 
should be documented in the appropriate sections of the eCRF. 
It is expected that patients will be treated according to good clinical practice and current 
guidelines, particularly with respect to substitution therapy with iron, vitamin B12 and 
folic acid. 
4.3.1 
Iron Supplementation 
An adequate iron status is a prerequisite to achieve and maintain target Hb levels. Iron 
deficiency during treatment may cause a reduced erythropoietic response to ESA therapy. 
In addition, ESA therapy results in increased erythropoiesis that may lead to a depletion 
of iron stores. The iron status will be monitored throughout the study by assessing serum 
ferritin and transferrin saturation (TSAT). TSAT will be calculated as described in 
Appendix 3. The percentage of hypochromic RBCs can be determined instead of TSAT.  
Patients should be iron-replete at baseline and should maintain an adequate iron status 
throughout the randomized treatment period. 
Adequate iron status is defined as serum ferritin  ≥  100 μg/L and TSAT  ≥  20% 
(or percentage of hypochromic red cells < 10%).  
Supplemental iron will be administered to prevent iron deficiency during the screening 
period and during the treatment period, when either serum ferritin is < 100 μg/L or 
TSAT is < 20% (or percentage of hypochromic RBCs is ≥ 10%).  
Iron supplementation will be administered orally or intravenously, according to centre 
practice. If oral iron is not sufficient to correct iron deficiency, iv iron should be given. 
If iron treatment is ongoing at the start of the study, it should not be interrupted.  
To avoid iron toxicity, iv iron therapy should be temporarily discontinued in patients with 
serum ferritin > 800 μg/L or TSAT > 50%, until serum ferritin is ≤ 800 μg/L and TSAT 
is ≤ 50%. 
In order to obtain accurate measures of the iron parameters, we strongly recommend to 
follow the European and the NKF-K/DOQI guidelines [6, 7] on the time interval needed 
between administration of an iv iron dose and the performance of the measurements. 
This interval depends on the iron preparation and single dose administered: blood 
sampling for iron parameters should be performed at least 1 week after the administration 
of a >100 mg/dose of any iv iron preparation. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 25 


All oral and iv iron supplementations administered within 3 months before screening and 
started/stopped at any time during the screening and treatment periods should be 
documented in the iron supplementation section of the eCRF. 
4.3.2 
Red Blood Cell Transfusions 
All RBC transfusions administered during the study should be documented (i.e., specified 
by number of units transfused) on the RBC transfusions section of the eCRF. 
The pretransfusion Hb level should be measured before each RBC transfusion and 
recorded in the eCRF. 
4.3.3 
Dialysis  
For patients on dialysis, dialysis modality (HD or PD), PD type, the number of 
HD sessions per week, the type of vascular access for HD, time since first dialysis and 
dialysis adequacy assessments should be documented in the eCRF.  
Dialysis treatment should be performed according to current guidelines [8, 9]. 
If a patient not on dialysis requires dialysis (HD or PD) due to worsening of renal 
function, CrCl/GFR should be determined (using either the abbreviated MDRD or the 
Cockcroft-Gault equations; see Appendix 3). For the continuation of the study, pre- and 
post-dialysis blood pressure should be measured at each visit. The start of dialysis and 
dialysis modality should be documented in the dialysis eform of the eCRF. 
4.4 
Criteria for Premature Withdrawal  
Patients have the right to withdraw from the study at any time for any reason. 
The investigator also has the right to withdraw patients from the study in the event of 
intercurrent illness, AEs, insufficient therapeutic response, pregnancy, unacceptable 
toxicity of the study drug or administrative reasons. 
In case of kidney transplantation, the patient should be withdrawn from study; the final 
visit should take place before the transplantation, otherwise there will be no final visit. 
The investigator should contact the patient or a responsible relative either by telephone or 
through an office/clinic visit to establish as completely as possible the reason for the 
withdrawal. A complete final evaluation at the time of the patient’s withdrawal should be 
made with an explanation of why the patient is withdrawing from the study. If the reason 
for removal of a subject from the study is an Adverse Event, the principal specific event 
will be recorded on the eCRF. The subject should be followed until the Adverse Event 
has resolved, if possible. 
An excessive rate of withdrawals can render the study non-interpretable; therefore, 
unnecessary withdrawal of subjects should be avoided. Should a subject decide to 
withdraw, all efforts will be made to complete and report the observations prior to 
withdrawal as thoroughly as possible. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 26 


4.5 
Replacement Policy [Ensuring Adequate Numbers of 
Evaluable Subjects] 
4.5.1 
For Subjects 
No subject prematurely discontinued from the study for any reason will be replaced.  
4.5.2 
For Centers 
A center may be replaced for the following administrative reasons:   
– Excessively slow recruitment. 
– Poor protocol adherence. 
5. 
SCHEDULE OF ASSESSMENTS AND PROCEDURES 
Written informed consent must be obtained from the patient before any study-specific 
assessment or procedure is initiated. 
A follow-up (final) visit will be performed for all patients at study end or at any time 
during the study in case of premature withdrawal. Thereafter patients should be treated 
according to individual center practice. In case of premature withdrawal due to kidney 
transplantation, the final visit should necessarily take place before the transplantation, 
otherwise there will be no final visit.  
The schedule of assessments and procedures to be performed during the screening and 
the randomized treatment periods are described in Table 1. 
All the results collected throughout the study should be documented in the eCRF. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 27 


Table 1 
Schedule of Assessments 
 
Screening 
[1]  
 
Randomized treatment period 
 
 
Visit 
S1 
Visit 
S2 
Visit 1 
R [2] 
 
Final  
Visit 
Informed Consent 
X 
 
 
 
 
Medical History [3] 
X 
 
X 
 
 
Pregnancy Test [4] 
X 
 
 
 
 
Physical Examination [5] 
X 
 
 
 
 
Blood Pressure [6] 
X 
X 
X 
monthly 
 
Hb [7] 
X 
X 
X 
monthly or twice monthly [7] 
X 
Platelet Count 
X 
 
X 
monthly 
 
CRP 
X 
 
 
every 3 months 
 
Other Safety Laboratory 
Parameters [8] 
 
X 
every 3 months 
 
Iron Parameters [9] 
X 
 
 
every 3 months 
 
Cholesterol, triglycerides, glucose, 
hemoglobin A1c (HbA1c)  
 
X 
once a year 
 
Cardiac markers [10] 
 
in case of suspected MI 
Coagulation laboratory tests [11] 
 
in case of bleeding adverse events 
Kt/V or URR or CrCl/GFR, serum 
creatinine [12] 
 
X 
every 6 months 
 
Anti-erythropoietin Antibody  
 
X 
once a year 
X 
12-lead ECG Recording 
 
X 
 
 
Concomitant Treatment 
X 
X 
ongoing, recorded at monthly visit 
X 
Adverse Events 
 
X 
ongoing,  recorded at monthly visit 
X 
Composite Endpoint Assessments 
[13] 
 
X 
ongoing,  recorded at monthly visit 
X 
Drug Administration 
X 
X 
ongoing,  recorded at monthly visit 
 
Blood samples should be drawn prior to injection of MIRCERA®/reference ESA. 
R = Randomization should be performed before the first scheduled MIRCERA® or reference ESA administration at     
study visit 1. 
1. 
The second Hb and BP assessments are to be made at a second screening visit with at least one day and a 
maximum of 2 weeks between first and second screening visit.  
2. 
Study visit 1 should take place on the day of the first MIRCERA® or reference ESA administration and not more 
than 2 weeks after visit S2.  
3. 
Medical history including demographics, the etiology of CKD, dialysis modality (HD or PD), PD type, number of HD 
sessions per week, time since first dialysis, type of vascular access for HD for dialysis patients, previous treatments 
including ESA treatment, anticoagulant during dialysis and iron supplementation, previous and concomitant diseases 
including risk factors and dialysis-related events (recorded before the first scheduled drug administration at study visit 1) 
and intercurrent events occurring during screening will be documented before the first scheduled drug administration at 
study visit 1.  
4. 
Serum pregnancy test only to be performed in female patients of childbearing potential. 
5. 
General physical examination includes height (measured only at screening) and body weight.  
6. 
Systolic and diastolic blood pressure, measured before blood sampling; BP should be determined both before and 
after the dialysis session for HD patients.  
7. 
Twice monthly Hb measurements until Hb has stabilized, and monthly thereafter.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 28 


8. 
Total white blood cell count, serum albumin, calcium, phosphorus, potassium.  
9. 
Serum iron, serum ferritin, serum transferrin or TIBC, calculated TSAT or percentage of hypochromic RBCs.  
10. E.g., troponin T, troponin I 
11. E.g., prothrombin time (PT) or INR, thrombin time (TT), partial thromboplastin time (PTT) 
12. CrCl/GFR should be estimated for patients not on dialysis either with the abbreviated MDRD or the 
Cockcroft-Gault equations. Kt/V or URR should be determined for HD patients, and the weekly Kt/V for 
PD patients.  
13. Composite endpoint assessments: deaths, AEs of MI, stroke. 
 
5.1 
Screening Examination and Eligibility Screening Form 
All subjects must sign and date the most current IRB/IEC-approved written informed 
consent before any study specific assessments or procedures are performed. 
After signed written informed consent is obtained, patients will be screened for 
eligibility. Patients must fulfill all the entry criteria for participation in the study. 
During the screening period, patients on ESA treatments will continue to receive their 
treatment at the same dose, route (iv or sc) and dosing interval as before screening.  
An Eligibility Screening Form [ESF] documenting the investigator’s assessment of each 
screened subject with regard to the protocol’s inclusion and exclusion criteria is to be 
completed by the investigator. 
A screening failure log along with the reasons for screening failure must be maintained 
by the investigator. 
Patients who fail screening may be re-screened if it is considered likely that they could 
later become eligible. There is a limit of 3 screening attempts for each patient.  
5.2 
Procedures for Enrolment of Eligible Subjects  
At the end of the screening period, patients fulfilling all the inclusion and none of the 
exclusion criteria will be randomized into the study. The randomization should be 
performed before the first scheduled ESA or MIRCERA® administration at visit 1. 
Visit 1 should not be more than 2 weeks after the second screening visit. 
Providing all eligibility criteria are met, patients with renal anemia not treated with an ESA 
will be randomly allocated 1:1 either to MIRCERA® once every two weeks (group A) or to 
a reference ESA treatment (group B) according to label for correction of their renal anemia. 
Patients with renal anemia on stable maintenance ESA therapy will be randomized 1:1 to 
continue their current ESA treatment (group B) or to change to MIRCERA® treatment 
once-monthly (group A). Stratification will be performed by treatment setting 
(correction/maintenance) and by baseline CRP category (≤ 30 mg/L/>30 mg/L).
The subject randomization number will be generated by Roche or its designee and 
incorporated into a set of subject numbers and associated treatment[s] which will be 
given to the investigator at the time of individual subject enrolment.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 29 


The investigator or designee will use the eCRF with the assigned subject number and 
enter the corresponding number for allocation to the treatment groups in the appropriate 
place on each subject’s eCRF. 
The subject randomization numbers are to be allocated sequentially in the order in which 
the subjects are enrolled according to the specification document agreed with the external 
randomization company/centre. 
5.3 
Assessments during the Screening Period 
5.3.1 
Clinical Assessments during the Screening Period  
The following clinical information and assessments will be collected/performed during 
the screening period and before first study drug administration:  
– Medical history: demographics, the etiology of CKD, dialysis modality (HD or PD), 
PD type, number of HD sessions per week, time since first dialysis, type of vascular 
access for HD for dialysis patients, previous treatments including ESA treatment and 
iron supplementation, previous and concomitant diseases including risk factors and 
dialysis-related events.  
– General physical examination: includes height and body weight determination. 
– Blood pressure will be measured before blood sampling using standard local 
techniques; BP should be determined both before and after the dialysis session for 
HD patients. The same technique (e.g., manual assessment, automated reading) 
should be used throughout the entire study for every patient. Blood pressure should 
be measured in the sitting position after at least 5 minutes rest. An appropriate-sized 
cuff should be used. Both systolic and diastolic blood pressures should be recorded. 
BP will be measured at 2 screening visits with at least one day and a maximum of 
2 weeks between measurements. 
– Intercurrent events occurring during the screening period will be documented before 
first study drug administration. 
– Treatments administered during the screening period including ESA treatment, 
iron supplementation, antihypertensive treatments and anticoagulation therapy used 
for HD. 
5.3.2 
Laboratory Assessments during the Screening Period 
Normal ranges for the study laboratory parameters must be supplied to Roche before the 
study starts. Blood sampling should always be performed before ESA administration. 
The following laboratory assessments will be performed during the screening period 
(before first study drug): 
– Hematology:  
– Hb: hemoglobin for each patient will be measured at 2 screening visits with at 
least one day and a maximum of 2 weeks between measurements.  
– Platelet count 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 30 


– Iron parameters:   
 
– Serum ferritin, serum iron  
– Serum transferrin (or TIBC) 
– TSAT (or hypochromic RBCs). TSAT will be calculated (see Appendix 3 
for calculation).  
– CRP 
– Serum pregnancy test for female patients of childbearing potential. Patients who are 
amenorrheic for at least 12 months are not considered of childbearing potential.  
5.4 
Assessments during the Treatment Period 
5.4.1 
Clinical Assessments during the Treatment Period  
The following clinical information and assessments will be collected/performed during 
the randomized treatment period and at the final visit: 
– MIRCERA® (group A) and ESA (group B) administration.   
– Other treatments including iron supplementation, antihypertensive treatments and 
anticoagulation therapy used for HD. 
– Blood pressure: at each study visit, except at final visit, blood pressure will be 
measured before blood sampling using standard local techniques; BP should be 
determined both before and after the dialysis session for HD patients. The same 
technique (e.g., manual assessment, automated reading) should be used throughout 
the entire study for every patient. Blood pressure should be measured in the sitting 
position after at least 5 minutes rest. An appropriate-sized cuff should be used. Both 
systolic and diastolic blood pressures should be recorded. 
– Adverse events: monitored throughout the randomized treatment period. Serious AEs 
(SAEs), including composite endpoint assessments, will be monitored up to 30 days 
after the last study drug administration (see section 7.2). 
5.4.2 
Laboratory Assessments during the Treatment Period 
Normal ranges for the local study laboratory parameters must be supplied to Roche 
before the study starts.  
The total volume of blood loss for laboratory assessments will be approximately 2-40 mL 
per visit with safety assessments representing a total of approximately 112 mL per year 
of participation.  
Blood sampling during the study should always be performed before MIRCERA® or 
ESA administration.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 31 


The following laboratory assessments will be performed during the randomized 
treatment period:  
– Hematology: 
– Hb at study visit 1, at monthly visit and at the final visit. Hb will be assessed 
twice monthly until Hb has stabilized. 
– Platelet count at study visit 1 and at monthly visit. 
– Total white blood cell count at study visit 1 and every 3 months 
– Blood chemistry:   
 
– CRP every 3 months. 
– Serum albumin, calcium, phosphorus, potassium at study visit 1 and every 
3 months. 
− Iron parameters:   
– Serum ferritin, serum iron, serum transferrin or TIBC, TSAT or percentage of 
hypochromic RBCs every 3 months. 
– Cholesterol, triglycerides, HbA1c, glucose at study visit 1 and once a year. 
– Anti-erythropoietin antibody determination at study visit 1, once a year and at the 
final visit. 
– Patients on HD: Kt/V or URR will be determined at study visit 1 and every 6 months; 
patients on PD: the weekly Kt/V at study visit 1, every 6 months (see Appendix 3 
for definitions).  
– Patients not on dialysis: serum creatinine, creatinine clearance/glomerular filtration 
rate at study visit 1, every 6 months (CrCl/GFR, estimated with the abbreviated 
MDRD or the Cockcroft-Gault equations [Appendix 3]). 
– 12-lead ECG recording at study visit 1 before dose administration. 
The biological samples for specific parameters (anti-erythropoietin antibody determination) 
which will be analyzed by central laboratories should be classified, packed and shipped as 
UN 3373 Biological substance, Category B for dispatch purposes, as required by the 
international regulations and procedures. 
5.5 
Genomics and Laboratory Biomarkers 
5.5.1 
Biomarker Sample Repository (BSR) 
The collected samples will be stored at Roche for up to 15 years after database closure, 
after which they will be destroyed. The samples will be used only for research purposes 
to identify dynamic biomarkers that are predictive of response to ESA treatment in 
CKD patients with anemia and related diseases. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 32 


6. 
INVESTIGATIONAL MEDICINAL PRODUCT  
6.1 
Dose and Schedule of MIRCERA® and Comparators   
MIRCERA® will be injected sc or iv once every two weeks during the correction period 
or once every month during the maintenance treatment period [3, 4, 14]. 
Treatment with MIRCERA® has to be initiated under the supervision of a physician 
experienced in the management of patients with renal impairment.   
It is recommended that Hb is monitored every two weeks until stabilized and 
monthly thereafter. 
Patients in the reference group will receive sc or iv injections of ESA according to the 
approved label during the treatment period [10, 11, 12, 13].  
6.1.1 
Starting Dose of MIRCERA® and ESA 
6.1.1.1 
Patients not currently treated with an ESA 
The recommended MIRCERA® starting dose for patients not currently treated with an 
ESA is 0.6 μg/kg body weight, administered once every two weeks as a single iv or 
sc injection. 
The starting dose of the reference ESA should be according to the approved label. 
6.1.1.2 
Patients currently treated with an ESA 
The starting dose of MIRCERA® for each patient in group A will be based on the 
calculated weekly dose of the ESA administered prior to the switch to MIRCERA® 
i.e., administered in week-1. The starting doses of MIRCERA® that should be 
administered at the time of substitution (visit 1) are described in Table 2.  
Table 2 
MIRCERA® starting doses (μg/month)  
Previous weekly 
darbepoetin alfa 
intravenous or 
subcutaneous dose 
(μg/week) 
Previous weekly 
epoetin 
intravenous or 
subcutaneous 
dose (IU/week) 
Monthly 
MIRCERA® 
intravenous or 
subcutaneous dose 
(μg/once monthly)  
<40 
<8000 
120 
40-80 
8000-16000 
200 
>80 
>16000 
360 
 
Patients randomized to the reference group B will receive reference ESA treatment in 
week 1 at the weekly dose administered in week-1, at the previous dosing interval and 
according to the local label during the study period. 
The first dose should be given after randomization, at the study visit 1. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 33 


6.1.2 
Dose Adjustments of MIRCERA® and ESA 
6.1.2.1 
Patients Not Currently Treated with an ESA 
Dose adjustments of MIRCERA® and reference ESA treatments may be made until the 
individual target Hb level is obtained (Hb range of 10 – 12 g/dL) [3, 4, 10-14]. 
The MIRCERA® dose may be increased by approximately 25% (or 50% according to 
approved label in the country) of the previous dose if the rate of rise in Hb is less than 
1.0 g/dL over a month. Further increases of approximately 25% (or 50% according to 
approved label in the country) may be made at monthly intervals until the individual 
target Hb level is obtained.  
If the rate of rise in Hb is greater than 2 g/dL in one month or if the Hb level is increasing 
and approaching 12 g/dL, the MIRCERA® dose is to be reduced by approximately 25% 
(or 50% according to approved label in the country). If the Hb level continues to increase, 
therapy should be interrupted until the hemoglobin level begins to decrease, at which 
point therapy should be restarted at a MIRCERA® dose approximately 25% below the 
previously administered dose.  
Dose adjustments should not be made more frequently than once a month. 
If the desired Hb concentration is reached for the individual patient, MIRCERA® may be 
administered once monthly using the dose equal to twice the previous once every 
two weeks dose.  
Dose adjustment for the reference ESA should be done according to the approved label 
[10, 11, 12, 13]. 
6.1.2.2 
Patients Treated with an ESA 
If a dose adjustment is required to maintain the Hb concentration of 10 -12 g/dL, 
the MIRCERA® monthly dose may be increased by approximately 25% [3, 4, 14]. 
If the rate of rise in Hb is greater than 2 g/dL over a month or if the Hb level is increasing 
and approaching 12 g/dL, the MIRCERA® dose is to be reduced by approximately 25% 
(or 50% according to approved label in the country). If the Hb level continues to increase, 
MIRCERA® therapy should be interrupted until the Hb level begins to decrease, 
at which point therapy should be restarted at a MIRCERA® dose approximately 25% 
below the previously administered dose. MIRCERA® Dose adjustments should not be 
made more frequently than once a month. 
Since the treatment experience is limited in patients on peritoneal dialysis, regular 
Hb monitoring and strict adherence to dose adjustment guidance is recommended in 
these patients. 
Dose adjustment for the reference ESA should be done according to the approved label 
[10, 11, 12, 13]. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 34 


6.2 
Preparation and Administration of MIRCERA® 
and Comparator[s] 
MIRCERA® in PFS will be administered by sc or iv injection. MIRCERA® sc injection 
sites are the abdomen, thigh or arm. If two sc injections are necessary (volume of 
injection >1 mL), then the second injection should be performed on the opposite side of 
the body (e.g., abdomen right/abdomen left). 
In order to assure study drug administration and documentation, MIRCERA® and 
reference ESAs must be administered by an appropriately trained health care 
professional; self-administration of study medications is allowed only under the 
supervision of a health care professional.  
Home administration will be allowed when no study visits are planned or blood samples 
are to be taken. Home administration may be performed under the supervision of 
appropriately trained medical staff aware of the study procedures. 
The reference ESAs will be administered to the patients according to approved labels.  
After injection, all empty blisters/medication boxes with patient identification must be 
retained and made available for the Roche Monitor to check at each visit (see section 6.5).  
6.3 
Formulation, Packaging and Labeling 
Local packaging in some countries may be different. 
6.3.1 
Formulation of MIRCERA®  
MIRCERA® will be provided in sterile single-use injectable solution in PFS containing 
0.3 mL or 0.6 mL solution respectively. The MIRCERA® solution contains the following 
excipients: sodium dihydrogen phosphate monohydrate, sodium sulphate, mannitol 
(E421), methionine, poloxamer 188, water for injections.  
The injectable solution is available in the following strengths (in µg): 
PFS 
30 
50 
75 
100 
120 
150 
200 
250 
360 
 
The PFS should be stored in a refrigerator at 2-8°C and protected from the light. 
The investigational site is responsible for maintaining a daily temperature log of 
this refrigerator. 
6.3.2 
Packaging and Labeling of MIRCERA® 
Study medication will be packaged and provided in an open label fashion. It will be 
supplied with either study-specific labels or as commercially available product 
with additional labeling, if required by national legislation. Each syringe will be 
available in an individual blister with a needle for sc or iv administration. The package 
labels will include the following information: protocol number, study drug name, 
strength, lot number, re-tests date/used by (as per local guidelines), patient number, 
administration date and safety precautions for clinical trials. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 35 


6.3.3 
Formulation of Reference ESAs 
The formulation of the reference ESAs (Aranesp®, Nespo®, Aranest®, Eprex®, 
Epogen®, Epopen®, Erypo®, NeoRecormon® and Recormon®) will be according to 
approved labels [10, 11, 12, 13]. 
Reference ESAs will be handled and administered according to approved labels. 
The drug should be stored in a refrigerator (2°C – 8°C). The investigational site is 
responsible for maintaining a daily temperature log of any refrigerator used for the 
reference ESAs storage. 
6.3.4 
Packaging and Labeling of Reference ESAs 
The reference ESAs used for the study will be provided either by Roche or by individual 
study centers, depending on country specifications.  
For study centers/countries where reference ESAs will be supplied by Roche, reference 
ESAs will be packed and labeled according to local specifications, in an open fashion. It 
will be supplied with either study-specific labels or as commercially available 
product with additional labeling, if required by national legislation. Each PFS 
will be available blistered in an individual box.  
6.4 
Blinding and Unblinding  
Not applicable, the study is open-label. 
6.5 
Assessment of Compliance 
Accountability and subject compliance will be assessed by maintaining adequate drug 
dispensing and return records.  
A Drug Inventory/Dispensing Log provided by Roche must be kept current and should 
contain the following information at a minimum: 
• the identification of the subject to whom the study medication was dispensed 
• the date[s], quantity of the study medication dispensed to the subject 
• the initials of the person confirming administration of the study medication 
• the date[s] and quantity of the study medication returned by the subject 
 
The inventory and dispensing logs must be available for ongoing inspection by the 
Monitor. After injection, all empty blisters of PFS of MIRCERA® or reference ESA will 
be kept in a container or in the medication box and will be made available for the Roche 
Monitor to check at each visit. All supplies, including partially used, expired and unused 
or empty containers and dispensing logs, must be kept at the study site and copies of the 
inventory and dispensing logs will be retrieved by the Roche Monitor at the end of 
the study. 
In case of home administrations, for assessment of compliance, subjects will be asked to 
return empty blisters/medication boxes with the drug administration records at each 
study visit.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 36 


6.6 
Destruction of the MIRCERA®/Reference ESAs 
The unused, partially used or expired MIRCERA®/reference ESA PFS provided by the 
Sponsor may be destroyed at the site or at the supplying depot following the current 
Roche and local Standard Operating Procedures as applicable. 
Local or institutional regulations may require immediate destruction of used 
MIRCERA®/reference ESA PFS for safety reasons. In these cases, it may be acceptable 
for investigational site staff to destroy dispensed MIRCERA®/reference ESA PFS 
before a monitoring inspection provided that source document verification is performed 
on the remaining inventory and reconciled against the documentation of quantity shipped, 
dispensed, returned and destroyed. Written authorization must be obtained from the 
sponsor at study start up before destruction. 
Written documentation of destruction must contain the following: 
– Identity [batch numbers or subject numbers] of MIRCERA®/reference ESA 
[if applicable] destroyed 
– Quantity of MIRCERA®/reference ESA PFS destroyed 
– Date of destruction (date discarded in designated hazardous container for 
destruction) 
– Method of destruction (the site must provide the Sponsor with documentation 
of their institutional policy and procedures for handling and disposing of 
drugs) 
– Name and signature of responsible person [or company] who discarded the 
investigational products[s] in a hazardous container for destruction 
 
7. 
SAFETY INSTRUCTIONS AND GUIDANCE 
7.1 
Adverse Events (AEs) and Laboratory Abnormalities 
7.1.1 
Clinical AEs 
According to the International Conference of Harmonization [ICH], an AE is any 
untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with 
this treatment. An AE can therefore be any unfavorable and unintended sign 
[including an abnormal laboratory finding], symptom, or disease temporally associated 
with the use of a medicinal [investigational] product, whether or not considered related to 
the medicinal [investigational] product. Pre-existing conditions which worsen during a 
study are to be reported as AEs. 
Clinical AEs encountered during the randomized treatment period will be recorded on an 
AE eform of the eCRF (see figure in Appendix 1).  
Kidney transplantation and routine diagnostic procedures/tests are not considered AEs and 
should therefore not be recorded on an AE eform of the eCRF.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 37 


In patients not on dialysis, start of dialysis should not be considered as an AE and should 
be recorded on a specific eCRF form. If the worsening of kidney function justifying 
dialysis is faster than expected, the worsening of kidney function may be recorded as an 
AE term and the dialysis procedure should be recorded in the treatment section of the AE 
eform. 
Cardiac laboratory tests (e.g., troponin I, troponin T) will be assessed in case of 
suspected MI.  
Coagulation laboratory tests (e.g., prothrombin time (PT) or INR, thrombin time (TT), 
partial thromboplastin time (PTT)) will be assessed in case of bleeding adverse events. 
7.1.1.1 
Intensity  
All clinical AEs encountered during the clinical study will be reported on the AE eform of 
the eCRF. Intensity of AEs will be graded on a three-point scale [mild, moderate, severe] 
and reported in detail on the eCRF.  
Mild 
discomfort noticed but no disruption of normal daily activity. 
Moderate 
discomfort sufficient to reduce or affect daily activity. 
Severe 
inability to work or perform normal daily activity 
 
7.1.1.2 
Drug - Adverse event relationship 
The relationship of the AE to the treatment should always be assessed by the investigator. 
The relationship can be one of two possibilities: 
– No (unrelated; equals not drug related).  
– Yes (the event has a reasonable suspected causal relationship to the drug, or causality 
is unknown). 
The criteria used for determining causality relationship can be found in Appendix 1. 
7.1.1.3 
Serious Adverse Events [Immediately Reportable to Roche] 
A Serious Adverse Event (SAE) is any experience that suggests a significant hazard, 
contraindication, side effect or precaution. It is any AE that at any dose fulfills at least 
one of the following criteria: 
– is fatal; [results in death**; NOTE: death is an outcome, not an event]  
– is life threatening [NOTE: the term "life-threatening" refers to an event in which the 
subject was at immediate risk of death at the time of the event; it does not refer to an 
event which could hypothetically have caused a death had it been more severe]. 
– requires in-patient hospitalization or prolongation of existing hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 38 


– is medically significant or requires intervention to prevent one or other of the 
outcomes listed above. 
**The term sudden death should only be used when the cause is of a cardiac origin as per 
standard definition (see guidance notes for completing the SAE reporting form [
]). 
The terms death and sudden death are clearly distinct and must not be used 
interchangeably
20
. 
The study will comply with all local regulatory requirements and adhere to the full 
requirements of the ICH Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2 (Appendix 2).  
7.1.2 
Treatment and Follow-up of AEs  
AEs, especially those for which the relationship to study medication(s) is not “unrelated”, 
should be followed up until they have returned to baseline status or stabilized. If after 
follow-up, return to baseline status or stabilization cannot be established an explanation 
should be recorded on the eCRF. 
7.1.3 
Laboratory Test Abnormalities 
Laboratory test results will be recorded on the laboratory results eform of the eCRF, 
or appear on electronically produced laboratory reports submitted directly from the 
central laboratory, if applicable. Recommendations for grading adverse events and 
laboratories abnormalities can be found in Appendix 4.   
Any treatment-emergent abnormal laboratory result which is clinically significant, 
i.e., meeting one or more of the following conditions, should be recorded as a single 
diagnosis on the AE eform in the eCRF: 
Accompanied by clinical symptoms 
Leading to a change in study medication [e.g. dose modification, interruption or 
permanent discontinuation] 
Requiring a change in concomitant therapy [e.g. addition of, interruption of, 
discontinuation of, or any other change in a concomitant medication, therapy 
or treatment]. 
Any laboratory result abnormality fulfilling the criteria for a serious adverse event [SAE] 
should be reported as such, in addition to being recorded as an AE in the eCRF. 
7.1.3.1 
Follow-up of Abnormal Laboratory Test Values 
In the event of medically significant unexplained abnormal laboratory test values, 
the tests should be repeated and followed up until they have returned to the normal range 
and/or an adequate explanation of the abnormality is found. If a clear explanation is 
established it should be recorded on the eCRF.  
7.2 
Handling of Safety Parameters 
7.2.1 
Reporting of Serious Adverse Events [immediately reportable] 
Any clinical AE or abnormal laboratory test value that is serious [as defined in 
Section 7.1.1.3 above] and which occurs during the course of the study, regardless of the 
treatment arm, must be reported to Roche within 24 hours of the investigator becoming 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 39 


aware of the event [expedited reporting]. The investigator must complete the SAE 
Reporting Form and forward it to the SAE Responsible. 
The investigator must fax the completed SAE reporting form directly to the Roche local 
country contact person for SAEs (local monitor, see the Administrative and 
Contact Information).  
Related SAEs MUST be collected and reported regardless of the time elapsed from the 
last study drug administration, even if the study has been closed.  
Unrelated SAEs must be collected and reported during the study and for up to 30 days 
after the last dose of study medication. 
This study adheres to the definition and reporting requirements of ICH Guideline for 
Clinical Safety Data Management, Definitions and Standards for Expedited Reporting, 
Topic E2. Complete information can be found in Appendix 2. 
As an exception, the following SAEs unrelated to study drug, which are common in the 
dialysis population, will not be reported in an expedited manner on an SAE reporting form 
(but will be recorded as SAEs on the AE pages of the eCRF): 
- 
Thrombosis of vascular access for dialysis in HD patients  
- 
Peritonitis in PD patients 
All SAEs, including the two categories listed above, occurring during the randomized 
treatment period or within 30 days after the last injection of MIRCERA® or other ESAs 
within study, should be documented as SAEs on the AE eforms of the eCRF (See Figure 
in Appendix 1).  
7.2.2 
Pregnancy  
No data are available from adequate, controlled studies of MIRCERA® or other ESAs in 
pregnant women. Therefore, women of childbearing potential must have a serum 
pregnancy test at screening and must use a reliable method of contraception throughout 
the study (see Appendix 3). 
A female subject must be instructed to stop taking the study medication and immediately 
inform the investigator if she becomes pregnant during the study. The investigator should 
report all pregnancies within one working day to the sponsor using the 
Pregnancy Reporting Form. The investigator should counsel the subject, discuss the risks 
of continuing with the pregnancy and the possible effects on the fetus. Monitoring of the 
patient should continue until conclusion of the pregnancy. Pregnancies occurring up to 
90 days after the completion of the study medication must also be reported to 
the investigator.  
7.3 
Warnings and Precautions  
No evidence available at the time of the approval of this study protocol indicated that 
special warnings or precautions were appropriate, other than those noted in the SmPC [14]. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 40 


7.4 
Loss of effect  
Hb values will be monitored regularly throughout the study, and dose adjustments to 
achieve target Hb levels will be made according to protocol guidance (6.1). 
Loss of effect is defined as: a decline in Hb of at least 2.8 g/dL in a 4-week period 
without transfusion or requirement for transfusion of one blood unit or more per week for 
a minimum of two consecutive weeks in the absence of overt bleeding or blood loss, 
under uninterrupted treatment with study drug and with dose changes according to 
protocol guidance [18]. 
If loss of effect is suspected, the cause should be actively sought. Possible causes include: 
iron deficiency, infection, inflammation, occult blood loss, hyperparathyroidism, 
myelofibrosis, and malignancy. If a cause for loss of effect is not found, a hematologist 
should be consulted (bone marrow examination) and an unscheduled blood sample 
should 
be 
obtained 
for 
a 
reticulocyte 
count 
and 
an 
anti-erythropoietin 
antibody determination.  
If a diagnosis of PRCA is not confirmed, the patient should be maintained on the study 
drug and other possible causes of loss of effect should be investigated. 
If a diagnosis of PRCA is confirmed, treatment with the study drug should be stopped. 
The patient should not receive another epoetin and causes of PRCA should be 
investigated. The patient should proceed with the study assessments as scheduled. 
In addition, reticulocyte counts and anti-erythropoietin antibody testing will be performed 
every 8 weeks until the end of the study (see Appendix 5). 
8. 
STATISTICAL CONSIDERATIONS AND ANALYTICAL PLAN 
8.1 
Primary and Secondary Study Endpoints 
8.1.1 
Primary Endpoints 
The primary efficacy endpoint for this study is the time to composite of:  
all-cause mortality  
non-fatal cardiovascular events (MI, stroke) 
 
defined as the time between first dose of study medication and the date of death or 
non-fatal cardiovascular events (MI, stroke), whatever occurs first. Patients for whom no 
endpoint event is captured on the clinical database are censored at their last day in 
the study. 
8.1.2 
Secondary Endpoints 
Secondary endpoints are the time to the individual components of the composite endpoint: 
the time to death, the time to non-fatal cardiovascular events (MI or stroke), the time to 
MI and the time to stroke. 
8.1.3 
Other Safety Endpoints 
The safety of the treatment will also be evaluated on the basis of AEs, laboratory tests 
and vital signs, as described in section 8.2.6. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 41 


All subjects who receive at least one dose of treatment will be included in the 
safety evaluation. 
8.2 
Statistical and Analytical Methods 
8.2.1 
Statistical Model  
8.2.1.1 
Primary Endpoint 
The analysis of time to event endpoints is based on the survivor function, which is the 
probability to survive or, more generally, to remain event-free beyond a certain point in 
time. The primary endpoint will be analyzed with a Cox’s proportional hazards model to 
estimate the hazard ratio and its 95% confidence interval between the two treatment 
groups. The underlying proportional hazards model is 
)
exp(
)
(
)
(
0
Z
t
t
β
λ
λ
=
. Thereby, β is 
the coefficient corresponding to the binary vector Z taking the value 0 for patients on the 
reference arm and the value 1 for patients on the MIRCERA® arm, and λ0(t) is the 
baseline hazard of the reference treatment. Based on this, the following non-inferiority 
hypothesis for the hazard ratio (hMR = exp(β)) between MIRCERA® and reference will 
be tested by comparing the upper limit of the 95% confidence interval for the hazard ratio 
to 1.20: 
 
H0: hMR ≥ 1.20   versus     H1: hMR < 1.20  
The null hypothesis will be rejected if the upper limit of the confidence interval is below 
1.20. The underlying Cox regression model will retain treatment as factor.  
In addition, analyses based on Cox models adjusted for the baseline stratification factors 
and other clinically relevant baseline variables such as CRP at screening, age and 
baseline risk factors will be reported.  
8.2.1.2 
Secondary Endpoints 
Kaplan-Meier methods and frequency tables will be used to describe the time to the 
composite endpoint as well as the time to the individual components of the composite 
endpoint for the MIRCERA® versus reference group. The survival function will be 
summarized for the 25th percentile, the median, the 75th percentile and their 
95% confidence intervals. The plot of Kaplan-Meier estimates for the two treatment 
groups will be presented. The un-stratified log-rank test will be used to compare survivor 
functions between the two treatment groups. 
In addition, analyses based on Cox models adjusted for the baseline stratification factors 
(including CRP) and other clinically relevant baseline variables such as age and baseline 
risk factors will be reported.  
8.2.2 
Sample Size 
The randomization will be stratified by treatment setting (correction/maintenance) 
and baseline CRP category (≤ 30 mg/L / >30 mg/L). The stratification will ensure that 
20% of patients will be recruited in the correction setting and 80% in the maintenance 
switch setting.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 42 


The expected yearly event rate is approximately 20%, based on  
– an expected 25% composite endpoint rate (a mortality rate of approximately 16% 
[15, 16] and non-fatal cardiovascular morbidity of approximately 9% [17]) in the 
maintenance setting (80% of patients) 
– a 7% rate for the combined endpoint in the correction setting (20% of patients) 
[CSR BA16738] 
Assuming linear recruitment over 30 months and a follow-up time of 18 months after 
randomization of the last patient, a sample size of 2800 patients, representing 
approximately 7700 patient-years of exposure, would be adequate to observe 1264 events 
of the composite endpoint of death and non-fatal cardiovascular events.  
1264 events are sufficient to ensure 90% power to establish non-inferiority of 
MIRCERA® to comparator ESAs in terms of the composite endpoint based on a 
non-inferiority margin of 1.20 and a one-sided significance level of 0.025.  
Duration 
(months) 
NI limit 
(HR) 
Event 
rate per 
year 
No. 
events / 
Nb 
patients 
Expected 
Event rate 
at end of 
study (%) 
Highest 
event rate 
based on 
NI limit 
(%) 
Absolute 
/ relative 
difference 
(%) 
Absolute and 
relative 
difference in 
deaths (%) 
48 
1.2 
0.2 
1264 / 
2800 
45.2 
51.2 
6.1 / 13 
3.6 / 13 
 
Note:  The overall event rate observed during the study is considerably lower 
than that expected at the planning stage.  Changing no other parameters leads to 
an extended study duration; the occurrence of 1264 events has been estimated to 
be approximately 10 years after study start.   
 
8.2.3 
Hypothesis Testing  
The primary endpoint is the time between first dose of study medication and the date of 
death or non-fatal cardiovascular events (MI, stroke), whatever occurs first. 
The hypotheses to be tested are:  
H0: hMR ≥ 1.20   versus     H1: hMR < 1.20 
Using the correspondence between tests and confidence intervals, the test for non-inferiority 
will be based on the upper limit of the two-sided 95% confidence interval for the hazard 
ratio of the two groups. When the upper confidence interval limit is lower than 1.20, 
the MIRCERA® group will be regarded as clinically non-inferior to the reference group. 
The corresponding p-value will be calculated via the standard normal distribution: 
⎟⎟
⎠
⎞
⎜⎜
⎝
⎛
−
Φ
=
<=
=
SE
h
T
t
P
p
MR
20
.1
ln
ˆ
ln
)ˆ
(
,  
where SE denotes the standard error of 
 and 
MR
hˆ
ln
Φ  is the cumulative distribution 
function of the standard normal distribution. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 43 


8.2.4 
Analysis Populations 
The primary analysis will be performed based on the safety population defined as all 
patients randomized who receive at least one dose and had at least one post-dose 
safety assessment.  
In addition, the primary analysis will be performed based on the intent-to-treat (ITT) 
population 
defined 
as 
all 
patients 
randomized 
according 
to 
the 
original 
treatment assignment.  
8.2.5 
Efficacy Analysis 
This is a safety study; no formal efficacy analyses will be performed. Hemoglobin over 
time and dose will be analyzed descriptively. 
8.2.5.1 
Interim Analysis 
No formal interim analyses are planned. Safety updates will be prepared for review by 
the DSMB at its scheduled meetings (see section 10.2). 
8.2.6 
Other Safety Data Analyses 
The safety parameters will be vital signs, AEs and the safety laboratory parameters 
including iron parameters.  
Adverse event data will be presented in frequency tables (overall and by intensity) 
by body system. In tables showing the overall incidence of adverse events, subjects who 
experienced the same event on more than one occasion are counted only once in the 
calculation of the event frequency. Adverse events will be summarized throughout the 
whole study treatment period and up to 30 days after the last administration of 
study treatment. 
Deaths will be listed and summarized descriptively. Vital signs and laboratory data will 
be analyzed descriptively and will be assessed for clinically relevant abnormalities as 
well as changes from baseline. The results of the exploratory statistical analysis of 
NT-proBNP and troponin T will be reported separately.   
Demographic and baseline disease characteristics will be summarized by treatment arm 
for all randomized patients. 
The secondary objectives (incidence of anti-erythropoietin antibody-mediated pure red 
cell aplasia (PRCA), gastrointestinal bleeding and thromboembolic events), will be 
analyzed using descriptive statistics and analytical methods such as risk ratios, 
Cox regression and ANOVA methods. 
9. 
DATA COLLECTION, MANAGEMENT AND QUALITY ASSURANCE 
The overall procedures for quality assurance of clinical study data are described in the 
Roche Standard Operational Procedures. 
Data for this study will be recorded via an Electronic Data Capture (EDC) system using 
electronic Case Report Forms. It will be transcribed by the site from the paper source 
documents onto the eCRF. (In no case is the eCRF to be considered as source data for 
this trial.) 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 44 


Accurate and reliable data collection will be assured by verification and cross–check of 
the eCRFs against the investigator’s records by the study monitor [source document 
verification], and the maintenance of a drug–dispensing log by the investigator.  
A comprehensive validation check program utilizing front-end checks in the eCRF and 
back-end checks in the Roche database will verify the data and discrepancies will be 
generated accordingly. These are transferred electronically to the eCRF at the site for 
resolution by the investigator. 
Throughout the study the SMT will review data according to the SMT Data Review Plan 
as described in the Data Quality Plan.  
9.1 
Assignment of Preferred Terms and Original Terminology 
For classification purposes, preferred terms will be assigned by the Sponsor to the 
original terms entered on the eCRF, using the most up-to-date version of the 
Medical Dictionary for Regulatory Activities (MedDRA) terminology for adverse events 
and diseases and the International Non-proprietary Name (INN) Drug Terms and 
Procedures Dictionary for treatments and surgical and medical procedures. 
10. 
STUDY COMMITTEES 
10.1 
Steering Committee 
A Steering Committee will be put in place consisting of a group of study investigators 
and representatives of the Sponsor. The tasks of the Steering Committee include protocol 
development, review of study conduct, and management of issues arising during the trial. 
10.2 
DSMB 
An independent Data and Safety Monitoring Board (DSMB) consisting of 3 clinical 
experts in the field and a statistician will be constituted to review the safety data, 
including adjudicated outcomes, collected during the study. A non-voting clinical 
scientist representative of Roche will also be available to assist the DSMB with 
clarification of issues related to the protocol and study management. 
The board will review baseline risk factors as specified in section 5.3 and the safety data 
when approximately 25% (316) of the required events have been recorded and 
adjudicated. In addition, the board will review the data when 50% (632) and 75% (948) 
of events have occurred. Following each meeting the DSMB will give recommendations 
regarding continuation or discontinuation of the study to the sponsor according to 
pre-specified rules recorded in the DSMB charter.  
The Board may recommend stopping the study due to safety reasons, as described in the 
DSMB charter.  
The analyses provided to the DSMB will be prepared by an external independent 
statistician from the independent data coordinating center (iDCC). Further details about 
the role and procedures of the DSMB will be provided in the DSMB charter.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 45 


10.3 
Endpoint Committee 
An independent Endpoint Adjudication Committee will be constituted to review all 
potential endpoint events. The Endpoint Adjudication Committee will consist of at least 
two cardiologists, one nephrologist and one neurologist with experience in clinical 
studies and in the adjudication of study endpoints. The committee will provide a blinded 
assessment of fatal and non-fatal events in the composite endpoint.  
Suspect events will be recorded by the treating personnel in the dialysis centers. 
The Sponsor will supply the Committee members with blinded patient level data for 
review. For the list of documents see Appendix 6. The suspect events will be adjudicated 
by blinded committee members, with subsequent blinded adjudication in the case 
of disagreement.  
The Endpoint Committee and the Sponsor will establish the classification definitions in 
accordance with the study protocol before the adjudication process begins. Further details 
about the role and procedures of the Endpoint Committee will be provided in a separate 
document, the Endpoint Adjudication Committee charter.  
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 46 


11. 
REFERENCES 
1. 
Singh AK et al. Correction of anemia with epoetin alfa in chronic kidney 
disease. N Engl J Med 2006;355:2085-98. 
2. 
Drüeke TB et al. Normalization of hemoglobin level in patients with chronic 
kidney disease and anemia. N Engl J Med 2006;355:2071-84. 
3. 
MIRCERA®, Core Data Sheet. 
4. 
MIRCERA®, Investigator’s Brochure, Ninth Version, September, 2007. 
5. 
K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: 
Evaluation, Classification, and Stratification. Guideline 4: Evaluation of GFR. 
Am J Kidney Dis 2002, In: 
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p5_lab_g4.htm 
(accessed Aug 3rd 2006).  
6. 
KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 
Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006;47 [Suppl 3]:S11-145. 
7. 
Revised European Best Practice Guidelines for the management of anemia in 
patients with chronic renal failure. Nephrol Dial Transplant 19(suppl 2):Sii1-Sii47, 
2004  
8. 
European Best Practice Guidelines on Haemodialysis. Nephrol Dial 
Transplant 22(Suppl 2):ii1-ii120, 2007 
9. 
European Best Practice Guidelines for Peritoneal Dialysis. Nephrol Dial 
Transplant 20(Suppl 9): ix24–ix27, 2005 
10.  
Aranesp® Summary of Product Characteristics, EMEA. In: 
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medi
cines/000332/human_med_000651.jsp&murl=menus/medicines/medicines.js
p&mid=WC0b01ac058001d125# 
11.  
Nespo® Summary of Product Characteristics, EMEA. In: 
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medi
cines/000333/human_med_000923.jsp&murl=menus/medicines/medicines.js
p&mid=WC0b01ac058001d125 
12. 
Eprex® Summary of Product Characteristics (revised text 27 July 2006). In: 
http://emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=8
89. 
13. 
NeoRecormon® Summary of Product Characteristics, EMEA. In: 
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medi
cines/000116/human_med_000921.jsp&murl=menus/medicines/medicines.js
p&mid=WC0b01ac058001d125# 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 47 


14. 
MIRCERA® Summary of Product Characteristics, EMEA. In:. 
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medi
cines/000739/human_med_000905.jsp&murl=menus/medicines/medicines.js
p&mid=WC0b01ac058001d125#  
15. 
Cheung AK et al. Cardiac diseases in maintenance hemodialysis patients: 
Results of HEMO study. Kidney Int 2004;65:2380-2389 
16. 
Excerpts from the USRDS. 2004 Annual Data Report: Atlas of end-stage 
renal disease in the United States. Am J Kid Dis 2005; 45: Suppl 1 
17. 
Enkoyan G et al. Effect of dialysis dose and membrane flux in hemodialysis. 
New Engl J Med 2002; 347: 2010-2019 
18. 
Eckardt KU, Casadevall N. Pure red-cell aplasia due to anti-erythropoietin 
antibodies. Nephrol Dial Transplant 2003;18:865-869. 
19. 
Deicher R, Hörl WH. Hepcidin: a molecular link between inflammation and 
anemia. Nephrol Dial Transplant 2004;19:521-524. 
20. 
Guidance Notes for Completing SAE Reporting Form (gcp_for000025; 
version 7.0). 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 48 


PART II: ETHICS AND GENERAL STUDY ADMINISTRATION 
12. 
ETHICAL ASPECTS 
12.1 
Local Regulations/Declaration of Helsinki 
The investigator will ensure that this study is conducted in full conformance with the 
principles of the “Declaration of Helsinki” or with the laws and regulations of the country 
in which the research is conducted, whichever affords the greater protection to the 
individual. The study must fully adhere to the principles outlined in “Guideline for Good 
Clinical Practice” ICH Tripartite Guideline or with local law if it affords greater 
protection to the subject. For studies conducted in the EU/EEA countries, the investigator 
will ensure compliance with the EU Clinical Trial Directive [2001/20/EC]. For studies 
conducted in the USA or under US IND, the investigator will additionally ensure 
adherence to the basic principles of “Good Clinical Practice” as outlined in the current 
version of 21 CFR, subchapter D, part 312, “Responsibilities of Sponsors and 
Investigators”, part 50, “Protection of Human Subjects”, and part 56, “Institutional 
Review Boards”. 
In other countries where a “Guideline for Good Clinical Practice” exists, Roche and the 
investigators will strictly ensure adherence to the stated provisions. 
12.2 
Informed Consent  
Written Informed Consent from Subjects: 
It is the responsibility of the investigator, or a person designated by the investigator 
[if acceptable by local regulations], to obtain signed informed consent from each subject 
prior to participating in this study after adequate explanation of the aims, methods, 
anticipated benefits, and potential hazards of the study. For the subject not qualified or 
incapable of giving legal consent, written consent must be obtained from the legally 
acceptable representative. In the case where both the subject and his/her legally 
acceptable representative are unable to read, an impartial witness should be present 
during the entire informed consent discussion. After the subject and representative have 
orally consented to participation in the trial, the witness’ signature on the form will attest 
that the information in the consent form was accurately explained and understood. 
The investigator or designee must also explain that the subjects are completely free to 
refuse to enter the study or to withdraw from it at any time, for any reason. The electronic 
Case Report Forms (eCRFs) for this study contain a section for documenting subject 
informed consent, and this must be completed appropriately. If new safety information 
results in significant changes in the risk/benefit assessment, the consent form should be 
reviewed and updated if necessary. All subjects (including those already being treated) 
should be informed of the new information, given a copy of the revised form and give 
their consent to continue in the study. 
For non-US-IND studies:In a life-threatening situation where a patient is unconscious or 
otherwise unable to communicate, the emergency is such that there is not enough time to 
obtain consent from the patient's legally acceptable representative, and there is no other 
or better treatment available, it is permissible to treat the patient under protocol with 
consent of the investigator, with appropriate documentation that the IEC had approved 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 49 


the procedures used to enroll patients in such situations. In addition, the patient or his/her 
legally acceptable representative should be informed about the trial as soon as possible 
and consent to continue, giving written consent as described above. 
12.3 
Independent Ethics Committees/Institutional Review Board  
Independent Ethics Committees (IECs) [non-US] For EEA member states, the sponsor 
will submit to the Competent Authority and Ethics Committees the protocol and any 
accompanying material provided to the subject (such as subject information sheets or 
descriptions of the study used to obtain informed consent as well as any advertising or 
compensation given to the subject). 
Approval from the committee must be obtained before starting the study, and should be 
documented in a letter to the investigator specifying the date on which the committee met 
and granted the approval. 
Any modifications made to the protocol after receipt of the IEC’s approval must be 
re-submitted by the investigator in the US and by the Sponsor in the EEA member states 
in accordance with local procedures and regulatory requirements. 
When no local review board exists, the investigator is expected to submit the protocol to 
a regional committee. If no regional committee exists, Roche will assist the investigator 
in submitting the protocol to the European Ethics Review Committee. 
Institutional Review Board [US]: It is the understanding of the sponsor that this 
protocol [and any modifications] as well as appropriate consent procedures and 
advertisements, will be reviewed and approved by an Institutional Review Board. 
This board must operate in accordance with the current Federal Regulations. The sponsor 
will receive a letter or certificate of approval prior to initiation of the study, and also 
whenever subsequent amendments/modifications are made to the protocol. 
13. 
CONDITIONS FOR MODIFYING THE PROTOCOL 
Requests from investigators to modify the protocol to ongoing studies will be considered 
only by consultation between an appropriate representative of the sponsor and the 
investigator [investigator representative[s] in the case of a multicenter trial]. 
Protocol modifications must be prepared by a representative of the sponsor and initially 
reviewed and approved by the Clinical Science Leader/Clinical Pharmacologist 
and Biostatistician. 
All protocol modifications must be submitted to the appropriate Independent Ethics 
Committee or Institutional Review Board for information and approval in accordance with 
local requirements, and to Regulatory Agencies if required. Approval must be obtained 
before any changes can be implemented, except for changes necessary to eliminate an 
immediate hazard to trial subjects, or when the change[s] involves only logistical or 
administrative 
aspects 
of 
the 
trial 
[e.g. 
change 
in 
monitor[s], 
change 
of 
telephone number[s]. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 50 


14. 
CONDITIONS FOR TERMINATING THE STUDY 
Both the sponsor and the investigator reserve the right to terminate the study at any time. 
Should this be necessary, both parties will arrange the procedures on an individual study 
basis after review and consultation. In terminating the study, Roche and the investigator 
will assure that adequate consideration is given to the protection of the subjects’ interests. 
15. 
STUDY DOCUMENTATION, ECRFS AND RECORD KEEPING 
15.1 
Investigator's Files / Retention of Documents 
The Investigator must maintain adequate and accurate records to enable the conduct of 
the study to be fully documented and the study data to be subsequently verified. 
These documents should be classified into two different separate categories [1] 
Investigator's Study File, and [2] subject clinical source documents. 
The Investigator's Study File will contain the protocol/amendments, DCS and schedule of 
assessments, 
Independent 
Ethics 
Committee/Institutional 
Review 
Board 
and 
governmental approval with correspondence, sample informed consent, drug records, 
staff 
curriculum 
vitae 
and 
authorization 
forms 
and 
other 
appropriate 
documents/correspondence, etc. In addition at the end of the study the investigator will 
receive the patient data, which includes an audit trail containing a complete record of all 
changes to data, query resolution correspondence and reasons for changes, in human 
readable format on CD which also has to be kept with the Investigator’s Study File. 
Subject clinical source documents [usually defined by the project in advance to record 
key efficacy/safety parameters independent of the eCRFs] would include subject 
hospital/clinic 
records, 
physician's 
and 
nurse's 
notes, 
appointment 
book, 
original laboratory reports, ECG, EEG, X-ray, pathology and special assessment reports, 
signed informed consent forms, consultant letters, and subject screening and enrollment 
logs. The Investigator must keep these two categories of documents (including the 
archival CD) on file for at least 15 years after completion or discontinuation of the study. 
After that period of time the documents may be destroyed, subject to local regulations.  
Should the Investigator wish to assign the study records to another party or move them to 
another location, Roche must be notified in advance. 
If the Investigator cannot guarantee this archiving requirement at the investigational site 
for any or all of the documents, special arrangements must be made between the 
Investigator and Roche to store these in a sealed container[s] outside of the site so that 
they can be returned sealed to the Investigator in case of a regulatory audit. Where source 
documents are required for the continued care of the subject, appropriate copies should be 
made for storing outside of the site. 
15.2 
Source Documents and Background Data 
The investigator shall supply the sponsor on request with any required background data 
from the study documentation or clinic records. This is particularly important when errors 
in data transcription are suspected. In case of special problems and/or governmental 
queries or requests for audit inspections, it is also necessary to have access to the 
complete study records, provided that subject confidentiality is protected. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 51 


15.3 
Audits and Inspections 
The investigator should understand that source documents for this trial should be made 
available to appropriately qualified personnel from the Roche Pharma Development 
Quality Assurance Unit or its designees or to health authority inspectors after appropriate 
notification. The verification of the eCRF data must be by direct inspection of 
source documents. 
15.4 
Electronic Case Report Forms 
eCRFs are to be completed using a Sponsor-designated EDC system.  Sites will 
receive training and have access to a manual for appropriate eCRF completion.  
eCRFs will be submitted electronically to the Sponsor and should be handled in 
accordance with instructions from the Sponsor. 
For each subject enrolled, an eCRF must be completed and electronically signed by the 
principal investigator or authorized delegate from the study staff. This also applies to 
records for those patients who fail to complete the study [even during a 
pre-randomization screening period if an eCRF was initiated]. If a patient withdraws 
from the study, the reason must be noted on the eCRF. If a patient is withdrawn from the 
study because of a treatment-limiting AE, thorough efforts should be made to clearly 
document the outcome. 
The investigator should ensure the accuracy, completeness, and timeliness of the data 
reported to the sponsor in the eCRFs and in all required reports. All eCRFs should be 
completed by designated, trained site staff.  eCRFs should be reviewed and 
electronically signed and dated by the investigator or a designee.  At the end of 
the study, the investigator will receive patient data for his or her site in a 
readable format on a compact disc that must be kept with the study records.  
Acknowledgement of receipt of the compact disc is required. 
16. 
MONITORING THE STUDY 
It is understood that the responsible Roche monitor [or designee] will contact and visit 
the investigator regularly and will be allowed, on request, to inspect the various records 
of the trial [eCRFs and other pertinent data] provided that subject confidentiality is 
maintained in accord with local requirements. 
It will be the monitor's responsibility to inspect the eCRFs at regular intervals throughout 
the study, to verify the adherence to the protocol and the completeness, consistency and 
accuracy of the data being entered on them. The monitor must verify that the subject 
received the study drug assigned by the randomization center (by controlling the written 
confirmation of the randomization by IVRS). The monitor should have access to 
laboratory test reports and other subject records needed to verify the entries on the eCRF. 
The investigator [or deputy] agrees to cooperate with the monitor to ensure that any 
problems detected in the course of these monitoring visits are resolved. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 52 


17. 
CONFIDENTIALITY OF TRIAL DOCUMENTS AND SUBJECT 
RECORDS 
The investigator must assure that subjects’ anonymity will be maintained and that their 
identities are protected from unauthorized parties. On eCRFs or other documents 
submitted to the sponsor, subjects should not be identified by their names, but by an 
identification code. The investigator should keep a subject enrollment log showing codes, 
names and addresses. The investigator should maintain documents not for submission to 
Roche, e.g., subjects’ written consent forms, in strict confidence. 
18. 
PUBLICATION OF DATA AND PROTECTION OF TRADE SECRETS 
The results of this study may be published or presented at scientific meetings. If this is 
foreseen, the investigator agrees to submit all manuscripts or abstracts to Roche prior to 
submission. This allows the sponsor to protect proprietary information and to provide 
comments based on information from other studies that may not yet be available to 
the investigator.   
In accordance with standard editorial and ethical practice, Roche will generally support 
publication of multicenter trials only in their entirety and not as individual center data. 
In this case, a coordinating investigator will be designated by mutual agreement. 
Any formal publication of the study in which input of Roche personnel exceeded that of 
conventional monitoring will be considered as a joint publication by the investigator and 
the appropriate Roche personnel. Authorship will be determined by mutual agreement. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 53 


Appendix 1 
AEs Categories for Determining Relationship to Test Drug 
UNRELATED 
This category is applicable to those AEs which are judged to be clearly and 
incontrovertibly due only to extraneous causes [disease, environment, etc.] and do not meet 
the criteria for drug relationship listed under remote, possible, or probable. 
RELATED 
PROBABLE [must have first three] 
This category applies to those AEs which are considered, with a high degree of certainty, to 
be related to the test drug. An AE may be considered probable, if: 
1. It follows a reasonable temporal sequence from administration of the drug. 
2. It cannot be reasonably explained by the known characteristics of the subject’s 
clinical state, environmental or toxic factors, or other modes of therapy administered 
to the subject. 
3. It disappears or decreases on cessation or reduction in dose. [There are important 
exceptions when an AE does not disappear upon discontinuation of the drug, yet 
drug-relatedness clearly exists; e.g., [1] bone marrow depression, 
[2] tardive dyskinesias.] 
4. It follows a known pattern of response to the suspected medication. 
5. It reappears upon rechallenge. 
 
POSSIBLE [must have first two] 
This category applies to those AEs in which the connection with the test drug 
administration appears unlikely but cannot be ruled out with certainty. An AE may be 
considered possible if, or when: 
1. It follows a reasonable temporal sequence from administration of the drug. 
2. It may have been produced by the subject’s clinical state, environmental or toxic 
factors, or other modes of therapy administered to the subject. 
3. It follows a known pattern of response to the suspected medication. 
 
REMOTE [must have first two] 
In general, this category is applicable to an AE which meets the following criteria: 
1. It does not follow a reasonable temporal sequence from administration of the drug. 
2. It may readily have been produced by the subject’s clinical state, environmental or 
toxic factors, or other modes of therapy administered to the subject. 
3. It does not follow a known pattern of response to the suspected medication. 
4. It does not reappear or worsen when the drug is readministered. 
 
In case of a probable, possible or remote relationship to test drug, please indicate the 
relationship to test drug as “Yes” in the AE eform of the eCRF, and, if it is a serious AE, 
check and specify “Study treatment” in section 2 “Possible causes of the event” on page 1 
of the SAE form. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 54 


Appendix 1 
AEs Categories for Determining Relationship to Test Drug 
[Cont.] 
 
Probable 
Possible 
Remote 
Unrelated 
Clearly due to extraneous causes 
– 
– 
– 
+ 
 
 
 
 
 
Reasonable temporal association with drug 
administration 
+ 
+ 
– 
– 
 
 
 
 
 
May be produced by subject clinical state, 
etc. 
– 
+ 
+ 
+ 
 
 
 
 
 
Known response pattern to suspected drug 
+ 
+ 
– 
– 
 
 
 
 
 
Disappears or decreases on cessation or 
reduction in dose 
+ 
– 
– 
– 
 
 
 
 
 
Reappears on rechallenge 
+ 
– 
– 
– 
 
Timeframes for Adverse Events/Serious Adverse Event Collection 
  
  
Last visit  
30 days after   
last dose   
 
Last dose
 
*In tercurrent events should be recorded on the Medical History pages in eCRF  
 
All SAEs  
  Drug-related SAEs  
  
R andomization   
  
All AEs/SAEs  
SAEs only 
Intercurrent 
events *   
First  
screening   
visit  
  
SAE Form 
 
eCRF   
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 55 


Appendix 2 
ICH Guidelines for Clinical Safety Data Management, 
Definitions and Standards for Expedited Reporting, Topic E2 
 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution. It is any AE that at any dose fulfills at least 
one of the following criteria: 
– is fatal; [results in death] [NOTE: death is an outcome, not an event] 
– is Life-Threatening [NOTE: the term "Life-Threatening" refers to an event in which 
the patient was at immediate risk of death at the time of the event; it does not refer to 
an event which could hypothetically have caused a death had it been more severe]. 
– requires in-patient hospitalization or prolongation of existing hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of the 
outcomes listed above 
Medical and scientific judgment should be exercised in deciding whether expedited 
reporting to the sponsor is appropriate in other situations, such as important medical 
events that may not be immediately life-threatening or result in death or hospitalization 
but may jeopardize the patient or may require intervention to prevent one of the outcomes 
listed in the definitions above. These situations should also usually be considered serious. 
Examples of such events are intensive treatment in an emergency room or at home for 
allergic bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; 
or development of drug dependency or drug abuse. 
An unexpected AE is one in which the nature or severity is not consistent with the 
applicable product information. 
Causality is initially assessed by the investigator. For Serious Adverse Events, possible 
causes of the event are indicated by selecting one or more options. (Check all that apply)  
– Pre-existing/Underlying disease - specify  
– Study treatment – specify the drug(s) related to the event 
– Other treatment (concomitant or previous) – specify 
– Protocol-related procedure 
– Other (e.g. accident, new or intercurrent illness) - specify 
The term severe is a measure of intensity, thus a severe AE is not necessarily serious. 
For example, nausea of several hours' duration may be rated as severe, but may not be 
clinically serious. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 56 


Appendix 2 
ICH Guidelines for Clinical Safety Data Management, 
Definitions and Standards for Expedited Reporting, Topic E2 
[Cont.] 
A serious adverse event occurring during the study or which comes to the attention of the 
investigator within 15 days after stopping the treatment or during the protocol-defined 
follow-up period, if this is longer, whether considered treatment-related or not, must be 
reported. In addition, a serious adverse event that occurs after this time, if considered 
related to test “drug”, should be reported. 
Such preliminary reports will be followed by detailed descriptions later which will 
include copies of hospital case reports, autopsy reports and other documents when 
requested and applicable. 
For serious adverse events, the following must be assessed and recorded on the AEs 
eform of the eCRF: intensity, relationship to test substance, action taken, and outcome 
to date. 
The investigator must notify the Ethics Review Committee/Institutional Review Board of 
a serious adverse event in writing as soon as is practical and in accordance with 
international and local laws and regulations. 
ROCHE LOCAL COUNTRY CONTACT for SAEs: Local Monitor  
See attached Protocol Administrative and Contact Information & List of Investigators 
form, gcp_for000227, for details of administrative and contact information. 
ROCHE HEADQUARTERS CONTACT for SAEs and other medical emergencies: 
Clinical Operations/Clinical Science 
See attached Protocol Administrative and Contact Information & List of Investigators 
form, gcp_for000227, for details of administrative and contact information  
24 HOUR MEDICAL COVERAGE:  Within the US, weekends, holidays and after 
5:00 pm, call 
 and ask for the physician on call. Outside the US, call the 
local emergency contact number provided by the Monitor. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 57 


Appendix 3 
Additional Information on Laboratory/Clinical Assessments 
 
– Creatinine Clearance  
GFR can be estimated using either the Cockroft & Gault formula 1 or the simplified or 
extended MDRD formulae. In general, the MDRD formulae provide a more accurate 
estimate of GFR in subjects with reduced renal function, regardless of patient weight 2.  
The abbreviated (also called “four-variable” or “simplified”) MDRD Study equation has 
been validated to estimate CrCl/GFR in CKD patients 
3 , 4 . It uses age (years), 
sex (female vs. non-female), race (African-American vs. non–African-American), 
and serum creatinine. 
Abbreviated MDRD formula 2
SI Units 
GFR = 186.3 x (serum creatinine [μmol/L] x 0.0113)-1.154  x (age)-0 203 x (0.742 if female) x (1.212 if 
African-American) 
GFR: glomerular filtration rate (mL/min/1.73 m2) 
Age (years) 
An automatic GFR calculator is available online at the National Kidney Foundation web 
site: http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm. 
Cockroft & Gault formula 1
SI Units 
Cr Clearance (mL/min)= f x (140 – age) x IBW / (0.81 x serum Cr (µmol/L)) 
f = 1.0 for males and 0.85 for females.  Age in years, IBW in kg 
IBW (male) = [0.9 x Height (cm)] – 88 
IBW (female) = [0.9 x Height (cm)] – 92 
                                                 
1 Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41 
2 Levey AS, Bosch JP, Breyer Lewis J, Greene T, Rogers N, Roth D & the Modification of Diet in Renal 
Disease Study Group. A More Accurate Method to Estimate Glomerular Filtration Rate from Serum 
Creatinine: A New Prediction Equation. Ann Intern Med. 1999; 130 (6): 461-470. 
3 Levey AS, Greene T, Kusek JW, Beck GJ. A simplified equation to predict glomerular filtration rate from 
serum creatinine. J Am Soc Nephrol 2000;11:155A. abstract. 
4 Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney 
disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137-47. [Erratum, Ann Intern 
Med 2003;139:605]. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 58 


Appendix 3 
Additional Information on Laboratory/Clinical Assessments 
(Cont.) 
Note: Because of the current variability in calibration of serum creatinine assays, assays not 
calibrated in agreement with the kinetic alkaline picrate assay used in the MDRD Study introduce 
a source of error into GFR estimates. 5 The MDRD formula was based on serum creatinine 
measurements calibrated to a serum creatinine standard that measures true serum creatinine. 
Therefore, the use of non-calibrated serum creatinine values in the formula could result in 
over-estimation of the GFR at lower serum creatinine concentrations. It is thus recommended to 
calibrate the measurement of serum creatinine against that of the MDRD core laboratory. 6 
The Roche Laboratory Data Manager will ensure that in collecting the normal ranges for each 
laboratory participating in this study, there is an indication as to whether the serum creatinine 
results will be calibrated or not. 
It is also recommended to report serum creatinine values as mg/dL to 2 decimal places 
(e.g., 0.92 mg/dL instead of 0.9 mg/dL) and those reported as μmol/L should be reported as the 
nearest whole number (e.g., 109 μmol/L instead of 109.3 μmol/L). The GFR numeric estimate 
should be rounded to the nearest whole number, such as “35” (mL/min/1.73 m2).3 The GFR 
numeric estimate should not be corrected for body surface area. 
                                                 
5 Myers GL, Miller WG, Coresh J et al. Recommendations for improving serum creatinine measurement: a 
report from the Laboratory Working Group of the National Kidney Disease Education program. Clinical 
Chemistry 2006;52:1, 5-18. 
6 Landis JR, Gaughan C, Joffe M. Inter-laboratory serum creatinine (sCr) calibration study. J Am Soc 
Nephrol 2003;14:294A. Abstract. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 59 


Appendix 3 
Additional Information on Laboratory/Clinical Assessments 
(Cont.) 
 
– Hemodialysis adequacy 
For assessing adequacy of hemodialysis, Kt/V or urea reduction ratio (URR) should be 
determined according to routine procedures established at each centre. 
– Peritoneal dialysis adequacy 
The total weekly Kt/V should be determined for assessing adequacy of peritoneal dialysis 
as follows: 
 
Kt/V 
K = urea clearance (mL/min) 
t = time of weekly dialysis (usually 7 days expressed as minutes, i.e. 10080 minutes) 
V = VD = volume of urea distribution in the total body water (mL) 
K = CDu + CRu 
CDu = dialytic urea clearance (mL/min) 
CRu = renal urea clearance (mL/min) 
p
d
d
D
U
V
 x 
u
U
 
 
C
=
 
Ud = dialysate urea concentration (mg/mL) 
Vd = dialysate flow rate (mL/min) 
Up = serum urea concentration (mg/mL) 
p
U
u
R
U
V
 x 
U
 
u
C
=
 
Uu = urine urea concentration (mg/mL) 
Vu = urine flow rate (mL/min) 
Up = serum urea concentration (mg/mL) 
The volume of urea distribution in the body water (VD) is estimated according to Watson nomogram, 
which takes into account sex, age, height, and lean body mass (LBM): 
 
For Men:  VD (liters) =2.447 + 0.3362 x LBM (kg) + 0.1074 x Height (cm) - 0.09516 x Age (years)  
For Women: 
VD (liters) =-2.097 + 0.2466 x LBM (kg) + 0.1069 x Height (cm) 
 
LBM can be calculated as follows7: 
LBM (men) = (1.10 x Weight (kg)) - 128 x (Weight2/(100 x Height (m))2) 
LBM (women) = (1.07 x Weight (kg)) - 148 x (Weight2/(100 x Height (m))2) 
 
                                                 
7 http://www halls md/body-mass-index/leanbody.htm 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 60 


CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 61 
Appendix 3 
Additional Information on Laboratory/Clinical Assessments 
(Cont.) 
– Hemolysis  
Acute hemolysis is usually associated with low haptoglobin and high lactate 
dehydrogenase levels. Reticulocytes may increase but this is masked in patients receiving 
erythropoietic 
agents 
since 
these 
agents 
stimulate 
reticulocyte 
production. 
Hemolysis may be confirmed by the following assessments: 
– Decline in haptoglobin below 30 mg/dL 
– Presence of free Hb in blood (>1% of total Hb) 
– Increased lactate dehydrogenase 
 
Conditions that result in chronic hemolytic anemia include but are not limited to: 
– Thalassemias 
– Homozygous sickle-cell disease (excluding sickle cell trait) 
– Autoimmune hemolytic anemias 
– Hereditary spherocytosis, elliptocytosis 
– Red blood cell (RBC) enzyme deficiencies (e.g. glucose-6-phosphate 
 
Dehydrogenase G6PD deficiency) 
 
– For United Kingdom only: Women of Childbearing Potential Without Effective 
Contraception 
Effective methods of contraception include oral, injectable or implantable contraceptives 
(e.g. pill, 3-month injection, hormonal depot preparation), intrauterine devices in 
combination with a barrier method (e.g. condom, diaphragm) and/or spermicidal gel or 
absolute abstinence.  
– Transferrin Saturation 
Transferrin saturation (TSAT) should be calculated using one of the following formulas 
(US units)8: 
[mg/dL]
in 
 transferr
Serum
70.9
 x 
[µg/dL]
iron 
 
Serum
 
 
[%]
 
TSAT
=
 
 
[µg/dL]
capacity 
 
binding
iron 
 
Total
100
 x 
[µg/dL]
iron 
 
Serum
 
  
[%]
 
TSAT
=
μg/dL
μmol/L
5.59
x ⎯
⎯
⎯
→
⎯
mg/dL
μmol/L
7.96
x ⎯
⎯
⎯
→
⎯
                                                
 
The conversion factors for iron and transferrin from SI units to US units are as follows: 
Iron: 
 
Transferrin: 
 
 
 
8 Wick M, Pinggera W, Lehmann P. Iron Metabolism, Anemias Diagnosis and Therapy, 4th edition, 2000, 
Springer-Verlag Wien - New York, 160-161 


Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities 
 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
HEMATOLOGY
 
 
 
Hemoglobin 
8 0 - 9 4 gm/dL 
7 0 - 7 9 gm/dL 
6 5 - 6 9 gm/dL 
Absolute Neutrophil Count 
1000 - 1500 /mm3
750 - 999 /mm3
500 - 749 /mm3
Platelets 
75,000 - 99,000 /mm3
50,000 - 74,999 /mm3
20,000 - 49,999 /mm3
CHEMISTRIES
 
 
 
Creatinine 
1 1 - 1 5 x upper normal limit 
1 6 - 3 0 x upper normal limit 
3 1 - 6 x upper normal limit 
Creatinine Phosphokinase 
(unrelated to exercise) 
> 1 0 - 2 0 x upper normal limit 
> 2 0 - 4 0 x upper normal limit 
> 4 0 - 6 0 x upper normal limit 
SODIUM 
 
 
 
Hyponatremia 
130 - 135 meq/L 
123 - 129 meq/L 
116 - 122 meq/L 
Hypernatremia 
146 - 150 meq/L 
151 - 157 meq/L 
158 - 165 meq/L 
POTASSIUM 
 
 
 
Hypokalemia 
3 0 - 3 4 meq/L 
2 5 - 2 9 meq/L 
2 0 - 2 4 meq/L 
Hyperkalemia 
5 6 - 6 0 meq/L 
6 1 - 6 5 meq/L 
6 6 - 7 0 meq/L 
PHOSPHOROUS 
 
 
 
Hypophosphatemia 
2 0 - 2 4 mg/dL 
1 5 - 1 9 mg/dL 
1 0 - 1 4 mg/dL 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 62 


Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities (Cont.) 
 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
CALCIUM 
(corrected for albumin) 
 
 
 
Hypocalcemia 
7 8 - 8 4 mg/dL 
7 0 - 7 7 mg/dL 
6 1 - 6 9 mg/dL 
Hypercalcemia 
10 6 - 11 5 mg/dL 
11 6 - 12 5 mg/dL 
12 6 - 13 5 mg/dL 
BILIRUBIN 
 
 
 
Hyperbilirubinemia 
1 1 - 1 5 x upper normal limit 
1 6 - 2 5 x upper normal limit 
2 6 - 5 x upper normal limit 
GLUCOSE 
 
 
 
Hypoglycemia 
55 - 64 mg/dL 
40 - 54 mg/dL 
30 - 39 mg/dL 
Hyperglycemia 
116 - 160 mg/dL 
161 - 250 mg/dL 
251 - 500 mg/dL 
URIC ACID 
 
 
 
Hyperuricemia 
7 5 - 10 0 mg/dL 
10 1 - 12 0 mg/dL 
12 1 - 15 0 mg/dL 
LIVER TRANSAMINASE (LFTs) 
 
 
 
AST (SGOT) or ALT (SGPT) 
1 25 - 2 5 x upper normal limit 
2 6 - 5 x upper normal limit 
5 1 - 10 x upper normal limit 
LDH 
1 25 - 2 5 x upper normal limit 
2 6 - 5 x upper normal limit 
5 1 - 10 x upper normal limit 
Alkaline Phosphatase 
1 25 - 2 5 x upper normal limit 
2 6 - 5 x upper normal limit 
5 1 - 10 x upper normal limit 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 63 


Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities (Cont.) 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
PANCREATIC ENZYMES 
 
 
 
Amylase 
1 1 - 1 5 x upper normal limit 
1 6 - 2 0 x upper normal limit 
2 1 - 5 0 x upper normal limit 
Pancreatic Amylase 
1 1 - 1 5 x upper normal limit 
1 6 - 2 0 x upper normal limit 
2 1 - 5 0 x upper normal limit 
Lipase 
1 1 - 1 5 x upper normal limit 
1 6 - 2 0 x upper normal limit 
2 1 - 5 0 x upper normal limit 
URINALYSIS
 
 
 
PROTEINURIA 
 
 
 
Spot Urine 
1+ 
2 - 3+ 
4+ 
24 Hour Urine 
200 mg - 1 g loss/day OR 
< 0 3% OR 
< 3 g/l 
1 - 2 g loss/day OR 
0 3 - 1 0% OR 
3 - 10 g/l 
2 - 3 5 g loss/day OR 
> 1 0% OR 
> 10 g/l 
Gross hematuria 
Microscopic only 
Gross, no clots 
Gross + clots 
CARDIAC
 
 
 
Cardiac Arrhythmia 
- - - - - - 
Asymptomatic; transient 
dysrhythmia, no Rx required 
Recurrent/persistent dysrhythmia; 
symptomatic Rx required 
Hypertension 
Transient increase 
> 20 mmHg; no Rx 
Recurrent; chronic increase 
> 20 mmHg, Rx req  
Requires acute Rx: out-patient 
hospitalization possible 
Hypotension 
Transient orthostatic hypotension; no 
Rx 
Symptoms correctable with oral fluid 
Rx 
Requires i v  fluids; no hosp  
required 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 64 


Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities (Cont.) 
 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
Pericarditis 
Minimal effusion 
Mild/mod asymp  Effusion, no Rx 
Symptomatic effusion, pain, EKG 
changes 
Hemorrhage, Blood Loss 
- - - - - - 
Mildly symptomatic, no Rx required 
Gross blood loss or 1 - 2 units 
transfused 
RESPIRATORY
 
 
 
Cough - for aerosol studies 
Transient - no Rx 
Treatment associated cough; inhaled 
bronchodilator 
Uncontrolled cough; systemic Rx 
required 
Bronchospasm 
Transient; no Rx; < 70% - 70% 
predicted FEV1 (or peak flow) 
Req  Rx, normalizes with 
bronchodilator; predicted FEV1 50% 
- 70% (or peak flow) 
No normalization w/bronchodilator; 
predicted FEV1 25% - 50% 
(or peak flow), retractions 
Dyspnea 
Dyspnea on exertion 
Dyspnea with normal activity 
Dyspnea at rest 
GASTROINTESTINAL
 
 
 
Oral Discomfort / Dysphagia 
Mild discomfort; no difficulty 
swallowing 
Difficulty swallowing but able to eat 
and drink 
Unable to swallow solids 
Nausea 
Mild or transient; reasonable intake 
maintained 
Mod  discomfort or intake decreased 
for < 3 days 
Severe discomfort or minimal intake 
for ≥ 3 days 
Vomiting 
Mild or transient; 2 - 3 episodes per 
day or mild vomiting lasting 
< 1 week 
Mod  or persistent; 4 - 5 episodes per 
day or vomiting lasting ≥ 1 week 
Sever vomiting of all food/fluids in 
24 hrs or orthostatic hypotension or 
i v  Rx req  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 65 


Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities (Cont.) 
 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
Diarrhea 
Mild or transient; 3 - 4 loose stools 
per day or mild diarrhea lasting 
< 1 week 
Mod  or persistent; 5 - 7 loose stools 
per day or diarrhea lasting ≥ 1 week 
Bloody diarrhea; or orthostatic 
hypotension; or > 7 loose stools/day 
or i v  Rx required 
Constipation 
Mild 
Moderate 
Severe 
NEUROLOGIC
 
 
 
Neuro-Cerebellar 
Slight Incoordination Or 
Dysdiadochokinesia 
Intention Tremor Or Dysmetria Or 
Slurred Speech Or Nystagmus 
Ataxia Requiring Assistance To 
Walk Or Arm Incoordination 
Interfering With Adls 
Neuro-Psych/Mood 
- - - - - - - 
- - - - - - 
Severe mood changes requiring 
medical intervention 
Paresthesia (burning, tingling, etc) 
Mild discomfort; no Rx required 
Mod  discomfort; non-narcotic 
analgesia required 
Severe discomfort; OR narcotic 
analgesia required with symptomatic 
improvement 
Neuro-Motor 
Mild weakness in muscles of feet but 
not able to walk and/or mild increase 
or decrease in reflexes 
Mod  weakness in feet (unable to 
walk on heels and/or toes), mild 
weakness in hands, still able to do 
most hand tasks and/or loss of 
previously present reflex or 
development of hyperreflexia and/or 
unable to do deep knee bends due to 
weakness 
Marked distal weakness (foot drop 
or unable to dorsiflex toes), 
and mod  proximal weakness, e g , 
in hands, interfering with ADLs 
and/or requiring assistance to walk 
and/or unable to rise from chair 
unassisted 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 66 


CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 67 
Appendix 4 
Recommendations for Grading of Adverse Events and Laboratory Abnormalities (Cont.) 
 
PARAMETER 
GRADE 1 MILD 
GRADE 2 MODERATE 
GRADE 3 SEVERE 
Neuro-Sensory 
Mild impairment (dec  sensation, 
e g  vibratory, pinprick, hot/cold in 
great toes) in focal area or 
symmetrical distribution 
Mod  impairment (mod  dec  
sensation, e g  vibratory, pinprick, 
hot/cold to ankles) and/or joint 
position or mild impairment that is 
not symmetrical 
Severe impairment (dec  or loss of 
sensation to knees or wrists) or loss 
of sensation of at least mod  degree 
in multiple different body areas 
(i e  upper and lower extremities) 
OTHER PARAMETERS
 
 
 
Fever; oral > 12 hours 
37 7 - 38 5 C or 
100 0 - 101 5 F 
38 6 - 39 5 C or 
101 6 - 102 9 F 
39 6 - 40 5 C or 
103 - 105 F 
Headache 
mild, no Rx 
Mod, or non-narcotic analgesia, Rx 
Severe; or responds to initial 
narcotic therapy 
Fatigue 
Normal activity reduced 25% 
Normal activity decr  25 - 50%  
Normal activity decr  > 50%; 
can’t work 
Allergic Reaction 
Pruritis w/o rash 
Localized urticaria 
Generalized urticaria angioedema 
Cutaneous/Rash/Dermatitis 
Erythema, pruritis 
Diffuse maculopapular rash or dry 
desquamation 
Vesiculation or moist desquamation 
or ulceration 
Myositis 
mild symptoms with an increased 
CK or asymptomatic with increased 
CK plus a positive EMG or biopsy 
positive EMG or muscle biopsy and 
either - mild symptoms with an 
increased CK asymptomatic with an 
increased CK > 4 wks or moderate 
myalgias for < 4 weeks requiring 
non-steroidal anti-inflammatory 
agents; or difficulty with mobility 
positive EMG or muscle biopsy and 
either moderate to severe myalgias 
for > 4 weeks non-steroidal 
anti-inflammatory agents; or needs 
some assistance walking 
Local Reaction (2• parenteral Rx not 
vaccination or skin test) 
Erythema 
Induration ≤ 10 mm or inflammation 
or phlebitis 
Induration > 10 mm or ulceration 
 
 


Appendix 5 
Educational Program For MIRCERA® Anti-erythropoietin-
mediated Pure Red Cell aplasia Associated with 
Erythropoietin Stimulating Agents 
 
Educational Program for MIRCERA®
(methoxy polyethylene glycol-epoetin beta) 
 
Physician’s Guide  
 
Diagnosing and reporting of adverse drug reactions 
associated with MIRCERA®
 
 
 
Anti-erythropoietin antibody-mediated pure red cell aplasia 
associated with erythropoietin stimulating agent
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 68 


Contents 
1. MIRCERA and anti-erythropoietin-mediated pure red cell aplasia (AEAB-mediated 
PRCA) 
2. What is the objective of this educational program?  
3. Loss of effect of ESA treatment 
3.1 If an ESA loses its effect after having been effective in a patient what should 
I do? 
3.2 What are the most frequent causes? 
4. What happens in AEAB-mediated PRCA? 
4.1 Findings in blood and bone marrow 
4.2 Timing of onset 
4.3 Discontinuation of ESAs 
5. Diagnosis of PRCA 
5.1 Haemoglobin drop 
5.2 Antibody testing 
5.3 Bone marrow examination 
6. Follow up after PRCA diagnosis 
7. Adverse drug reaction reporting 
8. Questionnaire 
9. How to obtain further information 
 
Supporting Information 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 69 


 
1. MIRCERA and anti-erythropoietin-mediated pure red cell 
aplasia (AEAB-mediated PRCA) 
MIRCERA is an erythropoietin-stimulating agent or ESA. 
A very rare side effect of ESAs is “anti-erythropoietin antibody-mediated pure red cell 
aplasia” or AEAB-mediated PRCA. 
This side effect is an important identified risk in the EU risk management plan for 
MIRCERA. 
2. What is the objective of this educational program? 
The objective of this booklet and the educational program is: 
• to increase early awareness and knowledge of AEAB-mediated PRCA associated 
with ESAs 
• to encourage doctors to report adverse drug reactions to MIRCERA, especially 
AEAB-mediated PRCA  
• to improve understanding of the importance of collecting detailed information on 
AEAB-mediated PRCA - through a questionnaire completed by the physician 
• to inform about Roche’s offer for free antibody testing after having received a 
report of a suspected case of AEAB-mediated PRCA. This includes where loss of 
effect of unknown cause is associated with MIRCERA.  
For full details on this topic, look at the MIRCERA Physician’s Prescribing Information 
(Summary of Product Characteristics). Look in particular at the section:  
• “Special warnings and special precautions for use” relating to important facts 
about erythropoietin-stimulating agents / MIRCERA and AEAB-mediated 
PRCA. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 70 


 
3. Loss of effect of ESA treatment 
3.1 If an ESA loses its effect, after having been effective in a patient what should 
I do? 
Investigate the main possible causes: 
• haemolysis 
• malnutrition 
• iron deficiency 
• aluminium toxicity 
• chronic blood loss 
• inadequate dialysis 
• inflammatory disorders 
• multiple myeloma, myelofibrosis 
• other malignancies 
• hyperparathyroidism / osteitis fibrosa 
• vitamin deficiencies – such as folate or vitamin B12  
• haemoglobinopathies – such as alpha- and beta-thalassemias or sickle cell anemia 
• adverse effects of concomitant drugs – such as cytotoxic and immunosuppressive 
agents and angiotensin-converting enzyme (ACE) inhibitors. 
If none of these conditions are diagnosed, anaemia should be fully investigated (see 
Section 5).  
3.2 What are the most frequent causes? 
For acquired PRCA, the following are the most frequent causes: 
• lymphoproliferative disorders 
• infections – such as parvovirus B19 
• systemic autoimmune disease – such as systemic lupus, rheumatoid arthritis 
• drugs – such as azathioprine, isoniazid, phenytoin 
• thymoma - in about 5% of cases  
• idiopathic - in about 50% of cases. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 71 


 
 
4. What happens in AEAB-mediated PRCA? 
Epoetin permits terminal maturation of erythroid precursor cells and thus treats anemia 
due to chronic kidney disease. AEAB-mediated PRCA is an acquired immune disease 
where erythropoiesis is inhibited by erythropoietin-specific neutralising antibodies. 
4.1 Findings in blood and bone marrow 
The current diagnostic criteria for PRCA have been defined as:  
fall in haemoglobin of about 0.1 g/dL/day 
reticulocyte count below 10 or 20x109/L 
no major changes in white cell count, platelet count, or differential leukocyte count 
normal cellularity of bone marrow, less than 1% erythroblasts (occasionally up to 5% 
proerythroblasts or basophilic erythroblasts), normal myeloid cells and 
megakaryocytes. 
4.2 Timing of onset 
The shortest interval of onset of PRCA after treatment starts was reported within 2 
months and the longest as 90 months. 
4.3 Discontinuation of ESAs 
There is consensus that ESAs should be discontinued in any patient with confirmed 
AEAB-mediated PRCA. You should: 
• investigate for the presence of anti-erythropoietin antibodies  
• perform a bone marrow examination.  
Patients must not be switched to another recombinant ESA. This is because of cross-
reactivity of antibodies with endogenous and all recombinant ESAs molecules. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 72 


5. Diagnosis of PRCA 
5.1 Haemoglobin drop 
European Best Practice Guidelines suggest to strongly suspect PRCA if a patient treated 
with an ESA: 
• has a sudden, rapid decline in Hb concentration of approximately 0.5-1 g/dL/week 
despite ongoing ESA treatment or  
• requires transfusions of 1-2 units of red blood cells per week to maintain the Hb 
level.  
In these cases, do a complete blood count with blood film examination and reticulocyte 
count. A reticulocyte count below 10 or 20x109/L strongly suggests a PRCA.  
5.2 Antibody testing 
On request from a physician, Roche will offer testing or re-testing of serum samples in a 
reference laboratory. This is free of charge service for cases of suspected or confirmed 
AEAB-mediated PRCA or unexplained loss of effect (as documented in an ADR report 
and the questionnaire).  
Sampling instructions will be send to the physician, for details see Section 9 “How to 
obtain further information”. 
5.3 Bone marrow examination 
A bone marrow examination should be triggered by a rapid and sustained decrease in the 
reticulocyte count.   
PRCA is characterised by:  
• normal cellularity 
• < 1% erythroblasts 
• occasionally erythroblasts up to 5% with evidence of a red cell precursor 
maturation block 
• myeloid and megakaryocytic lineages are normal 
Bone marrow findings help to distinguish PRCA from aplastic anaemia and 
myelodysplastic syndrome. If no bone marrow examination is possible, a suspected 
diagnosis could suffice, but the level of confidence of the diagnosis may be lower.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 73 


 
6. Follow up after PRCA diagnosis 
You should check reticulocyte count regularly during follow-up. This is the best 
laboratory marker of red blood cell production. The reticulocyte count tells us about bone 
marrow activity with regard to daily red cell production. A drop in haemoglobin will be 
preceded by a change in the rate of red cell production. An unchanged reticulocyte count 
suggests that treatment is effective.  
Any decline in reticulocyte count should be investigated. As one of the proposed 
diagnostic criteria for AEAB-mediated PRCA an absolute reticulocyte count below 10 or 
20x109/L was suggested.  
7. Adverse drug reaction reporting  
We need to know as much as possible about suspected case reports of AEAB-mediated 
PRCA potentially associated with MIRCERA treatment.  
You should consider an adverse drug reaction report where there are: 
confirmed report of AEAB-mediated PRCA – such as positive AEAB findings or bone 
marrow examination showing PRCA 
suspected AEAB-mediated PRCA with insufficient or inconclusive results. This 
includes follow-up on updated investigational results and updated results of 
continued monitoring of these patients 
reports of unexplained loss of effect, especially: 
• after excluding alternative causes of PRCA (see Section 3) 
• if a patient previously had a stable haemoglobin concentration after having 
had established the MIRCERA dose (i.e. not during titration). Loss of effect 
could be reflected by findings such as “refractory anemia,” massive dose 
increase of the already established dose of MIRCERA, or a decrease in drug 
effect.  
Investigate through anti-erythropoietin antibody testing and haematological consultation 
in suspected AEAB-mediated PRCA or the unexplained loss of therapeutic effect.  
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 74 


 
 
8. Questionnaire 
After receiving an adverse drug reaction report for AEAB-mediated PRCA or loss of 
effect, Roche will send the reporting physician a guided questionnaire.  
This questionnaire is called:  
“Erythropoietin Stimulating Agents (ESAs) questionnaire on  adverse event of 
anti-erythropoietin-mediated pure red cell aplasia, inadequate response to ESA 
treatment, anemia refractory to ESA treatment, and unexplained loss of effect of 
ESA treatment.”  
The questionnaire will be updated with information already received.  
If appropriate, these collected data will support communication of a substantial change 
(e.g., via a label update).  
The questionnaire will collect data such as: 
• diagnostic results to confirm the diagnosis or clinical suspicion 
• relevant comorbidities or concomitant drugs 
• alternative conditions to explain a sudden drop in haemoglobin 
• exposure to epoetin brands with regard to the onset of first signs/symptoms 
suggestive of AEAB-mediated PRCA.  
This guided questionnaire is only for when MIRCERA is used outside a clinical study. In 
clinical studies, the study protocol will guide how to follow up a report of potential 
AEAB-mediated PRCA or loss of effect. 
9. How to obtain further information 
For further information on adverse drug reaction reporting including the 
Questionnaire: 
Please address the local Roche affiliate [Address] 
 
For further information on antibody sampling and shipment: 
Please address the local Roche affiliate [Address] 
 
For further information on MIRCERA including literature: 
Please address the local Roche affiliate [Address] 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 75 


Supporting Information 
Need and clinical importance of adverse drug reaction reporting  
The aim of pharmacovigilance is the detection, assessment, and prevention of adverse 
reactions. A critical number of case reports are needed for a signal. Detection of rare 
adverse effects is increased and accelerated the more physicians contribute to spontaneous 
reporting of adverse reactions [Meyboom 1999]. According to Waller and Evans [2003], 
spontaneous adverse reaction reporting could be defined as an approach to collate 
individual case reports of clinical suspicion of an adverse drug reaction with the main 
aim of detecting unknown serious potential drug toxicity. The primary role of 
spontaneous reporting from post-marketing experience is signal generation for type ’A’ 
effects (dose-related pharmacological effects of the drug) and type ‘B’ effects (e.g., allergic 
or idiosyncratic reactions, AEAB-mediated PRCA) [Meyboom 1999].   
ADR reporting for a drug newly introduced to the market is not only identification and 
quantification of unexpected adverse drug reactions but also the identification of 
subgroups of patients at particular risk (e.g., related to comorbidities, age, gender, and 
dose). After introducing a drug to the market, safety is further continuously monitored to 
ensure that the benefit/risk assessment remains acceptable and to communicate 
appropriate information to health professionals [Talbot 2004]. Spontaneous ADR 
reporting is understood as a cornerstone of pharmacovigilance [Waller 2003]. 
Important facts about AEAB-mediated PRCA and ESAs 
All exogenous proteins could be potentially immunogenic. With therapeutic proteins, the 
reported incidence of antibody formation varies considerably depending on, for example, 
genetic background of the patient, the type of disease, type of protein, the route of 
administration, dose frequency, and duration of treatment, in addition, manufacturing, 
handling and storage might introduce contaminants, or alter the 3-dimensional structure 
of the protein via oxidation or aggregate formation [Schellekens 2002]. 
  
During the first 10 years (1988–1998) of epoetin treatment, three reports of 
AEAB-mediated PRCA were published [Bergrem 1993, Peces 1996, Prabhakar 1997] 
referring to treatment in several million patients. Since 1998, there had been a sudden 
upsurge of reports of AEAB-mediated PRCA in patients with chronic kidney disease. The 
majority of these were reported in patients treated subcutaneously with the human serum 
albumin-free epoetin alfa formulation marketed outside the U.S. (Eprex) with a peak in 
reports in 2001 and 2002 [Rossert 2004]. 
 
Testing approaches 
Two testing approaches were utilised during the development program of MIRCERA and 
will be applied for investigations for future post-marketing experience. The first test is a 
bridging ELISA test that is the method for quantification of anti-EPO antibodies and of 
anti-methoxy polyethylene glycol-epoetin beta (anti-MIRCERA) antibodies. The second 
type of testing is a neutralising antibody assay, which is a functional assay based on the 
use of a standard in vitro assay to detect EPO or methoxy polyethylene glycol-epoetin 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 76 


beta activity. This assay measures EPO- or methoxy polyethylene glycol-epoetin 
beta-stimulated proliferation of an EPO receptor-expressing cell line in the presence and 
absence of patient serum. The presence of neutralizing anti-EPO or anti-methoxy 
polyethylene glycol-epoetin beta antibodies reduces or suppresses cell proliferation. This 
assay can optionally be applied to samples with discrepancies between antibody titer 
determined by antibody ELISA and clinical diagnosis. Since the antibody ELISA assays 
have a several fold higher sensitivity compared with the neutralizing antibody assay, this 
assay is not expected to provide additional clinically relevant information for samples 
with low antibody titers or confirmed PRCA. 
Literature 
A brief summary indicates main aspects of the publications, which are grouped according 
to the aspect of practical and basic guidance on patient evaluation and detailed aspects of 
the topic as briefly indicated in a summary for each publication. 
Practical and Basic Guidance on Patient Evaluation 
• Revised European Best Practice Guidelines on Anaemia Management (Section I. 
Anaemia evaluation) Nephrol Dial Transplant, 2004; 19(Suppl 2): ii2-ii5. 
− Which patients should be evaluated and when should the work-up begin. 
− Investigations for appropriate work-up of anaemia in CKD. 
− Diagnosis of renal anaemia. 
• Revised European Best Practice Guidelines on Anaemia Management (Section IV. 
Failure to respond to treatment) Nephrol Dial Transplant, 2004; 19(Suppl 2): 
ii32-ii36. 
− Failure to reach or maintain target haemoglobin. 
− Criteria to suspect antierythropoetin-mediated pure red cell aplasia 
(AEAB-mediated PRCA). 
− Criteria to confirm AEAB-mediated PRCA. 
• Casadevall N., Cournoyer D., et al. Recommendations on haematological criteria for 
the diagnosis of epoetin-induced pure red cell aplasia. Eur J Haematol 2004; 
73:389-396. 
− Recommendations for diagnostic approach including discussions on 
potential findings. 
 
Further Reading / These publications are available on request 
• Bennett CL., Luminari S., et al. Pure Red-Cell Aplasia and Epoetin Therapy. N. 
Engl. J. Med., September 30, 2004; 351(14): 1403-1408. 
− Description of worldwide collection of reports of AEAB-mediated PRCA 
emphasising the need of spontaneous reporting by physicians in order to 
document a change in the occurrence rate. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 77 


• Bennett CL., Cournoyer D. et al. Long-term outcome of individuals with pure red cell 
aplasia and antierythropoietin antibodies in patients treated with recombinant 
epoetin: a follow-up report from the Research on Adverse Drug Events and Reports 
(RADAR) Project. Blood. 2005;106:3343-3347. 
− Information on treatment and long-term follow-up of 191 patients with 
AEAB-mediated PRCA. 
• Casadevall N., Nataf J., et al. Pure Red-Cell Aplasia and Antierythropoietin 
Antibodies in Patients Treated with Recombinant Erythropoietin. N Engl J Med 
2002; 346(7): 469-475. 
− Clinical characterization of 13 patients with AEAB-mediated PRCA. 
• Eckardt K-U., Casadevall N. Pure red-cell aplasia due to anti-erythropoietin 
antibodies. Nephrol Dial Transplant 2003; 18: 865-869. 
− Diagnosis, causes of AEAB-mediated PRCA. 
• Rossert J., Casadevall N., et al. Anti-Erythropoietin Antibodies and Pure Red Cell 
Aplasia. J Am Soc Nephrol 2004; 15: 398-406.  
− Diagnosis, assays, epidemiology, risk factors. 
• Schellekens H. Factors influencing the immunogenicity of therapeutic proteins. 
Nephrol Dial Transplant. 2005; 20 (Suppl 6):vi3-9. 
− Consequences of antibody formation. 
• Schellekens H. Immunogenicity of Therapeutic Proteins: Clinical Implications and 
Future Prospects. Clin Ther 2002; 24:1720-1740. 
− Effects of antibodies on endogenous protein production, clinical effects of 
antibodies, factors influencing Immunogenicity. 
 
Further references mentioned in the text 
• Bergrem H., Danielson BG., et al. A Case of Antierythropoietin Antibodies 
Following Recombinant Human Erythropoietin Treatment. In: Bauer C, Koch KM, 
Scigalla P, Wieczorek L, eds. Erythropoietin: Molecular physiology and clinical 
applications. New York: Marcel Dekker. 1993; 265-273. 
• Cavill I., Williams JD. Benefits of recombinant human erythropoietin. Lancet 2002; 
360 Nov 16: 1606 -1607. 
• Meyboom RHB., Egberts AC., et al. Pharmacovigilance in Perspective. Drug Safety, 
December 1999, 21(6): 429-447. 
• Peces R., de la Torre M., et al. Antibodies against recombinant human 
erythropoietin in a patient with erythropoietin-resistant anemia. N Engl J Med. 
1996; 335: 523-524. 
• Prabhakar SS., Muhlfelder T. Antibodies to recombinant human erythropoietin 
causing pure red cell aplasia. Clin Nephrol. 1997; 47:331-335. 
• Talbot J., Waller P. Steven’s Detection of New Adverse Drug Reactions, Chapter 1 
Introduction, pp1-2, 5th ed. 2004. 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 78 


• Waller PC., Evans SJW. A model for the future conduct of pharmacovigilance. 
Pharmacoepidemiol Drug Safety 2003; 12: 17-29. 
• Weber G., Gross J., et al. Allergic Skin and Systemic Reactions in a Patient with 
Pure Red Cell Aplasia and Anti-Erythropoietin Antibodies Challenged with 
Different Epoetins. J Am Soc Nephrol 2002; 13:2381-2383. 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 79 


Appendix 6 
Endpoints Documentation Checklist 
1. Updated eCRF 
2. Serious Adverse Event Forms 
3. Ancillary documents (when applicable): 
a) Copies of pertinent laboratory, imaging and cardiac testing reports 
b) Copies of hospital admission notes and all pertinent hospital records and progress 
notes surrounding the event (physician and nursing notes) 
c) Copies of surgical, consultant and pathology reports 
d) Hospital discharge summary 
e) Certified death/autopsy summary (if applicable) 
 
CONFIDENTIAL Roche Protocol BH21260D (RO0503821) – Page 80