Conditions: Osteoporosis Renal Osteodystrophy Kidney Transplant; Complications
Keywords: Denosumab Bone density Kidney transplant Prolia
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 8
Healthy volunteers: no

Brief summary:
This is a Phase 2 Multi-Center Clinical Trial (safety and effectiveness trial) in 60 patients (40 denosumab; 20 placebo) who have had a kidney transplant for 12-months or longer with more than 30% of kidney function. The investigators will test whether denosumab safely improves bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) and improves bone strength by high resolution peripheral quantitative computed tomography (HR-pQCT) in the subset of patients recruited at Columbia University Irving Medical Center. These data will inform the development and execution of a larger trial to test if denosumab prevents fractures in kidney transplant recipients.

Detailed description:
Bone fractures are 3-times more common in kidney transplant recipients than in the general population and risk of dying after a hip fracture is 60% higher compared to kidney transplant recipients without a fracture. Unfortunately, there are no anti-fracture strategies that have been proven to be effective in double blinded randomized clinical trials for kidney transplant recipients. This is because some anti-fracture medications that are commonly used to treat osteoporosis and prevent fractures in the general population (i.e., bisphosphonates), may be harmful to the skeleton when kidney function is less than 30% of normal. In addition, intravenous bisphosphonates may be toxic to the kidneys, which further limits their utility in patients with a kidney transplant.

Denosumab, a monoclonal antibody against RANKL, inhibits osteoclast function and is not harmful to the kidney. Denosumab prevents fractures in men and women with age-related and glucocorticoid-induced osteoporosis. Recently, a non-blinded randomized trial of denosumab versus usual care during the first year of kidney transplantation in 90 patients reported the bone mineral density (BMD) measured by dual energy X-ray absorptiometry (DXA) increased at the spine and hip and that bone strength measured by high resolution peripheral quantitative computed tomography (HR-pQCT) increased in patients treated with denosumab. Adverse events in denosumab-treated patients included greater risk of urinary tract infections, diarrhea, and transient levels of low serum calcium that were asymptomatic. This study demonstrated that denosumab safely increased BMD at the spine and hip in new kidney transplant recipients. However, long-term kidney recipients, who comprise the vast majority of patients living with a transplanted kidney and who are also at increased risk of fracture, were not included.

Arms:
arm 1: Denosumab 60 mg subcutaneous injection every 6 months for 12 months (i.e., 2 injections) arm 2: Placebo subcutaneous injection every 6 months for 12 months (i.e., 2 injections)

Interventions: intervention 1: Denosumab Inj 60 mg/ml intervention 2: Placebo
Intervention descriptions: intervention 1: Treatment will be administered by study personnel as a subcutaneous injection every 6-months for one year. intervention 2: Placebo will be administered by study personnel as a subcutaneous injection every 6-months for one year.

Protocol document:
Prot_SAP_000.pdf: 
The Effects of 12-months of Denosumab 
on Bone Density, Quality and Strength in 
Prevalent Kidney Transplant Recipients
ClinicalTrials.gov ID: NCT03960554
Date of IRB approval: 11/29/2022


1 
TITLE: The Effects of 12-months of Denosumab on Bone Density, Quality and Strength in Prevalent 
Kidney Transplant Recipients 
Amgen 20187326 
Sponsor-Investigator 
Thomas L. Nickolas MD MS 
Associate Professor of Medicine 
Columbia University Irving Medical Center, NY, NY 10032 
Tel: 212-305-9847; Fax: 212-305-4981 
Email: tln2001@cumc.columbia.edu 
Participating Site Principal Investigators 
Tamara Isakova MD MMSc 
Associate Professor of Medicine 
Northwestern University, Feinberg School of Medicine, Chicago, IL 60611 
Tel: 312-503-6921 
Email: tamara.isakova@northwestern.edu 
Stuart M. Sprague DO 
Chief of Nephrology at NorthShore University HealthSystem and Clinical Professor of Medicine at Uni-
versity of Chicago Pritzker School of Medicine 
Evanston, IL 
Tel: 847-570-2512 
Email: SSprague@northshore.org  
Key Personnel 
Donald J. McMahon: Statistician 
Protocol V9 


2 
A. HYPOTHESES AND AIMS
In 2014, >17,000 kidney transplantations were performed, >200,000 persons were living with a function-
ing transplant, and >90% were expected to live beyond the third post-transplant year. Bone fractures are
3-times more common in kidney transplant recipients than in the general population1, one-quarter of re-
cipients were reported to sustain a fracture within the first 5-years of transplantation2, and after hip frac-
ture mortality risk increased by up to 60%3. There are no proven anti-fracture strategies for kidney trans-
plant recipients. Studies demonstrating anti-fracture efficacy of therapies proven to prevent fracture in
recipients of other solid organs4 and in patients with age-related and glucocorticoid-induced osteoporosis
have not been conducted in kidney transplant recipients. Thus, there is an unmet clinical need to develop
and study strategies that prevent fractures in kidney transplant recipients to improve long-term skeletal
outcomes and survival.
Prevention of fractures after kidney transplantation with bisphosphonates is controversial due to their 
potential for nephrotoxicity. Furthermore, bisphosphonates are cleared by the kidney and there is concern 
that over-accumulation in bone may occur in patients with < 30% of kidney function, resulting in over-
suppression of bone turnover. Denosumab, a monoclonal antibody against RANKL, inhibits osteoclast 
function and is not cleared by the kidney. Denosumab prevents fractures in patients with age-related 
osteoporosis and safely prevents fractures in immunosuppressed patients with glucocorticoid-induced 
osteoporosis. Recently, a non-blinded randomized trial in 90 patients during the first year of kidney trans-
plantation that compared denosumab to routine therapy, demonstrated that denosumab suppressed bi-
omarkers of bone turnover, increased bone mineral density (BMD) by dual energy X-ray absorptiometry 
(DXA) at the spine and hip by 5.1% and 1.9% respectively5, and in a subset of 10 patients who underwent 
imaging by high resolution peripheral quantitative computed tomography (HR-pQCT) and saw an in-
crease in estimated bone strength by 3.9% at the tibia using finite element analysis6. Adverse events in 
denosumab-treated patients included higher incidence of urinary tract infections, diarrhea, and transient 
asymptomatic hypocalcemia5,7. This study demonstrated that denosumab safely increased BMD at the 
spine and hip in de-novo kidney transplant recipients. However, long-term kidney recipients who com-
prise the vast majority of patients living with a transplanted kidney, and who are also at increased risk of 
fracture, were not included.  
To generate additional data that will support the need for a clinical trial to assess efficacy of denosumab 
for prevention of fracture in kidney transplant recipients, we now propose to conduct a multi-center dou-
ble-blinded placebo-controlled randomized trial of 60 patients (40 treatment, 20 placebo) treated with 
twice yearly denosumab for 1-year to test the effect of denosumab on BMD in the long-term kidney trans-
plant recipient population. We hypothesize that denosumab versus placebo will safely improve bone den-
sity by DXA. We also hypothesize that denosumab versus placebo will improve bone quality and strength 
as assessed by HR-pQCT in the subset of patients recruited at Columbia University Irving Medical Center 
(CUIMC). 
Aim 1. To determine if 1-year of treatment with denosumab versus placebo increases BMD by DXA. 
Sixty (40 Denosumab / 20 Placebo) patients will undergo testing of BMD at the spine, hip and forearm 
by DXA at enrollment, 6-months and end of treatment. 
Aim 2. To determine if bone mechanical competence measured by HR-pQCT with application of micro-
finite element analysis is improved by 1-year of denosumab treatment compared to controls. A subset of 
20 (10/group) participants will undergo HR-pQCT imaging of the radius and tibia at baseline, 6-months 
and end of treatment. Changes in bone mechanical competence (hardness) and cortical and trabecular 
microarchitecture will be quantified and compared between the two treatment groups. 
Protocol V9


3 
B. INVESTIGATORS AND STUDY SITES
B.1. Principal Investigators
B.1.a. Lead Study Site (CUIMC Site)
Columbia University Irving Medical Center, NY, NY
Thomas L. Nickolas MD MS is a federally funded investigator and internationally renowned expert in
the biology, physiology and epidemiology of renal osteodystrophy and mineral disorders that occur in
CKD.
B.1.b. Participating Sites (Non-CUIMC Sites)
Northwestern University Medical Center, Chicago, IL
Tamara Isakova MD MMSc is a federally-funded investigator and internationally renowned expert in the
biology, physiology and epidemiology of mineral metabolism in CKD.
NorthShore University HealthSystem, Evanston, IL; University of Chicago, Chicago, IL 
Stuart M. Sprague DO is the Chief of Nephrology at NorthShore University HealthSystem and Clinical 
Professor of Medicine at University of Chicago Pritzker School of Medicine, he is an internationally rec-
ognized expert in mineral and bone disorders in CKD. He is affiliated with University of Chicago, whose 
patients will be referred to NorthShore University for study procedures. 
B.2. Co-Investigators
Donald J. McMahon MS is a senior biostatistician. He has worked for over 20 years in metabolic bone
disease and has overseen the design, implementation, data collection, and data analysis of multiple NIH
funded studies on metabolic bone diseases.
B.3. Population and Recruitment Locations: We will enroll prevalent kidney transplant recipients at
four clinical sites. The centers and their characteristics and numbers of prevalent transplant recipients
meeting our study’s inclusion criteria are in Table 1:
Table 1: Proposed Recruitment Centers 
Prevalent 
Transplant 
Patients 
New Transplants 
per Year 
DXA Ca-
pable 
HRpQCT 
Capable 
Columbia University Irving Medical Center, NY, NY 
3000 
200 
+ 
+ 
Northwestern University Medical Center, Chicago, IL 
1000 
250 
+ 
NorthShore University Health System, Evanston, IL 
200 
15 
+ 
University of Chicago, Chicago, IL* 
1150 
80 
+ 
*Potential patients will be referred for recruitment to NorthShore University
B.4. Investigator and Research Team Meetings
The PIs and clinical research coordinators at all locations will have teleconferences by video and audio
link on a weekly basis after the first recruited patient for the first six months and on a bimonthly basis
afterwards. Ad hoc meetings will occur on an as needed basis to discuss adverse events, protocol devi-
ations, protocol changes and/or other issues that affect study execution and management.
C. STUDY TREATMENT
C.1. Study Drug and placebo: Denosumab is an anti-resorptive agent; it is monoclonal antibody against 
RANKL (receptor activator of NkB ligand) and inhibits osteoclast development and function. Denosumab 
60 mg is given as a SQ injection every 6-months. This RCT will use a placebo comparator group because 
there is no approved treatment for low bone mass and increased fracture risk in kidney transplant recip-
ients. Active drug and placebo will be provided by the manufacturer and both will be given as a subcuta-
neous injection every 6 months for 12-months.
Protocol V9


4 
D. STUDY PROCEDURES
D.1.a. Study Timeline: This is a
3-year study (Figure 1). Sixty
men and women (40 Denosumab
/ 20 Placebo) ≥ 18-years, who are
≥ 12 months after kidney trans-
plantation, with GFR ≥ 30 mL/mi-
nute/1.73 m2 (MDRD or CKD-EPI
per local lab reporting), and sta-
ble allograft function will be en-
rolled over the first 1.5-years of
the study, treated with 12-months
of denosumab or placebo, and
followed until end-of-study for
post-treatment complications.
D.1.b. Participant Remunera-
tion: All patients will receive a to-
tal of $400.00 over the course of
the study. This will be distributed to them at each visit according to the following payment schedule:
•
Screening Visit: $25
•
Baseline Visit: $75
•
2-weeks post-baseline Visit: $25
•
1-week pre 6-month Visit: $25
•
6-months Visit: $75
•
2-weeks post-6 month Visit: $25
•
12-months Visit: $150
D.2. Recruitment, Informed Consent, Screening & Evaluation, Enrollment & Randomization, Study
Treatment, and Post-Treatment Follow-up and Bone Care 
D.2.1. Recruitment: Potential participants will be identified based on inclusion / exclusion criteria item-
ized below. After permission to approach the patient is provided by the patient’s nephrologist, the study 
will be explained to them. If they agree to further screening to determine if they adhere to the full eligibility 
criteria, informed consent (ICF) will be obtained. After consent is obtained, screening to rule out the 
following exclusion criteria will occur: (1) assessment of bone mineral density (BMD) to rule out a T-Score 
≥ -1.0 at the spine; (2) thoracic and lumbar spine X-rays to assess for occult vertebral fractures; and (3) 
assessment for serum calcium ≤ 9.0 mg/dL and 25OHD ≤ 30 ng/mL.
D.2.1.a. Inclusion and Exclusion Criteria We will include 60 men and women who are ≥12 months after 
kidney transplantation with stable allograft function. We will exclude patients expected to need dialysis 
and/or die within two-years of enrollment, and medical conditions that may alter fracture risk independent 
of transplantation effects. Given the risk of hypocalcemia associated with denosumab, we will ensure that 
all patients have pre-treatment levels of serum calcium and 25OHD of ≥ 9.0 mg/dL and ≥ 30 ng/mL 
respectively. Due to the known risk of osteonecrosis of the jaw, we will ensure that all participants are 
receiving dental care, are in good dental health, and will be excluded if they will be having a dental 
invasive dental procedure over the course of the study. Furthermore, due to concerns regarding risk of 
vertebral fractures after discontinuation of denosumab, we will exclude patients with prevalent vertebral 
fractures and all patients must agree to referral to a bone disease specialist at the completion of their 
participation in this study. Our inclusion and exclusion criteria are:
Protocol V9
Figure 1: Study Timeline 


5 
Protocol V9  
Inclusion criteria 
1.
Men and women
2.
All race-ethnicities
3.
Age ≥ 18 years
4.
≥ 12-months after kidney transplantation (living or deceased donor recipient)
5.
Stable allograft function over the previous year defined as:
a. No rejections
b. No more than a 15% decline in GFR over the prior year
6.
Allograft GFR ≥ 30 mL/minute/1.73 m2 (MDRD or CKD-EPI per local lab reporting)
7.
25OHD ≥ 30 ng/mL (determined at screening visit)
8.
Serum calcium ≥ 9.0 mg/dL (determined at screening visit)
9.
T-Score at the spine including and between -1.0 and -3.5 (determined at screening visit) and/or t-
score at all other skeletal sites ≤ -1.0
10. Must have had a routine dental exam within 12-months of study recruitment
11. Must agree to continue with routine dental exams over the course of the study
12. Has not undergone an invasive dental procedure (i.e., tooth extraction, dental implants, oral surgery)
within ≤ 3-months of recruitment
13. Must agree to referral to metabolic bone disease specialist at the end of the study
14. Women of child bearing potential must be willing to use one form of effective contraception over the
course of the study
Exclusion Criteria 
1.
Allograft GFR < 30 mL/minute/1.73 m2 (MDRD or CKD-EPI per local lab reporting)
2.
Within 24-months of starting renal replacement therapy
3.
Prevalent or occult vertebral fractures
4.
History of post-transplantation non-basal cell carcinoma cancers within 5-years of enrollment and not
in remission
5.
Non-ambulatory
6.
Malignancy requiring chemotherapy or metastatic to bone within 5-years of enrollment and not in
remission
7.
Non-transplant related metabolic bone diseases that alter bone mineral density, including but not
limited to Primary hyperparathyroidism, Paget’s, Osteogenesis Imperfecta
8.
Within one-year of parathyroidectomy
9.
Untreated hyperthyroidism for 6-months or longer
10. Untreated hypothyroidism for 6-months of longer
11. Medical diseases (end stage liver, lung or heart, intestinal malabsorption)
12. Use within the prior year of bisphosphonates, teriparatide, selective estrogen receptor modulators,
testosterone, estrogen in the form of hormone replacement therapy*, denosumab, abaloparatide, cal-
citonin, and romosozumab
13. Allergy to components within the denosumab preparation or to denosumab
14. Weight > 300 pounds
15. PTH > 450 pg /mL
16. Will undergo an invasive dental procedure (i.e., tooth extraction, dental implants, oral surgery) within
the next 12-months
17. Pregnant
18. Planned pregnancy during the course of the study
*OCPs are not exclusionary
D.2.2. Screening and Evaluation


6 
Protocol V9 12.29.20 
D.2.2.a. Pregnancy: All pre-menopausal women will undergo a urine pregnancy test prior to receiving
study drug, vertebral X-rays and BMD testing, and at the 12-month study visit.
D.2.2.b. Vertebral fractures: All patients will undergo screening thoracic and lumbar spine lateral X-rays
to assess for occult vertebral fractures. Any thoracic and lumbar spine lateral X-ray results that were
obtained within 12-months of the screening visit may be used.
D.2.2.c. Lumbar spine T-Score between -1.0 and -3.5: A screening BMD will be obtained if a DXA from
within the 5-years prior to recruitment is not available. Any screening DXA that was obtained within 3-
months of the baseline visit can be used as the baseline DXA as long as it was obtained on the same
DXA machine as the one that will be used for this protocol. Any screening DXA that is obtained during
the screening visit will also be used as the baseline DXA to ensure that patients are not exposed to
additional radiation.
D.2.2.d. Calcium and 25OHD assessment: All participants will undergo screening of serum calcium
and 25-hydroxy vitamin D to assess for risk of denosumab induced hypocalcemia. Prior to enrollment, all
patients will need to have 25OHD levels ≥30 ng/mL and serum calcium levels ≥9 mg/dL. Lab results that
were obtained within 3 weeks of the screening visit may be used. If 25OHD levels of < 30 ng/mL and
serum calcium levels < 9 mg/dL prior to enrollment, they will be given the following supplements:
•
Vitamin D
o
Vitamin D: 25OHD 20-30 ng/mL - Ergocalciferol 50,000 IU daily x 4 days
o
Vitamin D: 25OHD < 20 ng/mL - Ergocalciferol 50,000 IU daily x 8 days
•
Calcium: Calcium carbonate 500 mg PO daily x 7 days
All participants will be rescreened for serum calcium and 25-hydroxy vitamin D labs after the supplemen-
tation period is complete. Participants will be allowed one rescreen visit.
D.2.3. Enrollment and Randomization: Each study site will randomize 20 participants and all analyses
will be adjusted for study site (see Section D.6.3.). After recruits have passed screening and evaluation,
the research teams at all study sites will redact and upload all source documentation of the screening
visit into the REDCap file repository labeled with the assigned study code. If the DXA being used for the
screen was from the patient’s prior medical history, a copy of this record should be obtained and a signed
medical record release form should be included per institutional policy. They will also fill out the “Screen
Eligibility Form”, which will notify Dr. Nickolas via email. Dr. Nickolas will review the screening documents
and sign off on the “Screen Eligibility Form” via electronic signature. Screening documents should in-
clude, but is not limited to, DXA results, spine x-ray results, laboratory results, pregnancy test results,
and dental exam confirmation. He will also email the research team to notify them of the approval before
randomization can occur. The non-CUIMC sites will notify the study statistician by email to release blinded
confirmation of randomization to local research study staff and the unblinded treatment assignment to
the local research pharmacy.
The CUIMC research pharmacy will randomize enrolled participants using a randomization scheme pre-
pared for this site. At the CUIMC site only, randomization will be 50% denosumab and 50% placebo since 
HR-pQCT imaging will occur only at CUIMC and our goal is to perform HR-pQCT imaging in 10 subjects 
on denosumab and 10 subjects on placebo. Therefore, in order to achieve the target group assignment 
of 40/20 denosumab/placebo for the total study, the randomization algorithm for the non-CUIMC sites 
will be adjusted to 3:1 denosumab:placebo. As described in section D.6.3., statistical analyses will be 
adjusted for study site to mitigate possible effects of bias by recruitment center. The investigators and 
clinical research coordinators will be blinded to treatment assignment for the duration of the study. Due 
to the uneven distribution of treatment randomization (i.e. 40/20), it will be impossible to blind the statis-
tician to randomization assignment. However, for reporting to the DSMB, the statistician will report ad-
verse events only by group assignment (e.g., group A and B), but will not unblind the investigators or the 
____


7 
DSMB to treatment group (i.e., active drug or placebo). The DSMB will be permitted to ask for study 
unblinding only for specific circumstances as outlined below in the section E.3.a.The Data Safety and 
Monitoring Board. 
D.2.3.a. Cholecalciferol and Calcium Supplementation: After enrollment and randomization and prior
to starting study drug, all participants will be started on cholecalciferol 1,000 IU daily and calcium car-
bonate 500 mg daily to prevent denosumab induced hypocalcemia. If a patient is already taking vitamin
D supplements prior to enrollment and their laboratory levels are at target, their vitamin D regimen will
remain the same. If a patient is already taking calcium supplements prior to enrollment, they will be asked
to switch to the regimen according to the study protocol. Additionally, patients whose calcium levels are
over the upper range of normal (based on institutional standards) will not be placed on any calcium sup-
plements. Subjects are required to bring their supplements to the 6- and 12-month visits to ensure and
verify compliance. The research team will count the number of pills and document the number of pills
taken since the last visit in the appropriate case report form. Management of post-injection hypocalcemia
will be reviewed by the independent medical monitor is outlined below in the section E.3.c.i. Manage-
ment of hypocalcemia.
D.2.4. Study Treatment (see Table 2): After enrollment and randomization, Study Treatment phase
will begin. During this phase, in-office visits will occur every 6 months and at that time participants will
complete questionnaires outlined in detail in Section D.7. Database and Clinical Research Data Col-
lection Forms. These forms pertain to medical, transplant and fracture history, dietary assessment and
frailty/physical activity, kidney function, and compliance with study medications. There can be up to a 7
day window between the Baseline visit and the study drug administration to allow for review of the bone
imaging results. Safety labs will be obtained: a renal panel will be obtained in the outpatient setting at the
following time points: both denosumab injection visits, two-weeks after each denosumab injection (weeks
2 and 25, respectively) to assess for hypocalcemia, and one-week prior to the second denosumab injec-
tion (week 23) to ensure that serum calcium is ≥ 9.0 mg/dL. If hypocalcemia is present after an injection,
we will proceed as outlined in the section E.3.c.i. Management of hypocalcemia. If calcium levels prior
to the second injection are ≤ 9.0 mg/dL, we will administer calcium supplementation as outlined in section
D.2.2.d. Calcium and 25OHD assessment.
Remote Visits: Remote visits using IRB-approved methods are permitted for data collection of medical 
history, concomitant medications, adverse events, physical activity questionnaire, and dietary question-
naire. Patients will be provided a copy of the questionnaires in person or digitally to facilitate the visit. 
D.2.4.a. Compliance: Treatment will be administered by study personnel as a SQ injection every 6-
months. Thus, compliance will be directly observed and we expect that all patients retained in the study
will have 100% compliance unless they drop-out or experience a treatment-related adverse event.
D.2.4.b. Study drug self-injection: Due to circumstances surrounding COVID-19, patients will have an
option to do self-injection of the study drug to limit the amount of time spent on the medical campus. The
research pharmacy will continue to blind the study drug in preparation for shipment. The study team will
make arrangements with a carrier to provide temperature-controlled transportation of the study drug and
communicate with the patient to ensure that the patient is home to receive the shipment. The study doctor
will then arrange a video visit with the patient for the injection. Follow-up with the patient after the self-
injection will occur as per regular protocol in order to monitor for adverse events.
D.2.4.c. Drop-outs: We are inflating our sample size by 10% to account for drop-out and loss to follow-
up (see D.6.3. Statistical plan and Sample Size Justification for both Aims 1 and 2). Since the pop-
ulation being studied represents a healthy subset of kidney transplant recipients, we expect that post-
transplant survival rates will exceed 90%, and we do not anticipate meaningful loss to follow-up due to
Protocol V9  


8 
Protocol V9  
death. A 10% drop-out rate will not compromise our ability to obtain meaningful statistical results on all 
our planned outcomes. For our primary outcome of the percent change in BMD by DXA, we will be able 
to obtain meaningful statistical results if we have up to 65% and 35% drop-out in the denosumab and 
placebo drug groups respectively. 
D.2.4.d. Participants will be withdrawn from continuation of drug administration after the first in-
jection due to the adverse events itemized below. Should a subject meet withdrawal criteria, all study
sites will update the “Enrollment/Study Completion Form” in REDCap with the final study status and note
the withdrawal criteria. The non-CUIMC sites will also upload redacted source documentation into RED-
Cap and notify Dr. Nickolas via email. All study sites will maintain the source documentation in the par-
ticipant’s study binder. These participants will be considered “Passive Participants”, meaning at the time
of withdrawal, only study medication will be stopped, and the participant will continue to be followed to
provide endpoint data at 12-months. These data will be adjusted in analyses to reflect that they were
obtained after a single injection of either study drug or placebo (See Section D.6.3). The following events
will be used to determine need for withdrawal:
o
De novo hypersensitivity to the study drug
o
Refractory hypocalcemia
o
Hypocalcemia not due to study drug and determined to be of unclear etiology
o
Refractory eczema or dermatitis
o
Refractory diarrhea
o
Multiple or refractory urinary tract infections
o
Pyelonephritis
o
The development of a serious infection that is not responsive to standard antibiotic therapy
o
Pregnancy
o
The need for emergent invasive dental procedures
o
Allograft rejection
o
Osteonecrosis of the jaw (ONJ)
o
Atypical femoral fractures
o
BMD loss by DXA ≥ 7% at any skeletal site
D.2.4.e. Study Stoppage: The study will be stopped at the discretion of the Data Safety and Monitoring
Board as described in Section E.3.a. If the number of serious adverse events, itemized in D.2.4.d ex-
ceeds 10% (6 participants) and a ratio of 2:1 or greater in the denosumab vs. placebo groups, the DSMB
will request an ad hoc audit to evaluate the relatedness between the adverse events and the study. If the
ad hoc audit identifies concerns, the DSMB may recommend study stoppage.
D.2.5. Post-Treatment Follow-up and Bone Care: After completion of the Study Treatment phase,
study participants will be contacted via telephone every three months for 12-months after study drug is
completed (15-, 18-, 21-, and 24-month visit) to assess for post-treatment adverse events (see D.7. 13
and 14). Furthermore, all participants will be scheduled to see a metabolic bone disease specialist within
one-month of completing the Study Treatment phase.
D.3. Aims 1 and 2. Methods
Data will be collected as per Table 2. At baseline, 6-months, and end of treatment:
•
Bone mineral density at the spine, hip and forearm by DXA in all patients
•
HR-pQCT (Scanco XtremeCT2, resolution 61 µm3) to measure cortical and trabecular volumetric
BMD and microarchitecture and trabecular and whole bone biomechanical competence (micro finite
element analysis [µFEA]) at the ultradistal radius and tibia in all patients recruited at CUIMC
•
Blood for research assays will be collected and stored at -80ºC, at baseline (pre-treatment) and after
6- and 12-months of treatment (Table 2: calcium, phosphorus, PTH, vitamin D metabolites, bone


9 
Protocol V9  
formation (bone specific alkaline phosphatase [BSAP], procollagen type-1 N-terminal propeptide 
[P1NP]), resorption (C-Telopeptide [CTX]) markers, FGF-23 and sclerostin, and other markers of 
skeletal health. 
•
Blood for screen and safety labs
•
Urine for pregnancy testing at screen, baseline/randomization, 6-, and 12-months
•
Questionnaires for dietary intake of calcium/vitamin D, physical activity, and frailty
•
Research staff will maintain a concomitant medication log throughout the study beginning with the
baseline visit to assess for exclusion criteria and potential drug interactions.  At the start of the 6- and
12-month visits, the research staff will reconcile any previous medications in the log and document
new medications.
Table 2: Study Procedures for Aims 1 and 2 
Recruit-
ment 
Screening 
Base-
line 
Study 
Drug 
Admin-
istra-
tion 
2-
weeks 
post 
Drug 
admin-
istra-
tion 
1-week
pre 6-mo
6-mo
 
2-weeks
post 6-
mo 
12-mo
 
15-, 18-, 
21-, 24-
mo 
Scheduling Window 
(- 3 weeks 
from 
Baseline 
Visit) 
(+ 7 
days 
from 
Base-
line) 
(+/- 3 
days) 
(- 2 
weeks) 
(+/- 
2 
wee
ks) 
(+/- 3 
days) 
(+/- 2 
weeks) 
Review of Eligibility 
Criteria 
X 
Screening Tests: ICF, 
Spine X-rays, DXA, 
renal panel,  calcium, 
and 25OHD and preg-
nancy testing 
X 
Review of interim 
history, adverse 
events, incident frac-
ture reporting, vital 
sign measurement 
X 
X 
X 
Physical activ-
ity/frailty question-
naires 
X 
X 
Block Calcium and 
Vitamin D Screener 
X 
Drug administration 
X 
X 
X 
Calcium/Vitamin D 
pill dispensation 
X 
X 
Calcium/Vitamin D 
pill count 
X 
X 
Concomitant Medica-
tions Reconciliation 
X 
X 
X 
Renal panel 
X 
X 
X 
X 
X 
X 
Urine Pregnancy test 
X 
X 
X 
X 
DXA: LS, TH, FN, 
Forearm (All sites) 
X 
X 
X 
HR-pQCT: radius and 
tibia 
(CUIMC site only) 
X 
X 
X 


10 
D.3.1. Imaging Methods for Measurement of Bone Mass, Microarchitecture, and Mechanical Com-
petence
D.3.1.a. Image Acquisition, Machine Calibration and QA/QC, Mechanical Analysis of Skeletal Im-
aging and Image Data Storage
D.3.1.a. i. Sanchita Agarwal, MS at CUIMC is an imaging and image analysis expert. She will coordinate
scan acquisitions of DXA and HR-pQCT as well as QA/QC, image acquisition protocols, DXA cross-
calibration, and will perform analyses of HR-pQCT datasets. Prior to the enrollment of the first patient,
Ms Agarwal will conduct a teleconference with the site PIs and CRCs to review image acquisition proto-
cols, which include but is not limited to scanning procedures, review of skeletal sites to be imaged, de-
velopment and review of the image acquisition form, protocol for the distribution of the circulating phan-
tom, and procedures for transfer of imaging data for review and analysis and long-term storage of image
files. Ms Agarwal will conduct teleconferences every 6-months after enrollment of the first patient to re-
view imaging data, QA/QC, challenges with image acquisition and coordination of data transfer to
CUIMC.
D.3.1.a.ii. Storage of DXA and HR-pQCT Imaging Data
•
DXA image data will be stored locally, at each study site, on DXA machines for scanner analysis.
Post analysis all image files will be stored, identified with only a study ID number, on a secure shared
drive at CUIMC indefinitely. DXA image files will be transferred to CUIMC by secure FTP server.
Quantitative analytical output of DXA image analyses, including but not limited to bone mineral con-
tent, area, density and T- and Z-Scores will be uploaded in CSV format and stored both on a secure
shared server (source document) and in REDCap. We will also upload to REDCap the imaging results
summary that is provided to the participants in a PDF format.
•
HR-pQCT imaging will occur only at CUIMC and data will be stored locally on the scanner for analysis.
Post-analysis all image data will be backed-up on a secure server as well as storage tapes, identified
with only a study ID number, at CUIMC indefinitely. Quantitative analytical data of HR-pQCT images
including but not limited to cortical and trabecular geometry, volumetric density, microarchitecture and
finite element analysis will be uploaded in excel format and stored both on a secure shared server
(source document) and in REDCap.
D.3.1.b. DXA Patients at all study sites will undergo measurement of areal BMD at baseline, 6- and 12-
months on a study-specific designated DXA machine that will be used throughout the whole study. Im-
aging procedures will occur after the urine pregnancy test has been performed and prior to study drug 
administration. We will obtain BMD at the spine (L1-4, AP), proximal femur, and forearm. CUIMC: Hologic 
QDR 4500 (Hologic, Inc., Waltham, MA) in the array (fan beam) mode. Phantoms are scanned daily for 
QA. Short term, in vivo precision is 0.68%, 1.36%, and 0.70% for spine, FN, and radius respectively. For 
DXA machine cross-calibration, a traveling phantom (European spine and forearm phantom) will be cir-
culated across sites prior to study start-up and study completion. All cross-calibration data will be rec-
orded and accounted for at time of analysis.
D.3.1.c. HR-pQCT Only patients recruited at CUIMC will undergo measurement of cortical and trabecular 
bone microarchitecture and biomechanical competence. We will use the XtremeCT-II (Scanco Medical
Protocol V9  
Research Biochemis-
tries: see Table 3 
X 
X 
X 
Adverse Event As-
certainment 
X 
X 
X 
X 
X 
X 
X 
Follow-up Phone Call 
X 


11 
Protocol V9 
AG, Brüttisellen, Switzerland, isotropic voxel size 61 µm). Patients will undergo imaging at baseline, 6- 
and 12-months. Methods and QC are described in our publications8,9. In brief, HR-pQCT imaging will be 
obtained at the non-dominant radius and tibia. The dominant limb will be scanned if there is a fracture or 
dialysis access at the non-dominant limb. Three regions of interest will be scanned: (1) fixed offset ROI; 
(2) relative offset ROI; and (3) a predominant cortical ROI at the 30% site. Precision: cortical and trabec-
ular volumetric BMD=0.9%±7.1% and 2.3±3.5%, respectively. Motion grading (score of 0 to 5) is done
for all scans at the time of image acquisition and scans with score > 3 will be repeated if the participant
agrees.
D.3.1.d. Finite Element Analysis (FEA) Ms. Agarwal will estimate mechanical competence (strength)
from HR-pQCT images. Each image is converted to a µFE model by directly converting bone voxels to
8-node elastic brick elements. A uniaxial compression is simulated equaling 1% strain using a homoge-
nous Young’s modulus if 6829 Mpa and Poisson’s ratio of 0.3 to estimate stiffness. This compression is
applied on the distal end of the bone segment. Failure load will be estimated based on the criterion by
Pistoia et al10.
D.4. Questionnaires
D.4.1. Grip Strength will be used to measure frailty
D.4.2. The Modified Baecke Questionnaire will be used to measure physical activity
D.4.3. The Block Calcium/Vitamin D Screener provided by NutritionQuest will be used to measure
dietary intake of calcium and vitamin D
D.5. Bone Biomarker Analysis
All assays will be done in the Bone Marker Lab at CUIMC. Every effort will be made to obtain 30 mL of
blood after an 8-hour fast and in the morning. Patients are permitted to take their medications prior to the
morning blood draw. If patients are taking insulin or hypoglycemic, they will hold those medications until
after the blood draw and after eating. All blood will be stored locally at each study site at -80°C. At study
end, the sera will be shipped to CUIMC and batch assayed. Biochemical assays are itemized in Table 3.
Table 3: Biochemical Assays 
Assays 
Method 
Type 
Assay Vol-
ume 
Manufacturer 
Phosphate 
Automated (integra) 
Serum 
200ul 
Roche 
Calcium 
Automated (integra) 
Serum 
Roche 
Vitamin D metabolites 
(25OHD; 1,25OHD; 
1,24OHD) 
LCMS 
Serum 
200ul 
Intact Parathyroid Hor-
mone (PTH) 
RIA 
EDTA plasma 
200ulx2 
Scantibodies 
Bone Specific Alkaline 
Phosphatase (BSAP) 
ELISA 
Serum, heparin plasma 
20ulx2 
Quidel 
Procollagen Type-1 N-
Terminal Propeptide 
(P1NP) 
RIA 
Serum 
50ulx2 
Orion Diagnostica (Espoo 
Finland) 
Carboxy-Terminal Cross-
linked Telopeptide of Type 
1 Collagen (CTX) 
ELISA 
Serum, EDTA plasma 
50ulx2 
Immunodiagnostic Systems, 
Scottsdale AZ, USA 
Tartrate Resistant Acid 
Phosphatase 5b (Trap-5b) 
ELISA 
Serum/ EDTA plasma 
100ulx2 
Immunodiagnostic Systems, 
Scottsdale AZ, USA 
FGF-23* 
ELISA 
EDTA plasma 
100ulx2 
Immunodiagnostic Systems, 
Scottsdale AZ, USA 
Sclerostin 
ELISA 
Serum or Plasma 
20ulx2 
Tedco Medical (Switzerland) 
*FGF23: intact and C-term


12 
Protocol V9  
D.6. Outcomes, Statistical Plan and Sample Size Justification
D.6.1. The primary outcome for Aim 1 is the percent change from baseline in DXA spine BMD at the
12-month endpoint. Secondary outcomes include the raw value change in DXA BMD at the spine and
the percent and raw value change in DXA BMD at the hip and forearm at the 12-month endpoint.
D.6.2. The primary outcome for Aim 2 is the percent change in HR-pQCT stiffness at the distal radius
and tibia at the 12-month endpoint. Secondary endpoints include the percent and raw value change from
baseline in HR-pQCT tibia and radius cortical volumetric density, thickness and porosity, and trabecular
volumetric density, number and thickness at the 12-month endpoint.
D.6.3. Statistical plan and Sample Size Justification for both Aims 1 and 2, between group differ-
ences in the percent change from baseline will be assessed with ANCOVA with the baseline value of the
outcome included as a continuous covariate, and with independent T-tests for the between group differ-
ence in the raw value change from baseline. No adjustment for multiple testing will be made for DXA
measures while a permutation step-down p-value adjustment will be made for HR-pQCT measures within
the tibia and radius vectors. Participants who have study drug withheld due to adverse events will be
followed to provide endpoint data at 12-months, and these data will be adjusted in analyses to reflect the
proportion of the study in which they received treatment (i.e., 1 for two injections and 0.5 for a single
injection). All models will block on recruitment site.
D.6.3.a. For the lumbar spine, according to Bonani et al 5, at 12 months the Control group had a decline
in LS BMD by 0.500%, 95% CI -1.8% to 0.9% and the denosumab group had an increase in LS BMD by
4.6%, 95% CI 3.3% to 5.9%. With n= 44 and n=46 in two groups, respectively, that translates to -0.5000
+ 4.5227 and +4.6 + 4.530, again respectively. This difference is a standardized effect size of 1.1277
which requires 13 subjects / group for 80% power, 5% alpha or 19 subjects / group for 80% power, 1%
alpha. With 40 denosumab and 20 placebo subjects, the harmonic mean of the sample size is 27, which
would provide 80% power, 5% alpha to detect an effect of denosumab equal to 3.02% or larger; or provide
80% power, 1% alpha to detect an effect of denosumab equal to 3.70% or larger.
D.6.3.b. For the total hip, Bonani et al 5, at 12 months the control group had an increase in TH BMD by
0.4%, 95% CI = -0.8% to 1.7% and the denosumab group had an increase in TH BMD by 2.3%, 95% CI
= 1.1% to 3.5%. With n= 44 and n=46 in two groups, respectively, that translates to -0.400 + 0.8186 and
+2.3 + 4.103, again respectively.  This difference is a standardized effect size of 2.32 which requires 4
subjects / group for 80% power, 5% alpha or 5 subjects / group for 80% power and 1% alpha. With 40
denosumab and 20 placebo subjects, the harmonic mean of the sample sizes is 27, which would provide
80% power, 5% alpha to detect an effect of denosumab at the hip equal to 1.036% or larger; or provide
80% power, 1% alpha to detect an effect of denosumab at the hip equal to 1.159% or larger.
D.6.3.c. Calculations for spine and hip assume that the mean of the placebo group is the same as that
reported by Bonani et al 5 and
that the variability in the 
groups also remains as re-
ported by Bonani et al 5. Data
from Brunova et al11, a study
conducted in prevalent solid 
organ transplant recipients
that also included recipients
of a kidney transplant only,
support the estimates of 
Table 4 
Bonani 
Brunova
  
Control 
Denosumab 
Denosumab
LS % change 12 
-0.5 + 4.52 
4.6 + 4.45
LS % change 20mo 
 
 
10.1 + 5.90 
*kidney trans-
plant only
TH % change 12mo 
0.4 + 4.18 
2.3 + 4.11
TH % change 20mo 
 
 
10.4 + 8.3
*kidney trans-
plant only 


13 
Protocol V9  
changes in LS and Hip BMD from Bonani et al (See Table 4). 
D.6.3.d. For stiffness at the radius and tibia by HR-pQCT. For HR-pQCT we will enroll 10 participants
per group and our primary outcome is the percent change in stiffness at the radius and tibia at the 12-
month endpoint. This sample size permits detection of a 1.32 SD difference in stiffness at the radius and
tibia with alpha 0.05 / beta 0.80. Based on Bonani et al 6, the mean percent difference ± SD in stiffness
at the radius and tibia over the first 12-months of kidney transplantation was 2.9% ± 3.3% and 5.6% ±
1.9%. Therefore, we expect to be able to detect a between-group difference in stiffness over 12-months
of treatment.
D.7. Database, Data Entry, and Clinical Research Data Collection Forms
•
This project will use REDCap at all sites. A centralized REDCap database will be developed by
CUIMC and used at all sites.
•
CUIMC and Northwestern will use REDCap as their source documentation for CRFs, excluding image
files for DXA and HR-pQCT, NutritionQuest Forms, and laboratory results.
•
NorthShore will maintain paper documents as their source documentation and will copy into REDCap.
•
Study visit data will be entered within one-month of the study visit completion unless otherwise stated
o
A copy of the Block Calcium/Vitamin D screener will be uploaded to the file repository in RED-
Cap, and the physical copy will be sent to NutritionQuest for scoring at the end of the study
•
Adverse event data will be entered within 48-hours of the study visit completion unless otherwise
stated
The following CRFs will be developed in REDCap for data collection: 
1) Screening form
2) Eligibility / Randomization form to document result of screening and randomization process
3) Demographic form
4) Baseline visit form (visit 1)
a. Visit 1 procedure checklist
b. Medical history
c.
Transplant history and allograft function
d. Family history
e. Social history
f.
Fracture history
g. Medication history
h. Block Calcium and Vitamin D Screener
i.
Modified Baecke physical activity
j.
Documentation of study drug injection (study drug compliance)
k.
Blood sample tracking
5) Concomitant medication reconciliation
6) Safety lab tracking form: Two-week renal panel
7) Safety lab tracking form: Twenty-three-week renal panel
8) 6 Month visit form (visit 2)
a. Visit 2 procedure checklist
b. Updated medical history
c.
Updated transplant history and allograft function
d. Updated medication history
e. Documentation of study drug injection (study drug compliance)
f.
Calcium and Vitamin D pill count
g. Blood sample tracking
9) Safety lab tracking form: Twenty-five-week renal panel
10) 12 Month visit form (visit 3)


14 
Protocol V9  
a. Visit 3 procedure checklist
b. Updated medical history
c.
Updated transplant history and allograft function
d. Updated medication history
e. Modified Baecke physical activity
f.
Documentation of study drug injection (study drug compliance)
g. Calcium and Vitamin D pill count
h. Blood sample tracking
11) 3-Month Follow-up Tracking
a. 15 Months Follow-up
i.
Confirmation of post-treatment bone care
ii.
Adverse and serious adverse event assessment (see D7. 13 and 14)
b. 18 Months Follow-up
i.
Confirmation of post-treatment bone care
ii.
Adverse and serious adverse event assessment (see D7. 13 and 14)
c.
21 Months Follow-up
i.
Confirmation of post-treatment bone care
ii.
Adverse and serious adverse event assessment (see D7. 13 and 14)
d. 24 Months Follow-up
i.
Confirmation of post-treatment bone care
ii.
Adverse and serious adverse event assessment (see D7. 13 and 14)
12) Termination form
a. Participants who complete the study
b. Participants who terminate study procedures early and the reason for termination
13) Adverse event tracking
a. Hypocalcemia
b. Incident fractures
c.
Urinary tract infections
d. Non-urinary tract infections
e. Refractory Diarrhea
f.
Incident cancers
g. Dermatitis and Eczema
h. Transplant rejection episodes
i.
Hypersensitivity
j.
Pyelonephritis
k.
Osteonecrosis of the jaw (ONJ)
l.
Atypical femoral fractures
m. Serious infection leading to hospitalization
n. Other expected AEs
o. Unexpected AEs
14) Serious adverse event forms
a. Will use MED-WATCH to monitor/document SAEs
15) Imaging (DXA and HR-pQCT) and biochemical data forms


15 
Protocol V9  
E. HUMAN SUBJECTS PROTECTIONS
E.1. Adverse Events and Serious Adverse Events
E.1.a. Definition of Adverse Event (AE)
•
Adverse event: any untoward or unfavorable medical occurrence associated with the use of an in-
tervention in humans, whether or not considered intervention-related
E.1.b. Definition of Serious Adverse Event (SAE)
•
Serious adverse event: an adverse event or suspected adverse reaction is considered serious if, in
the view of the investigator, it results in any of the following outcomes:
o
Death
o
Life-threatening adverse event
o
Inpatient hospitalization or prolongation of existing hospitalization
o
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life
functions
o
A congenital anomaly/birth defect.
Important medical events that may not result in death, be life-threatening, or require hospitalization may 
be considered serious when, based upon appropriate medical judgment, they may jeopardize the partic-
ipant and may require medical or surgical intervention to prevent one of the outcomes listed in this defi-
nition. These events should also be treated like an SAE. 
E.1.c. Classification of an Adverse Event
E.1.c.i. Severity:
•
Mild – Events require minimal or no treatment and do not interfere with the participant’s daily activi-
ties
•
Moderate – Events result in a low level of inconvenience or concern with the therapeutic measures.
Moderate events may cause some interference with functioning
•
Severe – Events interrupt a participant’s usual daily activity and may require systemic drug therapy
or other treatment
E.1.c.ii. Relatedness:
•
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible
contributing factors can be ruled out. The clinical event, including an abnormal laboratory test result,
occurs in a plausible time relationship to study intervention administration and cannot be explained
by concurrent disease or other drugs or chemicals. The response to withdrawal of the study interven-
tion (dechallenge) should be clinically plausible. The event must be pharmacologically or phenome-
nologically definitive, with use of a satisfactory rechallenge procedure if necessary.
•
Probably Related – There is evidence to suggest a causal relationship, and the influence of other
factors is unlikely. The clinical event, including an abnormal laboratory test result, occurs within a
reasonable time after administration of the study intervention, is unlikely to be attributed to concurrent
disease or other drugs or chemicals, and follows a clinically reasonable response on withdrawal
(dechallenge). Rechallenge information is not required to fulfill this definition.
•
Potentially Related – There is some evidence to suggest a causal relationship (e.g., the event oc-
curred within a reasonable time after administration of the trial medication). However, other factors
may have contributed to the event (e.g., the participant’s clinical condition, other concomitant events).
Although an AE may rate only as “possibly related” soon after discovery, it can be flagged as requiring
more information and later be upgraded to “probably related” or “definitely related”, as appropriate.
•
Unlikely to be related – A clinical event, including an abnormal laboratory test result, whose temporal
relationship to study intervention administration makes a causal relationship improbable (e.g., the
event did not occur within a reasonable time after administration of the study intervention) and in


16 
Protocol V9  
which other drugs or chemicals or underlying disease provides plausible explanations (e.g., the par-
ticipant’s clinical condition, other concomitant treatments). 
•
Not Related – The AE is completely independent of study intervention administration, and/or evi-
dence exists that the event is definitely related to another etiology. There must be an alternative,
definitive etiology documented by the clinician.]
E.1.c.iii. Expectedness
•
Expected adverse event: An event that is listed in the investigator brochure and/or occurs at the
expected incidence rate or severity that has been observed in the prior literature
•
Unexpected adverse event: An event that is not listed in the investigator brochure or occurs at an
incidence rate and/or severity that has not been observed in the prior literature
E.1.d. Adverse Event Reporting and Timeline: AEs will be collected continuously throughout this study
and will occur at all study visits, including but not limited to visits for study drug injections and safety and
pre-injection labs. All AEs will be captured by the research team at all sites on the appropriate case report
form (CRF) and then documented in the REDCap database within 3 days of the research team becoming
aware of its occurrence. Information to be collected includes event description, time of onset, assessment
of severity, and relationship to the study drug or to study procedures (e.g., imaging, supplements). All
AEs occurring while on study must be documented appropriately regardless of relationship. At each in-
person study visit, the research staff will inquire about the occurrence of AE/SAEs since the previous visit
and update any unresolved AEs. All AEs will be followed to adequate resolution.
E.1.e. Serious Adverse Event Reporting and Timeframe
Within 24-hours, the study investigators at all sites will report to the study sponsor any serious adverse
event, whether or not considered study intervention related, including those listed in the protocol or in-
vestigator brochure and must include an assessment of whether there is a reasonable possibility that the
study intervention caused the event.
•
All SAEs will be followed until satisfactory resolution or until the site investigator deems the event to
be chronic or the participant is stable. Other supporting documentation of the event may be requested
by the study sponsor and should be provided as soon as possible.
•
Any unexpected fatal or life-threatening suspected adverse reaction will be reported to the FDA and
all participating investigators as soon as possible, but in no case later than 7 calendar days after the
sponsor’s initial receipt of the information.
•
Both any non-life threatening or non-fatal serious adverse reaction and any potential serious risks,
identified from other clinical trials or other sources, will be reported to the FDA and all participating
investigators in an IND safety report as soon as possible, but in no case later than 15 calendar days
after the sponsor determines that the information qualifies for reporting.
•
Reporting to the FDA will occur via MED-WATCH
E.2. Unanticipated Problems
E.2.a. Definition of Unanticipated Problems (UP)
•
Unanticipated Problems will be defined as any incident, experience, or outcome involving risk to
subjects or others in any human subjects research that meet all of the following criteria:
o
Unexpected (in terms of nature, severity, or frequency) given (a) the research procedures that
are described in the IRB-approved protocol and informed consent form, and (b) the charac-
teristics of the subject population being studied.
o
Related or possibly related to participation in such research (i.e. there is a reasonable possi-
bility that the incident, experience, or outcome may have been caused by the procedures
involved in such research); and
o
Suggests that the research places the subject or others at a greater risk of harm (physical,
psychologic, economic, or social) than was previously known or recognized.


17 
Protocol V9  
E.2.b. Unanticipated Problem Reporting and Frequency
E.2.b.i. The study investigators at all sites will report UPs according to their own institutional policies.  In
addition, the study investigators at non-CUIMC sites must report any UPs occurring at their sites to the
study sponsor within 48-hours. The study sponsor shall adhere to the following workflow as applicable:
•
Submit the UP report to the CUIMC IRB within 7 days of either its occurrence or acquiring knowledge
of its occurrence
•
Submit a MED-WATCH form to the FDA by following the reporting guidelines detailed in Section
E.1.e.
•
Disseminate the UP report to the study investigators at non-CUIMC sites
•
Submit a report to Amgen according to Section E.5. Table 5
E.2.b.ii. The UP report will include the following information:
•
Protocol identifying information: Protocol title and number, PI’s name, and the IRB project number
•
A detailed description of the event, incident, or outcome
•
An explanation of the basis for determining that the event, incident, or outcome represents an UP
•
A description of any changes to the protocol or other corrective actions that are proposed in response
to the UP
E.3. Events of Special Interest
E.3.a. Fractures: Incident fractures occurring during the study will result in referral to a metabolic bone
disease specialist for management options. If the participant and the referring bone disease specialist
request unblinding and clinical treatment.
E.3.b. Infections, Cancers and Cardiovascular Events: Treatment of infections, cancers and cardio-
vascular events will be deferred to the participant’s nephrologist.
E.3.c. Hypocalcemia: Defined as an albumin adjusted serum calcium level less than the lower limit of
normal for the core lab at each center. Serum calcium and albumin will be measured 1-week before and
2-weeks after each injection by local labs. At enrollment and prior to the first injection, all patients will be
placed on calcium carbonate and cholecalciferol. Patients with post-injection hypocalcemia will be man-
aged by the following protocol:
E.3.c.i. Management of hypocalcemia
1.
The medical monitor at each recruitment site will review the corrected serum calcium from the safety
labs obtained two-weeks after each injection and in the occurrence of a hypocalcemic event will send
an email to the site PI and CRC with notification. The site PI and CRC will manage hypocalcemia with
calcium and calcitriol based on the following dosing algorithm.
2.
Drop in corrected serum calcium WNL of the reference range
a. No dose change
3.
Drop in serum calcium < LLN of the reference range but ≥ 7.5 mg/dL without symptoms of hypocalce-
mia
a. Increase calcium carbonate to 500 mg twice daily and recheck in one week
i.
If calcium has normalized: no dose change to calcium supplement
ii.
If calcium remains < LLN but ≥ 7.5 mg/dL, increase calcium carbonate to 500 mg three-
times daily and recheck in one week
iii.
If calcium remains < LLN but ≥ 7.5 mg/dL, start calcitriol 0.25 mcg three-times weekly
4.
Drop in serum calcium < 7.5 mg/dL or below the reference range with symptoms of hypocalcemia
a. Increase calcium carbonate to 500 mg three-times daily and start calcitriol 0.25 mcg daily and
recheck in one week
i.
If calcium has normalized: no dose changes
ii.
If calcium level < LLN but ≥ 7.5 mg/dL without symptoms, increase calcitriol to 0.25 mcg


18 
Protocol V9  
twice daily and recheck in one week 
iii.
If calcium level < 7.5 mg/dL or below the reference range with symptoms of hypocalce-
mia, increase calcium carbonate to 1,000 mg three-times daily and recheck in one week
iv.
If calcium level < LLN but ≥ 7.5 mg/dL without symptoms, proceed as in 4.a.ii
5.
Hypocalcemia occurring > 2 weeks from study drug administration and from non-study safety
labs: The research teams at all sites will adjudicate whether or not the hypocalcemic event is due to
study drug administration. If the event is due to the study drug, the event will be managed as per
above. If the event is not due to the study drug, the etiology will need to be either determined and
corrected before study drug is administered, or the participant will be withdrawn from study drug
administration and will be followed as a passive participant per Section D.2.4.d.
E.4. Safety Oversight
E.4.a. The Data Safety and Monitoring Board (DSMB)
•
An independent DSMB will be established to monitor patient safety and to evaluate the progress of
the study and adverse events related to study participation. The DSMB will be comprised of a trans-
plant nephrologist, a bone disease specialist and a statistician. Our DSMB members include:
o
Peter Reese MD MSCE, Division of Nephrology, The University of Pennsylvania, Philadel-
phia, PA
o
Bart Clarke MD, Division of Endocrinology, Mayo Clinic, Rochester, MN
o
Shoukoufeh Khalatbari MS, Biostatistics Program, Michigan Institute for Clinical and Health
Research, University of Michigan, Ann Arbor, MI
•
The DSMB will meet prior to study initiation to ensure that study procedures are compliant with IRB
and HIPAA guidelines, to establish reporting guidelines of adverse events to the PIs and sponsor,
and to recommend protocol revisions.
•
After enrollment of the first study participant, the DSMB will meet every six months, or on an as
needed basis, during the study’s duration to review enrollment rates, protocol adherence, and moni-
toring and reporting of adverse events.
•
Over the course of the study, the DSMB may ask for unblinding, a change of the protocol
and/or consent of the study, or study stoppage based on their review of the data.
•
The DSMB will make decisions about unblinding, a change of the protocol and/or consent of
the study, or study stoppage if the number of adverse or serious adverse events exceeds
10% (6 participants) and a ratio of 2:1 or greater in the denosumab vs. placebo groups, or
vice versa, although the DSMB’s decisions will not be restricted to those specific circum-
stances.
•
As a potential step prior to recommending study stoppage or changes to the study, the
DSMB may consider initiating an ad hoc audit conducted by the CUIMC departmental QA
monitor. The audit will focus on relationships between the relatedness of adverse events
and study drug and procedures.
•
The DSMB will be supplied the following data by the CUIMC PI, CRC, and statistician:
o
CONSORT Diagram
o
Data tables that summarize demographic and baseline clinical characteristics
o
Data quality tables that capture missing visits
o
Safety assessments of aggregate tables of adverse events and serious adverse events
o
Aggregate tables of clinical laboratory values
o
Listings of protocol deviations and violations
o
Summary of protocol changes since the prior DSMB meeting
•
The DSMB will be responsible for reviewing and making recommendations based upon data pertain-
ing to safety and adverse events. The recommendations of the DSMB will be as follows:
o
Continue without amendment
o
Continue with amendment


19 
Protocol V9  
o
Suspend enrollment
o
Discontinue study
E.4.b. Independent Medical Monitor: An unblinded medical monitor at each recruitment site will review
safety labs and make recommendations on management of hypocalcemia. The medical monitor will ad-
here to the following workflow:
•
Review unblinded safety labs
•
Report the adverse event (i.e. hypocalcemia) to the site investigator and local CRC and also to
the study sponsor via email
o
The local CRC will update both the adverse event case report form and REDCap with the
necessary information
•
Report the actual safety lab values to the study statistician, who will compile a table that will be
reported to the DSMB at the regular 6-month meetings
E.5. Study Site Monitoring:
•
Remote and on-site monitoring visits will each occur at least once annually.
•
All study documentation and source documents that is captured in paper format and recorded into a
central REDCap EDC database has to be made available during study site monitoring visits.
•
Recording of paper documentation into REDCap will be verified according to protocol.
•
Non-CUIMC recruitment sites will be monitored remotely by the CUIMC Lead CRC prior to study
initiation, after the completion of the first subject’s baseline visit, and then annually after recruitment
of the first patient until study completion.
o
On-site monitoring will occur once yearly.
o
Targeted review of data (< 100% data verification) through the REDCap database will occur
at least once per year during the remote site monitoring visit, and total data verification will
occur during the annual on-site monitoring visit.
•
CUIMC recruitment site will be monitored on-site by a CUIMC departmental QA monitor prior to study
initiation, after the completion of the first subject’s baseline visit, and at least annually after recruitment
of the first patient until study completion.
E.6. Safety Reporting to Amgen and Regulatory Authorities: We will comply with Amgen policies on
safety reporting, as outlined in the Amgen Safety Reporting Guidelines (Table 5). Reports will be sent to
Amgen through either fax (1-888-814-8653) or email (svc-ags-in-us@amgen.com) within the specified
timeframe below.
Table 5: Safety Reporting Timeframe to Amgen 
Safety Data 
Timeframe for Submission to Amgen 
Suspected Unexpected Serious Adverse Reaction (SU-
SARs) 
Sent to Amgen at time of regulatory submission 
Pregnancy/Lactation 
Within 10 calendar days of Sponsor awareness 
Annual Safety Report (eg, EU Clinical Trial Directive [CTD] 
DSUR, and US IND Annual Report) 
Annually 
Other Aggregate Analyses (any report containing safety data 
generated during the course of a study 
At time of ISS sponsor submission to any body governing 
research conduct (eg, RA, IRB, etc) 


20 
Final (End of Study Report, including): 
•
Unblinding data for blinded studies
•
Reports of unauthorized use of a marketed product
At time of ISS sponsor submission to any body governing 
research conduct (eg, RA, IRB, etc) but not later than 1 
calendar year of study completion 
E.7. Institutional Review Board
IRB approval of the protocol and informed consent form/procedures at all study sites will be obtained
prior to recruitment and all subjects will have ICF prior to any study procedures.
E.8. Incidental Findings (IF)
Skeletal imaging in this protocol involves X-rays of the thoracic and lumbar spine, DXA of the spine, hip
and forearm and HR-pQCT of the distal radius and tibia. X-rays of the thoracic and lumbar spine are
clinical scans used to identify vertebral fractures. DXA imaging is a clinical scan that is used for the
diagnosis and monitoring of osteoporosis. HR-pQCT is a research scan that is used to assess microar-
chitectural aspects of bone quality; it is not used in the clinic and is not FDA approved for clinical use. As
pertains to this protocol, according to CUIMC IRB policy, X-rays of the thoracic and lumbar spine require
IF review.
E.8.a. Summary of IF's for spine X-ray imaging may include but are not limited to:
1. Vertebral fractures
2. Sclerotic lesions
3. Aortic aneurysms
4. Osteoarthritis
5. Scoliosis
6. Aortic calcifications
7. Osteophytes
E.8.b. Plan for Imaging Review. X-ray images will be reviewed by a radiologist per clinical standard and
the results will be reported in the electronic health record.
E.8.c. IF Disclosure Plan: The results of all spine X-rays will be reviewed either verbally or by written
communication with the study participant by the PI at each study site (CUIMC: Dr. Nickolas; Northwest-
ern: Dr. Isakova; NorthShore: Dr. Sprague).
E.8.d. IF Classification: IF’s will be classified as A or B and all Class A / B IF’s will be reviewed verbally
E.8.d.i. Class A IF: These are life-threatening or severe. The likelihood of identifying a Class A IF by
spine X-ray imaging is highly unlikely. If a Class A IF is identified, that information will be communicated
immediately and directly to the study participant and their primary care provider.
E.8.d.ii. Class B IF: These are not necessarily immediately life threatening or severe, but are likely to be
deemed by a subject to be important to his/her health. If a Class B IF is identified, that information will be
communicated immediately and directly to the study participant and their primary care provider and/or
nephrologist.
E.8.e. All IF's of Clinical Significances and the management of such findings will be documented in the
research records for the study.
E.8.f. At the time of a continuing review, if an IF was noted during the previous approval period, the PI
will provide the IRB with the following information:
1. The number of required Review Images
Protocol V9  


21 
2. A list of the subject study numbers
3. The type of scan
4. The date of the scan
5. A description of the IF of Clinical Significance
6. The date of communication with the subject and the outcome, if known.
E.9. FDA IND Sponsor Responsibilities
E.9.a. The Sponsor-Investigator has completed the CUIMC IRB course TC0096: FDA Requirements of
Sponsor-Investigator Studies
E.9.b. The Sponsor-Investigator agrees to comply with the FDA and IRB outlined responsibilities, includ-
ing but not limited to
•
Ensuring proper monitoring
•
Ensuring the study is conducted in accordance with the protocol
•
Reviewing ongoing investigations/evaluating safety and efficacy/reporting to the FDA and IRB
•
Keeping and retaining records/documentation
•
Submitting amendments, IND Safety Reports, and Annual reports to the FDA
E.10. Informed Consent
Informed consent will be obtained from all participants. The purpose of the study will be explained to
patients prior to recruitment as part of the informed consent procedures, which is defined as “to determine
the effects of denosumab on your bone density”. The study methods, namely the administration of deno-
sumab; assessment of medical, dietary intake, fracture history, and physical activity; the evaluation by
imaging modalities; and the collection of blood will be described. The fact that the informed consent and
the study protocol have been approved by the IRB will be emphasized. The potential risks and direct
benefits to the patient will be explained. The potential benefit from this study to future patients will be
explained. The fact that the patient has the option not to participate and will receive the same standard
medical care regardless of participation will be emphasized. The rights of the patient, including the vol-
untary nature of participation and the right to withdraw the consent at any time, will be explained. We will
also explain that this research does not affect the clinical management of the patient as determined by
their nephrologist. In addition, patients will be informed that by enrolling they will have more intensive
monitoring of bone health than they would if they do not participate. Thus, participating in this study
should not put the subject at any risk for altering management deemed appropriate by the patient’s neph-
rologist. The methods in place for maintaining patient confidentiality will be explained. This will include
registering all data under a subject specific alpha-numeric system, storing all records in password pro-
tected and encrypted files. A copy of the signed informed consent will be placed in the patient’s perma-
nent medical record, a second copy of all consents will accompany the data to be kept in the PI’s office,
and a third copy will be provided to the participant.
E.11. Potential Risks
The potential risks are related to exposure to the study drug, vitamin D and calcium carbonate, loss of
confidentiality, venipuncture, and radiation exposure from DXA for measurement of bone density and
HR-pQCT for measurement of volumetric density and microarchitectural parameters.
E.11.a. Loss of confidentiality: due to breaches in data security or deductive disclosure. To ensure that
participants’ confidentiality is not compromised. To minimize these risks, only investigators and the study
research staff will have access to the data. All data are recorded with linkages to subject identities to be
able to track changes over their longitudinal participation in the study. A data collection/tracking system
Protocol V9  


22 
based on REDCap, developed for use in previous studies, is used in this research, and will ensure con-
fidentiality for all participants. All collected data will be identified by study identification numbers but not 
names. Only the study investigators will have access to a master list with the study identification numbers 
and names. The master lists for CUIMC, Northwestern and NorthShore will be kept on secure servers on 
their respective research shared access networks. All data containing PHI will be stored on password-
protected encrypted computers or the secure research servers. Computers are password protected, en-
crypted and regularly backed-up to prevent data loss. Paper documents, such as consent forms, will be 
stored in locked cabinets in areas of restricted access. Only the research staff will have access to this 
information, unless written permission is received from the participant or parent/legal guardian as appli-
cable. The data collected as part of this study will be retained indefinitely. All data and records generated 
during this study will be kept confidential in accordance with Institutional policies and HIPAA on subject 
privacy, and the investigators and other site personnel will not use such data and records for any purpose 
other than conducting the study. 
The methods in place for maintaining patient confidentiality will be explained to the subjects during the 
Informed Consent process. This will include registering all data under a subject specific alpha-numeric 
system and storing all records in password protected and encrypted files in the PIs’ office. Participant 
data will be de-identified and entered into a password secured database and will be available only to 
investigators and key personnel directly involved in this research. All electronic data will be analyzed on 
password-protected, encrypted workstations. Only investigators directly involved in this research study 
will have access to subject identities. In addition, such data will be available to the IRB. 
E.11.b. Venipuncture: The risks of venipuncture for blood drawing include pain, bleeding, bruising, in-
fection and inflammation at the site. The risks of venipuncture will be minimized by the use of trained
experienced professional staff to obtain all blood samples.
E.11.c. Radiation: The total expected radiation dose for the entire study will vary depending on whether
the participant is undergoing HR-pQCT scanning in addition to DXA scanning (participants recruited at
CUIMC will under HR-pQCT imaging). The amount of radiation that participants will receive as a result
of participation in the study will be discussed with each participant in detail as part of informed consent
procedures. Females will undergo a urine pregnancy test prior to the DXA, HRpQCT, and study drug
administration. Pregnant females will be excluded from the study at any time point in order to protect the
unborn fetus. Radiation safety approval will be obtained prior to initiating recruitment at all centers as part
of the IRB approval process.
E.11.c.i. Thoracic and Lumbar Spine X-rays: All recruits will undergo spine X-rays to assess for occult
vertebral fractures. T- and L-spine X-rays each deliver 0.3 mSv of total body radiation. Therefore, over
the course of this study, participants will be exposed to 0.6 mSv of total body radiation from spine X-rays.
E.10.c.ii. DXA: Scanning will occur at baseline, 6- and 12-months. A single DXA scan at the spine, hip,
forearm and whole body using the Hologic QDR4500 in fast scan mode is associated with 0.01 mSv of
total body radiation. Therefore, over the course of this study, participants will be exposed to 0.03 mSv of
total body radiation from DXA.
E.11.c.iii. HR-pQCT: Participants enrolled at the CUIMC site will undergo bone quality imaging at the
radius and tibia by HR-pQCT at baseline, 6- and 12-months in addition to DXA. The HR-pQCT scan
region of interest will be at 3-sites: fixed, relative and a cortical bone proximal site. A single HR-pQCT
scan delivers 0.03 mSv of total body radiation. Therefore, over the course of this study, participants will
be exposed to 0.09 mSv of total body radiation from HR-pQCT.
Protocol V9 


23 
Protocol V9  
E.11.c.iv. Total Radiation Exposure for participants at CUIMC: Total body radiation exposure deliv-
ered from spine X-rays, 3 DXA scans, and 3 HR-pQCT scans is 0.72mSv. Compared total body radiation
due to a year’s worth of background radiation (3.1 mSv), 0.72 mSv is approximately equivalent to 85 days
of radiation.
E.11.c.v. Total Radiation Exposure for participants at non-CUIMC sites: Total body radiation
exposure delivered from spine X-rays and 3 DXA scans is 0.63 mSv. Compared total body radiation due
to a year’s worth of background radiation (3.1 mSv), 0.63 mSv is approximately equivalent to 74 days of
radiation.


24 
Protocol V9  
References 
1.
Naylor KL, Jamal SA, Zou G, et al. Fracture Incidence in Adult Kidney Transplant Recipients.
Transplantation 2016;100:167-75.
2.
Nikkel LE, Hollenbeak CS, Fox EJ, Uemura T, Ghahramani N. Risk of fractures after renal
transplantation in the United States. Transplantation 2009;87:1846-51.
3.
Abbott KC, Oglesby RJ, Hypolite IO, et al. Hospitalizations for fractures after renal
transplantation in the United States. Ann Epidemiol 2001;11:450-7.
4.
Shane E, Addesso V, Namerow PB, et al. Alendronate versus calcitriol for the prevention of
bone loss after cardiac transplantation. N Engl J Med 2004;350:767-76.
5.
Bonani M, Frey D, Brockmann J, et al. Effect of Twice-Yearly Denosumab on Prevention of
Bone Mineral Density Loss in De Novo Kidney Transplant Recipients: A Randomized Controlled Trial.
Am J Transplant 2016;16:1882-91.
6.
Bonani M, Meyer U, Frey D, Graf N, Bischoff-Ferrari HA, Wuthrich RP. Effect of Denosumab on
Peripheral Compartmental Bone Density, Microarchitecture and Estimated Bone Strength in De Novo
Kidney Transplant Recipients. Kidney & blood pressure research 2016;41:614-22.
7.
Bonani M, Frey D, de Rougemont O, et al. Infections in de novo kidney transplant recipients
treated with the RANKL inhibitor denosumab. Transplantation 2016.
8.
Ramalho J, Marques IDB, Hans D, et al. The trabecular bone score: Relationships with
trabecular and cortical microarchitecture measured by HR-pQCT and histomorphometry in patients with
chronic kidney disease. Bone 2018;116:215-20.
9.
Agarwal S, Rosete F, Zhang C, et al. In vivo assessment of bone structure and estimated bone
strength by first- and second-generation HR-pQCT. Osteoporos Int 2016;27:2955-66.
10.
Pistoia W, van Rietbergen B, Lochmuller EM, Lill CA, Eckstein F, Ruegsegger P. Estimation of
distal radius failure load with micro-finite element analysis models based on three-dimensional
peripheral quantitative computed tomography images. Bone 2002;30:842-8.
11.
Brunova J, Kratochvilova S, Stepankova J. Osteoporosis Therapy With Denosumab in Organ
Transplant Recipients. Front Endocrinol (Lausanne) 2018;9:162.