Conditions: Diabetes Mellitus, Type 2
Keywords: hyperfiltering Type 2 Diabetes Mellitus
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 72
Healthy volunteers: yes

Brief summary:
The investigators propose to treat newly diagnosed, hyperfiltering T2DM patients with or without microalbuminuria with dapagliflozin or metformin for 4 months. The metformin-treated group will serve as controls for improved glycemic control, since the investigators have shown that insulin therapy to normalize A1c reduces hyperfiltration and kidney size in T1DM patients.

Detailed description:
Hyperfiltration is a characteristic feature in experimental models of diabetes and is causally related to an increase in intraglomerular pressure. In newly diagnosed diabetic patients, both type 1 and type 2, hyperfiltration and enlarged kidney size commonly are observed, and these hemodynamic/anatomic abnormalities are associated with an increased risk for the development of diabetic nephropathy.

In poorly controlled diabetic individuals, the filtered load of glucose is markedly increased and glucose - with sodium - reabsorption by the SGLT2 transporter in the proximal tubule is augmented. As a consequence sodium delivery to the macula densa is reduced, making the kidney think that it is under perfused and this results in afferent renal arteriolar vasodilation. The efferent arteriole of the hyperfiltrating diabetic kidney also is hypersensitive to angiotensin II despite the absence of systemic RAS activation. The net result of these hemodynamic changes is an increase in intraglomerular pressure and hyperfiltration. Further, angiotensin is a potent growth factor and contributes to the increase in size of individual glomeruli and total kidney size. Since the intraglomerular pressure is related to the radius (r3) by the Law of LaPlace, the increase in glomerular size also contributes to hyperfiltration.

Based upon the preceding sequence, it follows that a drug that blocks glucose, along with sodium, reabsorption in the proximal tubule would enhance sodium delivery to the macula densa, cause afferent renal arteriolar constriction, reduce intraglomerular pressure/hyperfiltration, and decrease kidney size. In hyperfiltering diabetic patients with microalbuminuria, the investigators also would expect the microalbuminuria to decrease. Consistent with this scenario, animal studies have documented that both acute and chronic inhibition of SGLT2 decreases hyperfiltration and prevents diabetic nephropathy. A recent study in hyperfiltering type 1 diabetic patients treated with empagliflozin has provided additional support for the tubular glomerular feedback hypothesis.

The investigators propose to treat newly diagnosed, hyperfiltering T2DM patients with or without microalbuminuria with dapagliflozin or metformin for 4 months. The metformin-treated group will serve as controls for improved glycemic control, since the investigators have shown that insulin therapy to normalize A1c reduces hyperfiltration and kidney size in T1DM patients

Arms:
arm 1: Subjects with eGFR above 125 ml/min per 1.73 m2 will be randomized to dapagliflozin, 5 mg/day. After 2 weeks (Visit 5), dapagliflozin will be increased to 10 mg/day, Subjects who are taking Metformin at time of randomization will have Dapagliflozin added to current metformin. arm 2: Subjects who Drug naïve we will give Metformin- XR, 1000 mg/day. After 2 weeks (Visit 5), metformin will be increased to 1000 mg bid (twice a day).Subject who are on metformin at time of randomization we will add Glipizide 5 mg( to be increased to 10 mg at Visit 5), Subject who are on Glipizide at time of randomization will have Metformin- XR, 1000 mg/day added. After 2 weeks (Visit 5), metformin will be increased to 1000 mg bid (twice a day). arm 3: Subjects with eGFR below 124 ml/min per 1.73 m2 will be randomized to dapagliflozin, 5 mg/day. After 2 weeks (Visit 5), dapagliflozin will be increased to 10 mg/day, Subjects who are taking Metformin at time of randomization will have add Dapagliflozin added to current metformin. arm 4: Subjects with eGFR below 124 ml/min per 1.73m2 drug naïve will receive Metformin- XR, 1000 mg/day. After 2 weeks (Visit 5), metformin will be increased to 1000 mg bid (twice a day).Subject who are on metformin at time of randomization we will add Glipizide 5 mg( to be increased to 10 mg at Visit 5), Subject who are on Glipizide at time of randomization we will add Metformin- XR, 1000 mg/day. After 2 weeks (Visit 5), metformin will be increased to 1000 mg bid (twice a day).

Interventions: intervention 1: Dapagliflozin intervention 2: Metformin intervention 3: Glipizide 5 MG
Intervention descriptions: intervention 1: SGLT2 inhibitor intervention 2: Oral diabetes medicine that helps control blood sugar levels. intervention 3: Oral diabetes medicine that helps control blood sugar levels.

Protocol document:
Prot_SAP_000.pdf: 
16-262H, Cersosimo, Protocol, 03-05-21, AMD.docx 
 
1 
Official Study Title: EFFECT OF FARXIGA ON RENAL FUNCTION AND SIZE IN TYPE 
2 DIABETIC PATIENTS WITH HYPERFILTRATION 
 
 
NCT number: NCT02911792 
 
IRB Approval Date: 03.05.2021 
 
 
Unique Protocol ID: HSC20160262H 
 
 
 
 
 
 
 
 
 
 


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2 
EFFECT OF FARXIGA ON RENAL FUNCTION AND SIZE IN TYPE 2 DIABETIC PATIENTS 
WITH HYPERFILTRATION 
 
INTRODUCTION 
 
 
Hyperfiltration is a characteristic feature in experimental models of diabetes and is 
causally related to an increase in intraglomerular pressure (1-3).  In newly diagnosed diabetic 
patients, both type 1 and type 2, hyperfiltration and enlarged kidney size commonly are 
observed (4-7), and these hemodynamic/anatomic abnormalities are associated with an 
increased risk for the development of diabetic nephropathy (4-6). 
 
In poorly controlled diabetic individuals, the filtered load of glucose is markedly 
increased and glucose – with sodium – reabsorption by the SGLT2 transporter in the proximal 
tubule is augmented (8-10).  As a consequence sodium delivery to the macula densa is reduced 
(9,10), making the kidney think that it is under perfused and this results in afferent renal 
arteriolar vasodilation (11).  The efferent arteriole of the hyperfiltrating diabetic kidney also is 
hypersensitive to angiotensin II despite the absence of systemic RAS activation (12,14).  The 
net result of these hemodynamic changes is an increase in intraglomerular pressure and 
hyperfiltration.  Further, angiotensin is a potent growth factor (13,14) and contributes to the 
increase in size of individual glomeruli and total kidney size (15,16).  Since the intraglomerular 
pressure is related to the radius (r3) by the Law of LaPlace, the increase in glomerular size also 
contributes to hyperfiltration (13,14). 
 
Based upon the preceding sequence, it follows that a drug that blocks glucose, along 
with sodium, reabsorption in the proximal tubule would enhance sodium delivery to the macula 
densa, cause afferent renal arteriolar constriction, reduce intraglomerular 
pressure/hyperfiltration, and decrease kidney size.  In hyperfiltering diabetic patients with 


16-262H, Cersosimo, Protocol, 03-05-21, AMD.docx 
 
3 
microalbuminuria, we also would expect the microalbuminuria to decrease.  Consistent with this 
scenario, animal studies have documented that both acute and chronic inhibition of SGLT2 
decreases hyperfiltration (16-18) and prevents diabetic nephropathy (19).  A recent study in 
hyperfiltering type 1 diabetic patients treated with empagliflozin has provided additional support 
for the tubular glomerular feedback hypothesis (11). 
 
We propose to treat newly diagnosed, hyperfiltering T2DM patients with or without 
microalbuminuria with Farxiga or metformin for 4 months.  The metformin-treated group will 
serve as controls for improved glycemic control, since we have shown that insulin therapy to 
normalize A1c reduces hyperfiltration and kidney size in T1DM patients (7). 
EXPERIMENTAL DESIGN 
 
Subjects:  T2D patients who are: (i) drug naïve, (ii) receiving metformin only, (iii) 
sulfonylurea only;  40 newly diagnosed, drug naïve or on monotherapy (only Metformin or 
Sulfonylurea), hyperfiltering patients with type 2 diabetes mellitus (T2DM) and 40 newly 
diagnosed, drug naive  or on monotherapy (only Metformin or Sulfonylurea) T2DM patients with 
normofiltration will participate in the study. Hyperfiltration is defined by GFR ≥ 135 
ml/min•1.73m2 and normofiltration by a GFR = 80-134 ml/min•1.73m2.  Other inclusion criteria 
include:  (i) age = 30-70 years; (ii) BMI = 20-45 kg/m2; (iii)  A1c = 7.0% to 12%; (iv) male or 
female; (v) willingness to participate in the 16 week study protocol; (vi) hematocrit ≥ 34%; (vii) 
GAD antibody negative; (viii) BP < 145/90 mmHg.  Exclusion criteria include:  (i) > 300 mg/day 
albumin excretion; (ii) ingestion of medications known to interfere with the renin-angiotensin 
system or renal function, including diuretic therapy; (iii) hospitalization for unstable angina, 
history of recent macrovascular (MI/stroke/TIA/ACS) disease, coronary artery revascularization 
(within 2 months prior to enrollment); (iv) proliferative diabetic retinopathy; (v) history of cancer 
or major organ system disease; (vi) New York Heart class II-IV heart failure; (vii) severe hepatic 
insufficiency and/or significant abnormal liver function defined as aspartate aminotransferase 


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4 
(AST) and/or alanine aminotransferase  (ALT) > 3x ULN or total bilirubin > 2.0 mg/dL (34.2 
µmo/L); (viii) treatment with steroids, beta blockers, alpha blockers, antiobesity drugs; (ix) 
pregnant or nursing mothers; (x) premenopausal females who are not practicing acceptable 
contraceptive methods; (xi) participation in another trial with an investigational drug within 30 
days; (xii) alcohol or drug abuse within the preceding 6 months; (xiii) any condition, psychiatric 
or medical, which in the opinion of the investigator would interfere with the successful 
completion of the study; (xiv) orthostatic hypotension (≥ 15/10 mmHg decrease upon standing 
for 3 minutes); (xv) positive serologic evidence of current infectious liver disease including 
Hepatitis B viral antibody IGM, Hepatitis B surface antigen, Hepatitis C virus antibody and HIV; 
(xvi) volume depleted patients; (xvii) estimated glomerular filtration rate <60 mL/min•1.73m2.  
Patients at risk for volume depletion due to co-existing conditions or concomitant medications, 
such as loop diuretics should have careful monitoring of their volume status.. 
Study Protocol 
 
Subjects will have a screening visit to determine eligibility (Visit #1).  Prior to or on the 
day of the screening visit subjects will give their informed, voluntary written consent.  During the 
screening visit, medical history will be taken and physical exam, including weight and height, will 
be performed.  Fasting blood samples will be obtained for routine blood chemistries, CBC, TSH, 
T4, HbA1c, FPG, , and lipid profile.  Urinalysis, urine albumin/creatinine ratio, two 8.5 ml of 
blood in ACD tubes to assess mitochondrial functions and EKG also will be obtained.  The study 
protocol will be explained to the subject and informed written consent will be obtained.  If the 
subject wishes, he/she will be allowed to take the consent form home to review before signing, 
as well as complete some of the tests on different days. 
 
Eligible subjects will be asked to collect two 24 hour urines (Visits #2 and #3) for 
determination of albumin, glucose, sodium, and creatinine excretion. On visit 2, we will draw 17 
ml of blood in two ACD tubes to assess mitochondrial functions.  On the same day, the two 24 


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5 
hour urines are collected, plasma creatinine, sodium, and albumin concentrations will be 
measured. 
 
Within 1-2 weeks, subjects will return to the CRC at 7 AM following an overnight fast 
(after 9-10 PM) for measurement of renal function (Visit #4) and indirect calorimetry. At 7 AM a 
catheter is inserted into an antecubital vein and priming doses of inulin (40 mg/kg) and/or iohexol 
(0.165 X Weight in kg) and para-aminohippurate (8 mg/kg) are given, followed by continuous 
infusions to maintain plasma concentrations of inulin, iohexol and PAH constant at 20 mg/dl, 
100umol/L, and 1.5 mg/dl, respectively. (We have decided to substitute Iohexol for Inulin to assess 
glomerular filtration rate in this study because the product Inulin is no longer commercially available in 
the market.  Since Inulin cannot be obtained for the purpose originally stated in the study protocol, we 
have opted to use Iohexol, a compound that determines glomerular filtration rate just as accurately and 
with the same precision as Inulin). A second catheter will be placed in the contralateral antecubital 
vein or in a hand vein for withdrawal of blood samples. During the infusion, the subject’s hand 
will be placed in a box heated to 70°C (158°F). Subjects also will ingest a water load (10-15 
ml/kg ideal body weight) to ensure spontaneous voiding.  Each voided urine will be replaced 
quantitatively to maintain the water diuresis.  After a 90 minute equilibration period for PAH, 
iohexol, and inulin, subjects will be asked to void and the voided urine will be discarded.  Three 
consecutive urine clearance periods of 30-60 minutes duration will be obtained by spontaneous 
voiding and plasma inulin, iohexol and PAH concentrations and hematocrit will be measured at 
the beginning and end of each clearance period.  Indirect calorimetry will be performed for 45 
minutes (30-75 minutes). Mean arterial blood pressure and heart rate will be continuously 
monitored by an automated sphygmomanometer over the brachial artery (DINAMAP).  At time 
zero, blood samples will be drawn for HbA1c, FPG, and plasma renin, angiotensin II, 
aldosterone, FFA , ketones, and NT-pro BNP and 17 ml of blood in two ACD tubes to assess 
mitochondrial functions, as well as 20 ml of urine.  At the end of the study another blood sample 
will be drawn for FPG, and plasma renin, angiotensin II, aldosterone, FFA , ketones, and NT-pro 
BNP . Renal size will be measured by magnetic resonance imaging (20). 
 
Following completion of the above studies, subjects who are (i) drug naïve will be 
randomized to dapagliflozin, 5 mg/day, or metformin-XR, 1000 mg/day.  Subjects taking (ii) 
metformin, will be randomized to dapagliflozin 5 mg/day or glipizide 5 mg/day.  Subjects taking 
(iii) sulfonylurea, will be randomized to dapagliflozin 5 mg/day or metformin-XR, 1000 mg/day.  If 
subjects are on metformin or on a sulfonylurea, the therapy, i.e. metformin or sulfonylurea 
(including the current dose), will be continued without change.  This is an open label study.  
After 2 weeks (Visit 5), dapagliflozin will be increased to 10 mg/day and metformin-XR to 1000 
mg bid; and subjects on glipizide will be increased to 10 mg. Subjects will return for follow up 


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6 
visits at months 1, 2, and 3 (Visits 6, 7, 8).   After 4 months two 24 hour urine collections for 
albumin, sodium, glucose, and creatinine on visit 9 we also collect 17 ml of blood in two ACD 
tubes as well as 20 ml of urine to assess the mitochondrial functions. (Visits #9 and #10) will be 
obtained and the measurement of kidney size (visit #11) and renal blood flow GFR (Visit #12) 
will be repeated as described above. Subjects will be called every two weeks to ensure 
compliance with the medication and they will return to the CRC every 4 weeks (Visits #6, #7, 
and #8) during which time weight, blood pressure, FPG, and HbA1c will be measured and 17 ml 
of blood in two ACD tubes as well as 20 ml of urine to assess the mitochondrial functions.  At 
study end, i.e. 4 months, HbA1c, FPG and plasma renin, angiotensin II, aldosterone, FFA , 
ketones, and NT-pro BNP will be measured.  
The treatment period could be extended based upon the circumstances (based upon the situation of 
COVID-19 pandemic) until the repeat studies are completed. 
 
Measurements:  Renal plasma flow (RPF) = PAH infusion rate ÷ plasma PAH 
concentration.  Renal blood flow (RBF) = RPF/(1-hct).  GFR = (UIN V)/PIN, Filtration fraction = 
GFR/RPF.  GFR also equals inulin and/or iohexol infusion rate ÷ plasma inulin and/or iohexol 
concentration.  Renal vascular resistance (RVR) = mean arterial pressure ÷ RBF.  Kidney size is 
measured by MRI (20).  All renal hemodynamic measurements will be expressed per body 
surface area (m2).  Plasma renin, angiotensin II, aldosterone, and N-terminal fragment of B-type 
natriuretic peptide (NT-pro BNP) will be measured by MRI (20). 
Statistical Analyses & Expected Results 
 
Based upon the randomization criteria, there will be four groups of type 2 diabetic 
subjects:  hyperfiltering (GFR ≥ 135 ml/min•1.73m2) (GROUP I) and normofiltering (GFR < 135 
ml/min•1.73m2) (GROUP II) treated with dapagliflozin and hyperfiltering (GROUP III) and 
normofiltering (GROUP IV) diabetic subjects treated with metformin and or a sulfonylurea. 


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7 
Metformin and sulfonylurea-treated subjects will serve as the control group for improved 
glycemic control. 
 
The primary endpoint is the change from baseline in GFR after treatment with 
dapagliflozin for 4 months in the hyperfiltering diabetic group (GROUP I) versus the change 
from baseline in GRF after treatment with metformin for 4 months in the hyperfiltering diabetic 
group (GROUP III).  We expect that dapagliflozin will significantly reduce hyperfiltration 
compared to baseline and compared to the hyperfiltering diabetic group treated with metformin 
and/or sulfonylurea .  We expect that metformin will have no effect or only a modest effect to 
reduce hyperfiltration (GROUP III).  The change from baseline in GFR in the normofiltering 
group  following 4 months of treatment with dapagliflozin (GROUP II) also will be examined and 
compared to the change from baseline in GFR in the hyperfiltering group treated with 
dapagliflozin (GROUP I).  We anticipate that dapagliflozin treatment for 4 months will cause a 
significant decline in GFR in the hyperfiltering group (GROUP I) but will have no effect on GFR 
in the normofiltering group (GROUP II) treated with dapagliflozin. 
 
Secondary endpoints include changes in renal plasma flow, renal blood flow, renal 
vascular resistance, and kidney size.  In the hyperfiltering diabetic group (GROUP I) treated with 
dapagliflozin we expect that RPF and RBF will decrease and RVR will rise significantly 
compared to the hyperfiltering group treated with metformin (GROUP III).  We also expect that 
kidney size will decrease significantly in the hyperfiltering group treated with dapagliflozin 
(GROUP I) versus the hyperfiltering group treated with metformin (GROUP III).  In the 
normofiltering group (GROUP II) treated with dapagliflozin, we do not expect to observe any 
significant changes in RPF, RBF, RVR, or kidney size. 
 
Tertiary (exploratory) endpoints include changes in blood pressure, body weight, 
extracellular fluid volume (inulin space of distribution), plasma renin activity, plasma angiotensin 


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8 
II, plasma aldosterone, and plasma NT-pro BNP in the 4 treatment groups.  We expect that 
blood pressure and body weight will decrease similarly in hyperfiltering (GROUP I) and 
normofiltering (GROUP II) diabetic patients treated with dapagliflozin.  Further, we anticipate 
that plasma renin, angiotensin II, and aldosterone levels will increase similarly following 
dapagliflozin treatment in both GROUPS I and II secondary to the mild intravascular volume.   
 
We expect that urinary albumin excretion (UAE), whether normoalbuminuria or 
microabluminuria, will decline in the hyperfiltering group treated with dapagliflozin (GROUP I) 
and remain unchanged in the normofiltering group treated with dapagliflozin (GROUP II). 
 
We anticipate that the HbA1c will decline similarly following dapagliflozin treatment in 
GROUP I and GROUP II. 
 
As a control for glycemic control, hyperfiltering (GROUP III) and normofiltering (GROUP 
IV) diabetic subjects will be treated with metformin for 4 months.  We expect that the decrease 
in HbA1c will be similar in metformin-treated (GROUPS III and IV) and dapagliflozin-treated 
(GROUPS I and II) groups.  Despite the similar reduction in HbA1c in metformin-treated and 
dapagliflozin-treated subjects, we do not expect that metformin treatment (in GROUP III and 
GROUP IV) will have any effect on RBF, RPF, RVR, kidney size, plasma renin/angiotensin 
II/aldosterone levels, NT-pro BNP, or urinary albumin excretion. 
 
SAMPLE SIZE CALCULATIONS: 
 
The sample size was calculated to evaluate the primary endpoint (change in GFR from 
baseline) between the hyperfiltering group treated with dapagliflozin (GROUP I) and the 
hyperfiltering group treated with metformin (GROUP III).  Assuming that dapagliflozin reduces 
the GRF by -33±24 ml/min•1.73m2 (172±23 to 139±25) and metformin has no significant effect 
on GRF (0±13; 117±11 to 117±15) (11), we calculated that a sample size of 18 per group would 
provide 90% power at alpha = 0.01 to detect a mean GFR difference from baseline of 33 


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9 
ml/min•1.73m2 in the dapagliflozin-treated versus metformin-treated groups (GROUP I versus 
GROUP III).  The sample size (n =18) would have similar power to detect a mean GFR 
difference from baseline of 33 ml/min•1.73m2 between the dapagliflozin-treated hyperfiltering 
group (GROUP I) versus the dapagliflozin-treated nonhyperfiltering group (GROUP II) [PASS 
Version 11, NCSS Kaysville Utah 2011].  To accommodate 10% loss to follow-up we will enroll 
20 (=18/0.9) subjects per group x 4 groups = 80 subjects. 
Based upon published data (11), we anticipate that a sample size of 18 also will be sufficient to 
provide significant within and between group differences for changes in RBF, RPF, and RVR 
between the dapagliflozin-treated hyperfiltering group (GROUP I) and the metformin-treated 
hyperfiltering group (GROUP III). 
STATISTICAL METHODS:  Continuously distributed outcomes will be summarized with the 
sample size, mean, standard deviation, median, minimum and maximum and categorical 
outcomes will be summarized with frequencies and percentages.  The significance of treatment 
group contrasts with respect to mean changes in GFR will be assessed with analyses of 
variance on changes from baseline with a Tukey correction for multiple comparisons.  Changes 
in renal plasma flow, renal blood flow, renal vascular resistance, and kidney size will be 
analyzed similarly. Within group assessments of the significance of changes in the mean from 
baseline will be carried out with paired t-tests. The significance of group contrasts on binary and 
categorical outcomes will be assessed with Fisher’s exact test; assessments of within-group 
changes from baseline will be carried with McNemar’s test.  If safety data are available, 
treatment groups will be contrasted with regard to the occurrence of adverse events with 
Fisher’s Exact test.  Continuously distributed outcomes may be log transformed to approximate 
normality prior to analysis.  All statistical testing will be two-sided with a nominal significance 
level of 5%.  SAS Version 9.3 and R will be used throughout.  Formatted tables and graphics 
will be prepared in Microsoft Word directly from the database using a series of SAS and R 


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10 
scripts.  All code, databases, and output will be delivered to the sponsor at the conclusion of the 
study.  
RESCUE THERAPY:  Only newly diagnosed, drug naïve  or on monotherapy (metformin or 
sulfonylurea) type 2 diabetic subjects with a HbA1c = 7.5-12.0% will be eligible.  Therefore, we 
anticipate that these individuals will have a good response to both dapagliflozin, metformin, and 
glipizide therapy.  If after 2 months the fasting plasma glucose concentration remains above 170 
mg/dl, the subject will be discontinued from the study and started on an antidiabetic regimen as 
deemed appropriate by the primary care physician.  All subjects who are discontinued will be 
replaced. 
Safety: The Principal Investigator is responsible for ensuring that all staff involved in the study 
is familiar with the content of this section and is properly trained. 
 
Definition of adverse events: An adverse event is the development of an undesirable 
medical condition or the deterioration of a pre-existing medical condition following or during 
exposure to a pharmaceutical product, whether or not considered causally related to the 
product.  An undesirable medical condition can be symptoms (e.g., nausea, chest pain), signs 
(eg, tachycardia, enlarged liver) or the abnormal results of an investigation (eg, laboratory 
findings, electrocardiogram).  In clinical studies, an adverse event can include an undesirable 
medical condition occurring at any time, including run-in or washout periods, even if no study 
treatment has been administered. The term adverse event is used to include both serious and 
non-serious adverse events. If a participant becomes pregnant, she will be asked to stop all 
study medication and sign the pregnancy consent form.  While being asked to sign the form, 
she will be taking part in the follow-up, her personal information related only to her pregnancy 
and outcome will be collected and reviewed to better understand the effects of dapagliflozin 
(Farxiga) on her pregnancy and the fetus/child. 


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11 
 
Definitions of serious adverse event: A serious adverse event is an AE occurring 
during any study phase (i.e., run-in, treatment, washout, follow-up), that fulfills one or more of 
the following criteria: 
• 
Results in death 
• 
Is immediately life-threatening 
• 
Requires in-patient hospitalization or prolongation of existing hospitalization  
• 
Results in persistent or significant disability/incapacity or substantial disruption of the 
ability to conduct normal life functions 
• 
Is a congenital abnormality or birth defect 
• 
Is an important medical event that may jeopardize the subject or may require medical 
intervention to prevent one of the outcomes listed above 
The causality of serious adverse events (their relationship to all study treatment/procedures) will 
be assessed by the investigator(s) and communicated to AstraZeneca and the Institutional 
Review Board. 
Recording of adverse events 
 
Time period for collection of adverse events: It is the responsibility of the investigator 
to perform periodic and special assessments for adverse events.  All adverse events will be 
summarized and reported annually to the Institutional Review Board.  The investigator and 
research staff will note all AEs offered by the subject after administration of either glipizide, 
metformin and/or dapagliflozin or placebo.  All clinical complaints volunteered by, or elicited 
from, the subject during the study will be recorded in the appropriate section of the case report 
form for the study period indicated.  AEs may include events that occur as a result of protocol-


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12 
mandated procedures (e.g., events due to invasive procedures).  If any AE occurs, the subject 
will receive appropriate treatment and medical supervision and will be followed until the AE is 
stabilized or to a point where it is no longer clinically significant.  As previously noted, all medical 
conditions and abnormal findings present before administration of the first dose of glipizide, 
metformin or dapagliflozin or placebo will be recorded as concurrent illnesses or baseline 
symptoms. 
 
Follow-up of unresolved adverse events: All AEs judged to be clinically significant, 
including clinically significant laboratory abnormalities, will be followed until resolution. The 
following variables will be collected for each AE: 
• 
AE (verbatim) 
• 
The date and time when the AE started and stopped 
• 
Whether the AE is serious or not (that is, the intensity – mild, moderate or severe) 
• 
Investigator causality rating against the Investigational Product or procedures 
(unlikely, possibly, probably, definitely) 
• 
Action taken with regard to investigational product/procedure 
• 
Adverse event caused subject’s withdrawal from study (yes or no) 
• 
Outcome (recovered, recovering, ongoing, fatal – see SAE). 
In addition, the following variables will be collected for serious adverse events: 
• 
Date AE met criteria for serious AE 
• 
Date Investigator became aware of serious AE 
• 
AE is serious due to: 


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13 
• 
Date of hospitalization 
• 
Date of discharge 
• 
Probable cause of death 
• 
Date of death 
• 
Autopsy performed 
• 
Causality assessment in relation to study procedure(s) 
• 
Causality assessment in relation to other medication 
• 
Causality assessment in relation to additional study drug 
• 
Description of AE. 
• 
Date reported to IRB 
It is important to distinguish between serious and severe AEs.  Severity is a measure of intensity 
whereas seriousness is defined by the criteria in the section titled: “Definitions of Serious 
Adverse Events”.  An AE of severe intensity need not necessarily be considered serious.  For 
example, nausea that persists for several hours may be considered severe nausea, but not a 
SAE. On the other hand, a stroke that results in only a limited degree of disability may be 
considered a mild stroke but would be a SAE. 
 
Adverse Events based on signs and symptoms: When collecting AEs, the recording 
of diagnoses is preferred (when possible) to recording a list of signs and symptoms.  However, if 


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14 
a diagnosis is known and there are other signs or symptoms that are not generally part of the 
diagnosis, the diagnosis and each sign or symptom will be recorded separately. 
 
Adverse Events based on examinations and tests: Deterioration as compared to 
baseline in protocol-mandated glucose values and/or blood pressure values should therefore 
only be reported as AEs if they fulfill any of the SAE criteria or are the reason for discontinuation 
of treatment with the investigational product. 
If deterioration in glucose concentration and/or blood pressure is associated with 
clinical signs and symptoms, the sign or symptom will be reported as an AE and the 
associated laboratory result/vital sign will be considered as additional information.  
Wherever possible the reporting investigator uses the clinical, rather than the 
laboratory term (eg, anemia versus low hemoglobin value). In the absence of 
clinical signs or symptoms, clinically relevant deteriorations in non-mandated 
parameters should be reported as AE(s). 
Any new or aggravated clinically relevant abnormal medical finding at a physical examination as 
compared with the baseline assessment will be reported as an AE. 
 
Reporting of serious adverse events:  
All SAEs have to be reported, whether or not considered causally related to the IP, or to the 
study procedure(s).  All SAEs will be recorded in the source document and reported annually to 
the UTHSCSA IRB during continuing review.   
Serious adverse events that do not require expedited reporting to the FDA need to be reported 
to AstraZeneca at least quarterly preferably using the MedDRA coding language for serious 
adverse events. 


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Investigator will review all SAEs and determine whether the reviewed incident, experience, and 
outcome represents a possible UPIRSO (Unanticipated Problem Involving Risk To Subjects Or 
Others). All possible UPIRSOs will be reported to the UTHSCSA IRB using the Prompt 
Reporting Form.  
a) 
Prompt reporting timeframe - report is made to the IRB within 7 days for UPIRSOs 
based on internal information (e.g., experienced by subjects enrolled by the investigator(s) at an 
institution affiliated with the UTHSCSA IRB) or 14 days for UPIRSOs based on external 
information (e.g., experienced by subjects enrolled by the investigator(s) at an institution not 
affiliated with the UTHSCSA IRB) 
b) 
Special shortened reporting timeframe: All UPIRSOs based on internal information that 
are either life threatening or fatal events must be reported within 48 hours. 
Investigators and other site personnel must inform the FDA, via a MedWatch/AdEERs form, of 
any serious or unexpected adverse events that occur in accordance with the reporting 
obligations of 21 CFR 312.32, and will concurrently forward all such reports to AstraZeneca.  A 
copy of the MedWatch/AdEERs report must be faxed to AstraZeneca at the time the event is 
reported to the FDA.  It is the responsibility of the investigator to compile all necessary 
information and ensure that the FDA receives a report according to the FDA reporting 
requirement timelines and to ensure that these reports are also submitted to AstraZeneca at the 
same time. 
When reporting to AstraZeneca, a cover page should accompany the MedWatch/AdEERs form 
indicating the following: 
• 
Investigator Sponsored Study (ISS) 
• 
The investigator IND number assigned by the FDA 


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• 
The investigator’s name and address 
• 
The trial name/title and AstraZeneca ISS reference number 
Investigative site must also indicate, either in the SAE report or the cover page, the causality of 
events in relation to all study medications and if the SAE is related to disease progression, as 
determined by the principal investigator. 
Send SAE report and accompanying cover page by way of fax to AstraZeneca’s designated fax 
line: 1-866-984-7229 or email to AEMailboxClinicalTrialTCS@astrazeneca.com 
Serious adverse events that do not require expedited reporting to the FDA need to be reported 
to AstraZeneca preferably using the MedDRA coding language for serious adverse events.   
In the case of blinded trials, AstraZeneca will request that the Sponsor either provide a copy of 
the randomization code/ code break information or unblind those SAEs which require expedited 
reporting. 
All SAEs have to be reported to AstraZeneca, whether or not considered causally related to the 
investigational product.  All SAEs will be documented.  The investigator is responsible for 
informing the IRB and/or the regulatory authority (FDA) of the SAE as per local requirements. 
For fatal or life-threatening AEs where important or relevant information is missing, active follow-
up is undertaken immediately.  The investigators or other site personnel will inform the 
UTHSCSA IRB of any follow-up information on a previously reported UPIRSO within 2 calendar 
days i.e., immediately but no later than 48 hours of when he or she becomes aware of it. 
SAFETY MONITORING BOARD 
Two independent physician-scientists associated with the UTHSCSA (Dr.Deivjit Tripathy and Dr. 
Nicholas Musi) will comprise the safety monitoring board for this study.  They will meet every 6 


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17 
months and review the adverse events and all potential risks arising from the study, study drugs 
and procedures.  They will report to the Principal Investigator any and all findings deemed 
serious and, which would require a protocol revision or study termination.  As necessary, a 
specific report also will be forwarded to the UT-IRB and to all sites involved in the study.   
INVESTIGATORS/SITES 
(1) 
Ralph A. DeFronzo, MD and Muhammad Abdul-Ghani, Ph.D., M.D. 
University of Texas Health Science Center 
San Antonio, Texas 
 
 
 


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REFERENCES 
 
1.  
Hostetter TH, Rennke HG, Brenner BM. The case for intrarenal hypertension in the 
initiation and progression of diabetic and other glomerulopathies. Am J Med 72:375-380, 
1982. 
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Hostetter TH, Troy JL, Brenner BM. Glomerular hemodynamics in experimental diabetes 
mellitus. Kidney Int 19:410-415, 1981. 
3.  
Brenner BM, Hostetter TH, Olson JL, Rennke HG, Venkatachalam MA. The role of 
glomerular hyperfiltration in the initiation and progression of diabetic nephropathy. Acta 
endocrinologica Supplementum 242:7-10, 1981. 
4.  
Ruggenenti P, Porrini EL, Gaspari F, Motterlini N, Cannata A, Carrara F, Cella C, Ferrari 
S, Stucchi N, Parvanova A, Iliev I, Dodesini AR, Trevisan R, Bossi A, Zaletel J, Remuzzi 
G, Investigators GFRS. Glomerular hyperfiltration and renal disease progression in type 
2 diabetes. Diabetes Care 35:2061-2068, 2012. 
5.  
Jerums G, Premaratne E, Panagiotopoulos S, MacIsaac RJ. The clinical significance of 
hyperfiltration in diabetes. Diabetologia 53:2093-2104, 2010. 
6.  
Magee GM, Bilous RW, Cardwell CR, Hunter SJ, Kee F, Fogarty DG.  Is hyperfiltration 
associated with the future risk of developing diabetic nephropathy? A meta-analysis. 
Diabetologia 52:691-697, 2009. 
7. 
Tuttle  KR, Bruton JL, Perusek MC, Lancaster JL, Koptt DT, DeFronzo RA.  Effect of 
strict glycemic control on renal hemodynamic response to amino acids and renal 
enlargement in insulin-dependent diabetes mellitus. NEJM 324:1626-32, 1991. 
8. 
Abdul-Ghani MA, Norton L, DeFronzo RA.  Role of sodium-glucose cotransporter 2 
(SGLT2) inhibitors in the treatment of type 2 diabetes.  Endocr Rev 32:515-531, 2011. 


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9. 
Stanton RC. Sodium glucose transport 2 (SGLT2) inhibition decreases glomerular 
hyperfiltration:  is there a role for SGLT2 inhibitors in diabetic kidney disease?  
Circulation 129:542-544, 2014. 
10.  
Vallon V, Richter K, Blantz RC, Thomson S, Osswald H.  Glomerular hyperfiltration in 
experimental diabetes mellitus: Potential role of tubular reabsorption. J Am Soc Nephrol 
10:2569-2576, 1999. 
11. 
Cherney  DZ, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, Faagan NM, Woerle 
HJ, Johansen OE, Broedl UC, von Eynatten M.  Renal hemodynamic effect of sodium-
glucose cotransporter 2 inhibition in patients with type 2 diabetes mellitus. Circulation 
129:587-97, 2014. 
12. 
Zatz R, Dunn BR, Meyer TW, Anderson S, Rennke HG, Brenner BM.  Prevention of 
diabetic glomerulopathy by pharmacological amelioration of glomerular capillary 
hypertension.  J Clin Invest 77:1925-1930, 1986. 
13. 
Taal MW, Brenner BM.  Renoprotective benefits of RAS inhibition:  from ACEI to 
angiotensin II antagonists.  Kidney Int 57:1803-1817, 2000. 
14. 
Anderson S, Vora JP.  Current concepts of renal hemodynamics in diabetes.  J Diab 
Complications 9:304-307, 1995. 
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Ellis EN, Steffes MW, Goetz FC, Sutherland DER, Mauer SM.  Glomerular filtration 
surface in type I diabetes mellitus.  Kidney Int 29:889-94, 1986. 
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Schwieger J, Fine LG.  Renal hypertrophy, growth factors, and nephropathy in diabetes 
mellitus.  N Engl J Med 312:617-21, 1985. 
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Malatiali S, Francis I, Barac-Nieto M.  Phlorizin Prevents Glomerular Hyperfiltration but 
not Hypertrophy in Diabetic Rats. Exp Diabetes Res 2008;2008:305403. 
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Thomson SC, Rieg T, Miracle C, Mansoury H, Whaley J, Vallon V, Singh P.  Acute and 
chronic effects of SGLT2 blockade on glomerular and tubular function in the early 
diabetic rat. Am J Physiol-Reg Integr Comp Physiol 302:R75-R83, 2012. 


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19. 
Pei F, Li B, Zhang Z,Yu F, Li X, Lu W, Cai Q, Gao H, Shen L.  Beneficial effects of 
phlorizin on diabetic nephropathy in diabetic db/db mice.  J Diab Comp 28:596-603, 
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Bakker J, Olree M, Kaatee R, de Lange EE, Moons KGM, Beutler JJ, Beek FJA.  Renal 
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Aim:  
To explore the changes in mitochondrial function from baseline as a prominent pathway in the dynamics 
of glomerular filtration rate in hyperfiltrating groups (Group I and Group III). 
Justification:  
Mitochondria are multivariate signal processors which convert macromolecular energy sources into a 
chemical and physical energies ATP and heat respectively. Aberrations of mitochondrial function could 
be resulting in type 2 diabetes. Since mitochondria are dynamic organelles and exist as heterogeneity in 
human tissues, the phenotypic spectrum of mitochondrial disorders can present either in infancy or 
adulthood, and in multisystemic or highly tissue-specific manner. Although several signature traits 
appear in patients, the functional assessment of mitochondria in normal and disease states are huge 
challenges for medical treatments. Our ability to define the genetic and environmental bases of these 
disorders has accelerated and new questions have arisen. Why are some diseases highly tissue-specific, 
and other multisystemic? We are all puzzled now why some drugs that inhibit mitochondria cause 
disease, while other modulators are protective against it? The answers to most of these questions are a 
mystery, but if identified these could provide fundamental insight into metabolism, lead to new 
therapies that are associated with mitochondrial dysfunction.  
Study protocol: 
In the past, we have developed several cutting-edge technologies to assess mitochondrial functional 
changes in normal and disease models in vitro. An exciting new frontier in mitochondrial medicine is 
defining the regulatory mechanisms that give rise to the observed heterogeneity nature of mitochondria 
within cells and tissues. We will be developing tools to better understand the mitochondrial biogenesis, 
movement, dynamics, shape, and quality control. For instance, mitochondrial mass and volume will be 
determined using volume scope (serial block-face scanning electron microscopy).  Our mission is to 
explore cutting-edge optical imaging-based methods to address major questions pertaining to 
mitochondrial signaling and cellular function in situ. To establish the assessment of mitochondrial 
bioenergetics parameters (morphology, membrane potential, NADH, ROS, Redox state, ATP, Ca2+) in 
leukocytes and platelets, we will image mitochondrial dynamics and function using live-confocal 
imaging. Although genetic tools are available to monitor mitochondrial nature in cellular milieu, we will 


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explore and identify the endogenous molecules that holds inherent fluorescent properties like NAD(P)H, 
metabolites, lipids, proteins. To accomplish these tasks, we will acquire intra-vital multiphoton imaging 
system which will have an ability to tune wide-range of visualization capability. The anticipated outcome 
of these approaches will significantly enhance our knowledge on the treatment outcomes and patient 
care. 
Platelets in circulating blood contain certain amounts of fully functional mitochondria, which have been 
used as a valuable tool for mitochondrial function research owing to their easy accessibility compared 
with other metabolically active tissues. The rapid development of understanding in platelet 
mitochondria will provide us a unique way to translate its function into knowledge on human health and 
disease. Future efforts in this direction are highly needed for extending our knowledge to the 
establishment of potential clinical biomarkers as well as precision medicine for diabetic related 
metabolic diseases. Although fewer studies have conducted some mitochondrial functional 
assessments, we are in a better position to assess multiple mitochondrial bioenergetics parameters, 
sensing as well as shape transition during human health style, disease progression, and treatment 
outcomes. Similarly, we will also utilize buffy coat (WBCs) to examine mitochondrial bienergetic 
parameters and mitochondrial DNA copy number and redox changes.