Conditions: Chronic Kidney Diseases
Keywords: Chronic Kidney Disease Intermuscular fat deposition Glucagon-like peptide-1 agonist Insulin resistance Mitochondrial function
Allocation: NA | Intervention model: SEQUENTIAL
Enrollment: 7
Healthy volunteers: no

Brief summary:
Chronic kidney disease (CKD) is a burden of morbidity and mortality. Increased protein breakdown in skeletal muscle (wasting) and ectopic fat deposition are important determinants of poor clinical outcome in patient with CKD. Insulin resistance plays a critical role in skeletal muscle wasting and ectopic fat deposition. Glucagon-like peptide-1 receptor agonists (GLP-1RA) decrease ectopic fat deposition in patients with type 2 diabetes, prediabetes, obese and overweight subjects.

The influence of GLP-1RA on ectopic fat deposition in CKD patients in unknown. The investigators' will test the hypothesis that GLP-1RA decreases intermuscular (ectopic) fat deposition in patients with stage 3-4 CKD. The investigators' will do so by addressing the following specific aims:

Specific Aim 1: To test the hypothesis that GLP-1RA decreases intermuscular fat deposition in patients with stage 3-4 CKD.

Specific Aim 2: To test the hypothesis that GLP-1RA improves skeletal muscle mitochondrial function in patients with stage 3-4 CKD.

Specific Aim 3: To test the hypothesis that GLP-1RA improves physical performance in patients with stage 3-4 CKD.

Specific Aim 4: To test the safety and feasibility of 12 weeks of dulaglutide 1.5 mg/wk administration as an adjunct therapy to the standard care of patients with stage 3-4 CKD.

Detailed description:

Arms:
arm 1: Patient will receive 1.5 mg injections per week for 12 weeks.

Interventions: intervention 1: dulaglutide injection
Intervention descriptions: intervention 1: All participants will undergo a 4-week run-in phase followed by 12 weeks of treatment (dulaglutide 1.5 mg/wk), followed by 4 weeks of follow up after discontinuing the study medication

Protocol document:
Prot_002.pdf: 
Date: 12/2/2024 
1 
 
                                                                                             
 
 
 
 
 
 
 Effects of Glucagon-Like Peptide-1 Agonists on Metabolism and 
Ectopic Fat Deposition in Chronic Kidney Disease: A Pilot and 
Feasibility Study  
 
 
 
 
T. Alp Ikizler, MD, Professor 
Division of Nephrology 
Vanderbilt University Medical Center 
S-3223 Medical Center North 
 
Rengin Elsurer Afsar, MD,  
Professor of Nephrology at  
Suleyman Demirel University, Turkey 
Visiting Scholar in Vanderbilt University Medical Center 
Department of Nephrology 
 
Lale Ertuglu, MD, 
Post Doc Fellow, Ikizler Lab 
Vanderbilt University Medical Center,  
Department of Nephrology 
 
Jorge Gamboa, M.D., Ph.D. 
Research Assistant Professor of Medicine 
Vanderbilt University Medical Center,  
Division of Clinical Pharmacology 
 
 
Katherine N. Bachmann, M.D., MSCI 
Assistant Professor of Medicine 
Vanderbilt University Medical Center,  
Division of Diabetes, Endocrinology, and Metabolism 
 
 
 


Date: 12/2/2024 
2 
 
 
1.0 Specific Aims 
Specific Aim 1: To test the hypothesis that GLP-1RA decreases intermuscular fat 
deposition in patients with stage 3-4 CKD.  
 
Primary Outcome: We will measure intermuscular fat deposition by magnetic resonance 
imaging (MRI) before and after 12 weeks of dulaglutide 1.5 mg/wk. administration in patients 
with stage 3-4 CKD.  
 
Specific Aim 2: To test the safety and feasibility of 12 weeks of dulaglutide 1.5 mg/wk 
administration as an adjunct therapy to the standard care of patients with stage 3-4 CKD. 
 
Safety and tolerability will be evaluated throughout the study by assessment of weight 
change, hypoglycemic episodes, continuous glucose monitoring (only in patients with type 2 
diabetes mellitus), serious adverse events (AE), treatment‐emergent AE, discontinuations 
attributable to AE, laboratory tests, vital signs, 12‐lead electrocardiograms, and 
allergic/hypersensitivity reactions.  
 
2.0 Inclusion/Exclusion Criteria 
We propose to study 10 patients with stage 3-4 CKD.  
Inclusion criteria:  
1. Patients with stage 3-4 CKD (eGFR 15-59 ml/min/1/73 m2)  
2. Age ≥ 18 years and ≤75 years  
Exclusion criteria: 
1. Patients with type 1 diabetes mellitus  
2. Patients with T2D who are on insulin therapy or who started a new antidiabetic medication 
within 1 month prior to study or who received incretin-based therapy within 3 months prior to 
study 
3. BMI <25 kg/m2, BMI >40 kg/m2 
4. HbA1c>8% measured within 1 month prior to study, or a history of hypoglycemic episode 
within 1 year prior to study, or a history of diabetic ketoacidosis  
5. Uncontrolled hypertension (>200/100 mmHg) despite optimal antihypertensive therapy  
6. Arrythmia, heart failure (NYHA class III-IV), valve disease or heart diseases other than 
coronary artery disease 
7. History of major gastrointestinal surgery, inflammatory bowel disease, pancreatitis or 
cholelithiasis 
8. Personal or family history of medullary thyroid cancer, or personal history of Multiple 
Endocrine Neoplasia (MEN)-2 
9. Pregnancy, breast feeding or intention to become pregnant  
10. Previous renal transplantation 
11. Acute or chronic infectious diseases 
12. Cancer or chemotherapy within 3 years prior to study 
13. Treatment with systemic corticosteroids within 3 months prior to study 
14. Known or suspected allergy to dulaglutide 
15. Claustrophobia or other contraindications for MRI 
 
 


Date: 12/2/2024 
3 
 
3.0 Study Enrollment and Design 
 
The study participants will be primarily selected from Vanderbilt’s outpatient clinics and 
the Nashville Veterans Affairs outpatient clinics. The study visits will be conducted at the 
Vanderbilt University Medical Center (VUMC) Department of Nephrology Outpatient Clinic 
and Vanderbilt University Institute of Imaging Science (VUIIS). Institutional review board 
approval and written informed consent will be obtained from all study subjects. Patients 
meeting inclusion-exclusion criteria will be identified by physician investigators and 
coordinators. Patients will be first approached by clinical staff.  Those who express interest will 
be informed about the study by the study personnel. The subjects will be selected based on the 
above inclusion/exclusion criteria.  
 
 
 
 
 
All participants will undergo a 4-week run-in phase followed by 12 weeks of treatment 
(Dulaglutide 1.5 mg/wk), followed by 4 weeks of follow up after discontinuing the study 
medication (Figure 5.1).  
 
6.0 Study Procedures 
 
After recruitment and review of eligibility, patients who gave informed consent will 
undergo the following procedures: 
 
Screening Visit: Patients will have a screening visit 4 weeks prior to the beginning of the 
study intervention to confirm that they meet the inclusion-exclusion criteria. Subjects will be 
presented detailed information regarding the study with an opportunity to discuss the study as 
needed for a complete consent discussion. This visit will include a medical history extracted 
from the patients’ medical records, demographic information, a medication history, HbA1c test 
(for patients with T2D), 12-lead electrocardiogram, vital signs and BMI measurement, urine, 
or blood pregnancy test (for females of childbearing potential) and serum creatinine test to 
confirm eGFR. Since the presence of any metal introduces unnecessary risk for MRI, a 
screening X-ray exam will be performed to confirm the absence of any metal in subjects where 
that is a possibility.  
Visit 1 (Week -4): The purpose of this visit is to determine baseline characteristics of the 
patients enrolled. We will review medical records, obtain dietary and physical activity recalls 


Date: 12/2/2024 
4 
 
and 12-lead electrocardiogram. We will measure baseline vital signs and perform 
anthropometric measurements and scheduled blood and urine laboratory tests. We will calculate 
basal HOMA-IR, QUICKI, ADIPO-IR and LAR. We will perform MRI to assess basal visceral 
and ectopic fat distribution characteristics and 31P MRS to assess basal skeletal muscle 
mitochondrial function. Baseline skeletal muscle endurance will be evaluated by six-minute 
walk test.  
Visit 2 (Week 0): Prior to the first dose of the drug, we will review medical records, 
measure vital signs, perform anthropometric measurements, obtain 12-lead electrocardiogram, 
dietary and physical activity recalls, laboratory tests in blood and urine, six-minute walk test 
and perform MRI and 31P MRS (Table 6.1).  
The first dose of the study drug Dulaglutide (Trulicity®) will be administered while the 
participant is at the Nephrology Outpatient Clinic. Patients will be instructed on administration 
and given information about the instructions for use. Participants will administer dulaglutide 
on a weekly basis. Safety measures and compliance will be assessed for each patient by phone 
calls every two weeks.  
Visit 3 (Week 12): We will perform the same procedures as week 0 at week 12 (Table 
6.1). Study drug administration will be terminated with the last dose given within 7 days before 
Visit 3. 
Visit 4 (Week 16): We will perform the same procedures as week 0 at week 16 (Table 
6.1).   
 
METHODS 
Anthropometric Measurements:  
1. Weight 
2. Height 
3. Waist circumference (measured at the midpoint between the top of the iliac crest and 
the lower margin of the last palpable rib in the mid axillary line (inch)) 
4. Hip circumference (measured at the largest circumference of the buttocks (inch)) 
5. Waist-to-hip ratio (waist circumference (inches)/hip circumference (inches)) 
6. Body mass index will be calculated by the following formula: 
 BMI= weight (kg)/height2 (m2) 
 
 
 
Research Laboratory Measurements: 
 
Subjects will be asked to come to the VUMC Department of Nephrology Outpatient Clinic 
in the morning under fasting conditions for blood and urine sampling. All blood and urine 
sampling will be performed at the VUMC Nephrology Outpatient Clinic. After blood sampling, 
samples for serum creatinine and hemoglobin will be transported at room temperature and all 
other samples will be transported on ice and centrifuged at 3,000 revolutions/min for 15 min 
before being kept frozen at −80°C. The following parameters will be assessed in blood. 
1. Fasting plasma glucose (by glucose oxidase method (Glucose analyzer 2; Beckman 
Coulter, Brea, CA)) 
2. Fasting insulin (by double-antibody radioimmunoassay (MilliporeSigma)) 
3. Fasting free fatty acids (by Methanolic HCl from Supelco (Cat. 3-3051); Measured by 
GC-FID from Agilent) 


Date: 12/2/2024 
5 
 
4. Leptin (by MILLIPEXMAP Human Serum Adiponectin Panel A kit (MilliporeSigma)) 
5. Adiponectin (by MILLIPEXMAP Human Serum Adiponectin Panel A kit 
(MilliporeSigma)) 
6. Creatinine (will be studied in The Vanderbilt Clinic (TVC) Patient Lab) 
7. Hemoglobin (will be studied in TVC Patient Lab) 
8. Albumin (by bromcresol green technique) 
9. High-sensitivity C-reactive protein (by high-sensitivity particle enhanced turbidometric 
Unicel Dxl Immunoassay system (Beckman Coulter)) 
10. Total cholesterol (enzymatically (Cliniqa, San Marcos, CA)) 
11. Triglycerides (enzymatically (Cliniqa, San Marcos, CA)) 
12. HDL-C (enzymatically (Cliniqa, San Marcos, CA) 
 
We will assess the following parameters in spot urine samples. 
1. Protein (will be studied in TVC Patient Lab)  
2. Albumin (Albuwell Hu ELISA kit from Exocell)   
3. Creatinine (Creatinine Companion kit from Ethos Biosciences) 
4. Sodium (IL 943 flame photometer, Instrumentation Laboratory, 180 Hartwell Road, 
Bedford, MA) 
 
Albumin/creatinine ratio (mg/g) and protein/creatinine ratio (mg/g) will be calculated in 
spot urine samples. 
 
eGFR will be calculated by the following formula:    
 
CKD-EPI creatinine equation: eGFR: 141 x min(SCr/κ, 1)α x max(SCr/k, 1)-1.209 x 
0.993Age [x 1.018 if female] [x1.159 if black], where SCr is serum creatinine (in mg/dl), κ is 0.7 
for females and 0.9 for males, α is -0.329 for females and -0.411 for males, min is the minimum 
of SCr/κ or 1, and max is the maximum of SCr/κ or 11.  
 
Systemic and peripheral IR will be calculated by the following formulas:  
HOMA-IR= Fasting plasma glucose (mmol/L)× Fasting insulin (μU/L)/22.5  
QUICKI= 1/[log (Insulin μU/mL) + log (Glucose mg/dL) 2. 
 
Adipose tissue IR will be calculated by the following formula: 
ADIPO-IR= Fasting FFA concentration (mmol/L) x fasting insulin concentration 
(pmol/L) 3.  
 
Individual FFA concentrations of palmitic, oleic, linoleic, linolenic, eicosapentaenoic, 
docosahexaenoic, palmitoleic, palmiteladic, arachidonic, myristic, elaidic and stearic acid will 
be added to calculate total FFA 3. 
 
Adipose tissue dysfunction will be calculated by the following formula:  
LAR: Leptin (ng/ml)/adiponectin (mg/ml) 4.  


Date: 12/2/2024 
6 
 
 
Magnetic Resonance Imaging and Intermuscular Fat (IMAT) Measurements  
On the same day as the VUMC Nephrology Outpatient Clinic Visits, patients will undergo 
MRI to measure VAT and IMAT. Intermuscular fat will be calculated using consecutive cross-
sectional images of the mid-thigh region between the patella and ischial spine. The analysis will 
be performed in all the quadriceps muscle heads using a custom-written Matlab (Mathwworks, 
Natick, MA) program, as previously described 5, 6.  IMAT will be defined as the fat beneath the 
deep fascia of the muscle. IMAT infiltration will be quantified as the ratio between IMAT and 
muscle volumes 6. 
 
31P Magnetic Resonance Spectroscopy 
We will measure in vivo knee extensor’s mitochondrial function using 31P-MRS to obtain 
the phosphocreatine recovery time constant, a measure of mitochondrial function, as we 
described previously 6. During the 2 days prior to testing, we will ask that subjects 1) to perform 
no moderate or heavy intensity exercise within 1 day of testing; 2) not to consume alcohol 
within the 1 day prior to testing; 3) not to consume caffeine or use tobacco within 6 hours prior 
to testing; and 4) not to eat a meal 3-6 hours before testing. Mitochondrial function will be 
evaluated using the non-invasive technique 31P-MRS, which provides the quantification and 
kinetics of phosphocreatine (PCr), other phosphate-energy carrier molecules, and inorganic 
phosphate in limb muscles. Each subject will lie prone for approximately 30 minutes with a coil 
positioned over the belly of the vastus lateralis muscle. The position of the coil will be 
confirmed using scout localizer images and a reference positioned within the center of the coil 
(Figure 6.1.A).  
 
After basal measurements, subjects will be asked to perform cycles of knee extension and 
rest using a research exercise device. Measurements will be recorded during the exercise 
protocol (approximately 90 seconds) and for additional 5 minutes (recovery period). We will 
repeat the exercise and recovery cycle at least two times.  Spectra will be used to evaluate the 
kinetics of PCr. The primary endpoint will be the half-time of PCr recovery (time to achieve 
half of basal concentration during the recovery period). A spectra obtained by the investigators 
is shown in Figure 6.1.B. This method is reliable and reproducible and has been considered the 
“gold standard” to measure mitochondrial function 7, 8.  
 
Six-Minute Walk Test 
On the same day of VUMC Nephrology Outpatient Clinic Visits, we will measure 
physical performance by the six-minute walk test. This test will be performed as previously 


Date: 12/2/2024 
7 
 
described 9, 10. Briefly, patients will be instructed to on a 30-meter corridor at a self-determined 
pace for a total of 6 minutes. Patients will be allowed to rest briefly by leaning against the wall 
or sitting during the test, or to stop prematurely if they are unable to complete the test. There 
will be no practice test, warm up period, or incentive provided for performance. The distance 
in meters will be recorded. Patients will not be encouraged to perform the test, but they will be 
informed about the time remaining. The detailed time schedule of the study procedures is shown 
in Table 6.1.  
 
Study Drug Administration 
Dulaglutide (Trulicity®) will be supplied as a 1.5 mg/0.5 mL single dose pen-injector for 
subcutaneous administration. Drug will be dispensed by the study personnel. Drug will be 
provided to the participant as labelled by the participant’s name at one dispence/monthly. A 
sharps container and injection cleaning supplies will be provided to the participant. Each 
participant will be instructed how to self-administer the study drug.  Patients will be asked to 
administer dulaglutide subcutaneously once weekly, on the same day of the week, independent 
of meals, at any time of the day (but always at the same time of the day in subsequent 
administrations) in abdomen, thigh or upper arm and will be advised to rotate the injection site. 
In T2D patients who are using concomitant insulin secretagogues (i.e., sulfonylurea), the dose 
of the insulin secretagogues will be reduced (i.e., by one-half) to reduce the risk of 
hypoglycemia.     
 
Dietary recall 
 
The participants will be asked to list the food and beverages you consume for 2 days (one 
weekday and one weekend day) and bring it back at your next visit (dietary recall). We will ask 
the patient to complete a diet recall form. The form is to ease patients to remember their diet 
and to increase the accuracy of diet recalls. Patients will be given the forms prior to their study 
visits. They will document everything they eat and drink on a weekday and on a weekend day.  
 
 
Activity Monitor (Physical Activity Recall) 
 
The physical activity monitor is about the size of a watch. It is worn on your non-dominate 
wrist (for example your left wrist if you are right-handed). Participants will wear this monitor 
for 7 days. They will wear it 24 hours per day, including when they sleep, shower, or do any 
other activities. We will also provide a physical activity log to document physical activity 
during the day. 
 
 


Date: 12/2/2024 
8 
 
Table 6.1. Schedule of the Procedures 
 
 
Week 
-4  
Week 
0 
Weeks 
0-12 
Weeks 
2, 4, 6, 
8, 10 
Week 
12 
Week 
16 
 
Screening 
Visit 
≠ 1 
Visit 
≠ 2 
 
 
Visit 
≠ 3 
Visit 
≠ 4 
Medical History 
√ 
√ 
√ 
 
 
√ 
√ 
HbA1c 
√ 
 
 
 
 
 
 
Vital signs  
√ 
√ 
√ 
 
 
√ 
√ 
Electrocardiogram 
√ 
√ 
√ 
 
 
√ 
√ 
BMI  
√ 
√ 
√ 
 
 
√ 
√ 
Pregnancy test  
(If needed) 
√ 
√ 
√ 
 
 
√ 
√ 
Serum creatinine 
√ 
√ 
√ 
 
 
√ 
√ 
Screening X-ray  
(If needed) 
√ 
 
 
 
 
 
 
Dulaglutide 
1.5 
mg/wk 
 
 
√ 
√ 
 
 
 
Continuous 
glucose 
monitoring (only in 
T2D patients) 
 
 
 
√ 
 
 
 
Phone calls 
 
 
 
 
√ 
 
 
Dietary recalls 
 
√ 
√ 
 
 
√ 
√ 
Physical 
activity 
monitor 
 
√ 
√ 
 
 
√ 
√ 
Anthropometric 
measurements 
 
√ 
√ 
 
 
√ 
√ 
Six-minute walk test 
 
√ 
√ 
 
 
√ 
√ 
Research Labs 
 
√ 
√ 
 
 
√ 
√ 
Urine sampling 
 
√ 
√ 
 
 
√ 
√ 
Systemic 
and 
peripheral 
IR 
calculation 
 
 
 
 
 
 
 
HOMA-IR 
 
√ 
√ 
 
 
√ 
√ 
QUICKI 
 
√ 
√ 
 
 
√ 
√ 
Adipose 
tissue 
IR 
calculation 
 
 
 
 
 
 
 
ADIPO-IR 
 
√ 
√ 
 
 
√ 
√ 
Calculation of LAR  
 
√ 
√ 
 
 
√ 
√ 
Magnetic 
resonance 
imaging 
 
√ 
√ 
 
 
√ 
√ 
31P magnetic 
resonance 
spectroscopy 
 
√ 
√ 
 
 
√ 
√ 
 


Date: 12/2/2024 
9 
 
 
REFERENCES 
 
1 
https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf 
2 
Singh B, Saxena A. Surrogate markers of insulin resistance: A review. World J Diabetes 2010; 1 
(2): 36-47. 
3 
Søndergaard E, Espinosa De Ycaza AE, Morgan-Bathke M et al. How to Measure Adipose Tissue 
Insulin Sensitivity. J Clin Endocrinol Metab 2017; 102 (4): 1193-1199. 
4 
Frühbeck G, Catalán V, Rodríguez A et al. Adiponectin-leptin ratio: A promising index to 
estimate adipose tissue dysfunction. Relation with obesity-associated cardiometabolic risk. 
Adipocyte 2018; 7 (1): 57-62. 
5 
Kumar D, Karampinos DC, MacLeod TD et al. Quadriceps intramuscular fat fraction rather than 
muscle size is associated with knee osteoarthritis. Osteoarthritis Cartilage 2014; 22 (2): 226-
234. 
6 
Gamboa JL, Roshanravan B, Towse T et al. Skeletal Muscle Mitochondrial Dysfunction Is 
Present in Patients with CKD before Initiation of Maintenance Hemodialysis. Clin J Am Soc 
Nephrol 2020; 15 (7): 926-936. 
7 
McCully KK, Turner TN, Langley J et al. The reproducibility of measurements of intramuscular 
magnesium concentrations and muscle oxidative capacity using 31P MRS. Dyn Med 2009; 8: 5. 
8 
Layec G, Bringard A, Le Fur Y et al. Reproducibility assessment of metabolic variables 
characterizing muscle energetics in vivo: A 31P-MRS study. Magn Reson Med 2009; 62 (4): 840-
854. 
9 
ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166 
(1): 111-117. 
10 
Martinson M, Ikizler TA, Morrell G et al. Associations of body size and body composition with 
functional ability and quality of life in hemodialysis patients. Clin J Am Soc Nephrol 2014; 9 (6): 
1082-1090. 
 

SAP_003.pdf: 
Title of the study: Effects of Glucagon-Like Peptide-1 Agonists on Metabolism and Ectopic 
Fat Deposition in Chronic Kidney Disease: A Pilot and Feasibility Study 
NCT number:  NCT05254418 
Date: 12/02/2024 
 
Statistical Considerations 
Sample size 
Up to ten subjects will be enrolled to participate in the study. This study design will provide 
preliminary data on the effects of GLP-1RA on ectopic fat deposition, mitochondrial function, 
and physical performance in patients with CKD. We performed a power analysis based on the 
study by Neeland et al, investigating the effects of liraglutide on VAT in overweight and obese 
patients. According to their results, liraglutide treatment for a median of 36 weeks results in a 
mean change in VAT of 12.49%, with a standard deviation of 9.3%. Using their findings, we 
estimated the power for detecting changes in VAT based on a sample size of 10 using paired-t 
test (Figure 10.1). For a sample size of 10, there is adequate power to detect a mean change of 
9% or more in VAT with a standard deviation of 9% and alpha value of 0.05.    
Figure shows how the power would change if the sample size were to be extended to 20 
following the pilot study.  
 
 


 
Data Analysis  
The comparison of primary and secondary outcomes, specifically the differences in (a) 
intermuscular fat deposition, (b) adipose tissue insulin resistance, (c) peripheral insulin 
resistance, (d) visceral tissue fat deposition, (e) phosphocreatine recovery time constant, (f) 
physical performance score, before and after dulaglutide administration will be assessed using 
Wilcoxon signed-rank tests.  
Generalized linear mixed effects models will be used to examine associations of GLP-
1RA with changes in outcomes with more than 2 repeated assessments. All p-values will be two-
tailed (α=0.05) and analyses will be completed using Stata 16.