Conditions: Calciphylaxis Calcific Uremic Arteriolopathy
Keywords: Calciphylaxis Calcific Uremic Arteriolopathy Dialysis End Stage Renal Disease Rare disease (ORPHA280062) Calcification Calcium Metabolism Disorders Calcinosis Metabolic Diseases
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 14
Healthy volunteers: no

Brief summary:
To evaluate the effect of SNF472 on top of standard of care on promoting wound healing and other parameters of therapeutic response in haemodialysis patients with calciphylaxis (calcific uraemic arteriolopathy, CUA).

Detailed description:

Arms:
arm 1: SNF472 for calciphylaxis

Interventions: intervention 1: SNF472
Intervention descriptions: intervention 1: SNF472 for calciphylaxis

Protocol document:
Prot_000.pdf: 
Laboratoris Sanifit 
SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
Final V4 
Page 1 of 72 
 11 Apr 2017 
 
Laboratoris Sanifit S.L. Phone/Fax: +34 971 439 925 info@sanifit.com www.sanifit.com 
PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
Clinical Trial Protocol Incorporating Amendment 1, 2, and 3 
Phase 2 Open Label Single Arm Repeat Dose Study to Assess the Effect 
of SNF472 on Wound Healing in Uraemic Calciphylaxis Patients 
 
Sponsor:                                         Laboratoris Sanifit 
Europa Building, 2nd floor 
07121 Palma de Mallorca 
SPAIN 
 
Academic Research Organisation:    Clinical Trial Center-Aachen (CTC-A)  
Studienzentrum der Medizinischen Fakultät der RWTH Aachen 
University Hospital RWTH Aachen 
Pauwelsstr. 30 
52074 Aachen 
GERMANY 
 
Principal Investigator:                      Prof Dr Vincent Brandenburg  
Clinic for Cardiology, Pneumology, Angiology and Internal Intensive 
Medicine (Medical Clinic I) 
University Hospital RWTH Aachen 
Pauwelsstr. 30 
52074 Aachen 
GERMANY 
 
ARO Protocol No:   15-091 
Sponsor Protocol No: SNFCT2015_04 
 
EudraCT: 2015-004313-25 
 
Investigational Medicinal Product Name: SNF472 
 
Development Phase: Phase 2a  
Date of Protocol:  V4 dated 11 April 2017 
 
Protocol/Amendment 
Date 
Type of Amendment 
Protocol Final 
02 December 2015 
Not applicable 
Amendment 1 
10 March 2016 
Substantial 
Amendment 1.1 
 
Right to Amend Request from 
MHRA 
Amendment 2 
08 October 2016 
Substantial 
Amendment 3 
11 April 2017 
Substantial 
This Clinical Trial will be conducted according to the clinical trial protocol and in compliance with Good Clinical Practice, with 
the Declaration of Helsinki (Version 1996) and with other applicable regulatory requirements. 
Confidentiality Statement 
This document contains confidential information of Laboratoris Sanifit. Do not copy or distribute without written permission 
from the Sponsor. 
 
 
 


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SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
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SIGNATURE PAGE 
Declaration of Sponsor or Responsible Medical Expert 
Protocol Title: Phase 2 Open Label Single Arm Repeat Dose Study to Assess the Effect of SNF472 on Wound 
Healing in Uraemic Calciphylaxis Patients 
 
 
This Clinical Trial Protocol was subjected to critical review and has been released by the Sponsor. The information 
that it contains is consistent with current knowledge of the risks and benefits of the investigational medicinal 
product, as well as with the moral, ethical and scientific principles governing clinical research as set out in the 
Declaration of Helsinki (1996), and the guidelines on Good Clinical Practice applicable to this clinical trial. This 
clinical trial involves research. 
 
Sponsor Signatory/Responsible Medical Expert 
 
                                                                                             
                
                                                                                
Rekha Garg, MD, MS 
 
Medical Monitor  
Laboratoris Sanifit. 
 
Date 
 
 
 
 
 
 
 
 
Carolina Salcedo, PhD 
 
Chief Scientific Officer 
Laboratoris Sanifit. 
 
Date 
 
 
 
 
 
 
 
 
 


Laboratoris Sanifit 
SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
Final V4 
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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
SIGNATURE PAGE 
Declaration of the Principal Investigator 
 
Protocol Title: Phase 2 Open Label Single Arm Repeat Dose Study to Assess the Effect of SNF472 on Wound 
Healing in Uraemic Calciphylaxis Patients 
 
This Clinical Trial Protocol was subjected to critical review and has been released by the Sponsor. The information 
that it contains is consistent with current knowledge of the risks and benefits of the investigational medicinal 
product, as well as with the moral, ethical and scientific principles governing clinical research as set out in the 
Declaration of Helsinki (1996), and the guidelines on Good Clinical Practice applicable to this clinical trial. This 
clinical trial involves research. 
 
Principal Investigator 
 
 
Prof Dr Vincent Brandenburg 
  
Principal Investigator 
Clinic for Cardiology, Pneumology, Angiology and 
Internal Intensive Medicine (Medical Clinic I) 
University Hospital RWTH Aachen,  
Aachen, GERMANY 
 
Date 
 
 
 
 


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SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
Final V4 
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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
PROTOCOL SYNOPSIS 
Protocol Title: 
Phase 2 Open Label Single Arm Repeat Dose Study to Assess the Effect of SNF472 on 
Wound Healing in Uraemic Calciphylaxis Patients 
Study Numbers: 
15-091 (CTC-A) 
Sponsor 
Protocol No.: 
SNFCT2015_04 
Development 
Phase: 
Phase 2a  
Sponsor: 
Laboratoris Sanifit 
Europa Building, 2nd floor,  
07121 Palma de Mallorca. 
SPAIN 
Principal 
Investigator: 
Prof Dr Vincent Brandenburg 
Study Centres: 
 
Clinic for Cardiology, Pneumology, Angiology and Internal Intensive Medicine  
(Medical Clinic I) 
University Hospital RWTH Aachen,  
Pauwelsstr. 30 
52074 Aachen, GERMANY 
 
Salford Royal Hospital 
Salford Royal NHS Foundation Trust 
Stott Lane 
Salford M6 8HD, UNITED KINGDOM 
Hospital Clinic de Barcelona 
Departamento de Nefrologia 
Villarroel 170 
08036 Barcelona, SPAIN 
 
Fresenius Medical Services 
920 Winter Street 
Waltham 
MA 02451-1457, USA 
 
Davita Clinical Research 
825 South 8th Street, Suite 300  
Minneapolis  
MN 55404, USA 
Study 
Objectives: 
To evaluate the effect of SNF472 on top of standard of care on promoting wound healing 
and other parameters of therapeutic response in haemodialysis patients with calciphylaxis 
(calcific uraemic arteriolopathy, CUA) 


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SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
Study Design: 
This is an open label, single arm clinical trial to investigate the effect of SNF472 in uraemic 
calciphylaxis patients, on top of standard of care. 
Investigational 
Medicinal 
Product: 
SNF472  
Presented as 10 mL or 5 mL of sterile liquid in transparent glass vials, containing either 
300 mg or 450 mg of SNF472, respectively. The SNF472 solutions used will be either 30 
mg/mL (Batch number P00142-L001E) or 90 mg/mL (Batch number PD14081) and will be 
diluted in a 100-mL saline bag and the contents of the whole bag will be administered to the 
patient by slow infusion. SNF472 will be administered between 2.5 h and a 4 h period using 
the dialysis system during the dialysis session.  
Number of 
Patients: 
15 evaluable CUA patients who complete the 12-week treatment period. 
A total of 15 evaluable subjects was determined necessary to show with 80% power that 
the percentage of subjects for which the primary ulcer is totally or partially healed after 12 
weeks of treatment is greater than 25%. For these calculations, it was assumed that the 
percentage of totally or partially healed subjects for SNF472 will be 60%. 
Study 
Population: 
 
Main inclusion criteria: 
1. Patients with either newly diagnosed CUA OR recurrent CUA that has been dormant 
with no skin lesion involvement for at least 90 days from study start (new or recurrent 
diagnosis must be made within 5 weeks of study start) 
2. Patients who signed the written informed consent to participate in this clinical trial (prior 
to any clinical trial-related procedures being performed), after reading the Patient 
Information Sheet and Informed Consent Form (ICF), and who had the opportunity to 
discuss the clinical trial with the Investigator or designee 
3. Males or females aged ≥18  
4. Patients on maintenance haemodialysis 
5. Patients with at least a minimum level of pain on VAS scale or on pain-killers stronger 
than NSAIDs 
6. Females of child-bearing potential should use a highly effective contraceptive measure 
throughout the study AND have a negative serum pregnancy test at entry. Male patients 
having sexual relationship in which pregnancy can occur should take adequate 
contraceptive precautions (wear a condom) (see section 8.3.1.) 
 
Main exclusion criteria: 
1. Body weight above 150 kg 
2. BMI >35 and central(abdominal) ulcers  
3. History of bisphosphonate treatment within 12 months before entering into the 
study 
4. Severely ill patients without reasonable expectation of survival for > 6 months 
according to the treating physician 


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Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
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5. Patients with scheduled parathyroidectomy during the run-in or study period 
6. Female patients who are either intending to get pregnant or are undergoing 
treatment to get pregnant, as well as breast-feeding females 
7. Participation in another clinical trial with an experimental drug within 90 days prior 
the inclusion 
8. Any psychological, emotional problems, any disorders or resultant therapy that is 
likely to invalidate informed consent, or limit the ability of the patient to comply with 
the Clinical Trial Protocol requirements 
9. Patients who, in the opinion of the Investigator, are considered unsuitable for any 
other reason 
Study 
Procedures: 
Written informed consent will be obtained from all patients before any study-related 
procedures are performed. 
The patient’s medical history, demographic, and baseline characteristics, as well as a 
picture of the wound deemed to be CUA, will be collected to determine the patient’s eligibility 
for inclusion, which will be analysed by Dr Vincent Brandenburg (the “gatekeeper”).  
Blood samples taken routinely from patients will be used as source data for the trial.  
SNF472 will be administered by infusion at a single, constant dosage for a minimum of 2.5h 
up to the whole duration of the dialysis session. SNF472 will be administered at three 
haemodialysis sessions per week for 12 consecutive weeks. 
Follow-up assessments including lesion documentation and clinical status will be done at 
regular intervals (ulcer size, features, Bates-Jensen Wound tool assessment, pain, and 
Wound QoL) over a period of 12 weeks (see Table 1). Additional assessments will include 
safety and assessment of pharmacokinetics (PK) and pharmacodynamic (PD) profiles. One 
sample of blood to measure biomarkers will be taken at the time of PK samples (see Table 
1). 
During the clinical trial, patients will be monitored closely for any adverse events (AEs).  
The time points where blood samples will be taken to evaluate safety, PK, PD, and 
biomarkers are specified in the Table of Assessments (see Table 1). 
Criteria for 
Evaluation: 
Safety: 
Safety parameters will include AEs and SAEs, clinical laboratory and haematology, clinical 
chemistry including plasma electrolytes, 12-lead ECG, and physical examination. 
Pharmacokinetics: 
Only Cmax (plasma concentration at the end of drug infusion) will be assessed. 
Pharmacodynamics: 
Plasma samples collected, at baseline and around the tmax, from all subjects, will be used 
for exploratory PD assessment by using an in vitro test to assess the propensity for 
hydroxyapatite crystal formation in plasma. 
Biomarker: 
Serum samples will be collected at baseline and at the end of the study, frozen, and used 
for exploratory biomarker assessment. The final list of biomarkers will be decided at a later 
time point.  


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SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
Statistical 
Methods: 
Statistical methods:  
All statistical analyses and programming of tables, lists, and figures will be performed by 
Syntax for Science (Palma de Mallorca, Spain) using the latest available version of SAS® 
(SAS Institute Inc., Cary, North Carolina, USA). 
Safety: 
All safety parameters will be summarised by time-point (where appropriate). 
Pharmacokinetics: 
Individual and mean Cmax values will be obtained  
Pharmacodynamics: 
Pharmacodynamia will be assessed by an in vitro method to determine the propensity for 
hydroxyapatite crystal formation in plasma. For each patient, on-study samples will be 
compared to baseline assessment and reported as a % inhibition of hydroxyapatite crystal 
formation compared to baseline.  
Biomarkers: 
Biomarkers will be assessed once the study is finished  
Schedule of 
Assessments: 
For a detailed Schedule and Time of Assessments to be performed during the clinical trial, 
refer to Table 1. 


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SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
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Table 1 Schedule of Assessments 
 
SCR 
TREATMENT PERIOD 
FU 
Week 
-2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lesions Overview 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Images Collection 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Visit  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Body Weight 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Biopsy (if performed 
by site)1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical 
Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
ECG*  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
ECG (pre dose & end 
of infusion)* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
1 Biopsy is not an inclusion criterion, but if performed the report and analysis will be documented 
* ECG assessment will be performed only at sites with appropriate equipment and trained personnel 
 


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Clinical Trial Protocol Incorporating Amendment 3 
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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
 
SCR 
TREATMENT PERIOD 
FU 
Week 
-2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Safety 
Laboratory 
Assessments2 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
PTH3 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Potassium, 
Magnesium, 
Iron 
(ferritin/transferrin) 
and Zinc  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Potassium, 
Magnesium, 
Iron 
(ferritin/transferrin) 
and Zinc (predose & 
end of infusion)* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
Ionised Calcium  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Ionised 
Calcium 
(predose & end of 
infusion)* 
 
X 
X 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
X 
X 
 
Pregnancy Test4 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
2 These data sets will be used from the routine monthly blood analysis performed on each patient 
3 PTH will be measured using the routine test used in the site. Recommendations are given in Section 7.1.3. 
4 Pregnancy test is to be serum at baseline and urine monthly thereafter 
 


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SCR 
TREATMENT PERIOD 
FU 
Week 
-2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Treatment 
History 
(prior medication)5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility6 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CUA Diagnosis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment 
(Intravenous 
SNF472)7 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Wound QoL Score 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Pain 
Score 
(VAS 
scale) 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Lesion 
Score 
(BJWAT) 
 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Biomarkers 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Plasma PK and PD 
sampling (predose & 
end of infusion)* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
5 Prior medication includes medications within 6 months of study start 
6 The inclusion/exclusion criteria will be assessed for each patient at Screening – final entry into the study depends on confirmation by the PI, Dr VB 
7 A Treatment Period includes 3 dialysis sessions/week x 12 weeks (36 treatments) 


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PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
 
 
SCR 
TREATMENT PERIOD 
FU 
Week 
-2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Concomitant 
Medication 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
End of Study Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 


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LIST OF STUDY STAFF 
This clinical trial will be conducted in US and EU sites.  
US: Dialysis clinics from Fresenius Medical Care North America and DaVita Healthcare Partners will be participating 
in the study. Frenova will utilize the Fresenius clinic network. DaVita Clinical Research will utilize the DaVita clinic 
network. Trial sites will be opened once a patient with CUA is identified.  
UK: The study will take place at the Salford Royal NHS Foundation Trust in Manchester. 
Spain: The study will take place at the Hospital Clinic in Barcelona. Patients from hospitals in the Barcelona 
metropolitan area, such as Vall de Hebron, Puigvert, Bellvitge, Hospital del Mar, Sabadell and Terrassa, will be referred 
to the Hospital Clinic. 
(Hereafter referred to as the “Clinical Units”).  
1. Clinical Units 
Principal Investigator 
Prof Vincent Brandenburg, MD 
Clinic for Cardiology, Pneumology, Angiology and Internal Intensive Medicine (Medical Clinic I) 
University Hospital RWTH Aachen, 
Pauwelsstr. 30 
52074 Aachen, GERMANY 
Vincent.Brandenburg@post.rwth-aachen.de 
Investigator 
Smeeta Sinha, MD 
Salford Royal Hospital 
Salford Royal NHS Foundation Trust 
Stott Lane 
Salford M6 8HD, UK 
smeetasinha@doctors.org.uk or 
smeeta.sinha@srft.nhs.uk 
Investigator 
Vicens Torregrosa, MD 
Unitat de diàlisis, 
Servei de Nefrologia i Trasplant Renal (SNiTR), 
Hospital Clinic Barcelona, 
Villarroel 170, 
08036-Barcelona, SPAIN 
vtorre@clinic.ub.es 
Fresenius Medical Services 
920 Winter Street, Waltham 
MA 02451-1457, USA 
Davita Clinical Research 
825 South 8th Street, Suite 300 
Minneapolis, 
MN 55404, USA 


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2. Sponsor 
Sponsor 
Laboratoris Sanifit 
Europa Building, 2nd floor  
07121 Palma de Mallorca 
Spain 
Sponsor Contact 
Ana-Zeralda Canals Hamann, PhD 
Laboratoris Sanifit 
Europa Building, 2nd floor  
07121 Palma de Mallorca 
Spain 
Phone: +34 971 439 925 
Mobile: +34 606 514 834 
Email: ana-zeralda.canals@sanifit.com 
Sponsor’s Medical Monitor 
Rekha Garg, MD, MS 
Sanifit 
4660 La Jolla Village Drive, Suite 500  
San Diego, CA 92122 
USA 
Mobile: +1 805 559 0144 
Email: rekha.garg@sanifit.com 
 
 
3. Academic Research Organisation (ARO) / Contract Research Organisation (CRO) 
ARO / Contact 
Clinical Trial Center-Aachen (CTC-A) 
Studienzentrum der Medizinischen Fakultät der RWTH 
Aachen 
University Hospital RWTH Aachen 
Pauwelsstr. 30 
52074 Aachen, GERMANY 
CRO Contact 
Frenova Renal Research 
920 Winter Street 
Waltham 
MA 02451-1457 
USA 
 
4. Independent Committee (Ulcer assessment)  
Reference pathologist 
Prof Kerstin Amann, MD 
Nephropathologische Abteilung 
University Hospital Erlangen 
Krankenhausstr. 8-10 
91054 Erlangen, GERMANY 
Kerstin.Amann@uk-erlangen.de 
Dermatologist 
Emma McMullen, MD 
Dermatology 
Salford Royal Hospital 
Salford Royal NHS Foundation Trust 
Stott Lane 
Salford M6 8HD, UK 
Emma.McMullen@srft.nhs.uk 


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5. Study Coordination 
Scientific Advisor Imaging, Core Reading Lab for 
main Endpoint (Imaging) 
Department of Medical Informatics (IMI) 
University Hospital RWTH Aachen 
Pauwelsstr. 30 
52074 Aachen, GERMANY 
 
Study Monitor US (Frenova) 
Charla Tambourine, RN, Lead Sr. CRA 
Frenova Renal research 
920 Winter Street, Waltham 
MA 02451-1457, USA 
Email: Charla.Tambourine@frenovarenalresearch.com 
Data Management 
DF/Net Research, Inc. 
140 Lakeside Avenue, Suite 310 
Seattle, WA 98122 USA 
+1.206.322.5931 
Study Monitor UK/Spain 
Heather Keeves 
Phases Clinical Research Ltd 
Newbury, RG14 1DY, UK 
Email: hkeeves@aol.com 
Pharmacovigilance Department 
Viglya S.L. 
C/Casanova 264, Ppal. 2a 
08021 Barcelona, Spain 
Phone: +34 931 641 844 
Fax: +34 931 760 213 
Email: pv.sanifit@viglya.com 
Statistics 
Juan Vicente Torres 
Syntax for Science 
Parc Bit, Edificio Naorte 
Ctra. Valldemossa km 7.4 
070121 Palma de Mallorca, SPAIN 
Phone: +34 971 910 842 
Email: jvtorres@syntaxfs.com 
24-Hour Emergency Contact EU 
+49 241 89 89575 ext (24 hours) 
Monday to Friday Phone +49 241 80 80202 
Clinic for Cardiology, Pneumology, Angiology and 
Internal Intensive Medicine (Medical Clinic I) 
University Hospital RWTH Aachen 
Pauwelsstr. 30 
52074 Aachen, GERMANY 
24 Hour Emergency Contact USA 
Phone: +1 781-392-6057 
Fresenius Medical Services 
920 Winter Street, Waltham 
MA 02451-1457, USA 
 


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6. PK and PD Laboratory 
PK Analysis 
Monica Abellan 
Study Director, Department of Bioanalytics, Metabolism 
and Screening 
ENVIGO S.A. 
Ctra. de Castellar a Sentmenat C-1415, km 29,300 
08211-Castellar del Vallès, Barcelona Spain 
Phone: +34 937 190 361 
Fax: +34 937 299 731 
Email: monica.abellan@envigo.com 
PD Analysis 
 
Miquel Ferrer, PhD 
Laboratoris Sanifit SL 
Europa Building, 2nd floor 
07121 Palma de Mallorca 
Spain 
Phone: +34 971 439 925 
Mobile: +34 606 118 899 
Email: miquel.ferrer@sanifit.com 
 
7. IMP Manufacture, IMP and Sample Storage 
IMP Manufacture 
Patheon 
Kingfisher Drive 
Covingham, Swindon 
Wiltshire, SN3 5BZ 
United Kingdom 
IMP Manufacture 
Laboratorio Reig Jofré, S.A. 
Pharmaceutical Development Services 
Gran Capità 6-10 
08970 Sant Joan Despí 
Barcelona 
Spain 
Sample Storage (USA) 
Spectra Clinical Research 
8 King Road 
Rockleigh, NJ 07628 
United States 
 
IMP and Sample Storage (Europe) 
Mathieu Denis, Project Manager 
CSM Europe SA (formerly B&C) 
Watson & Crick Hill 
Rue Granbonpré 11 (Gate C) 
1435 Mont-Saint-Guibert, Belgium 
Phone: +32 10 237 439 
Fax: +32 (0)10 470 860 
Email: mdenis@csmondemand.com 
IMP and Sample Storage (USA) 
YOURWAY TRANSPORT BIOPHARMA SERVICES 
6681 Snowdrift Road 
Allentown, PA 18106, United States 
Toll Free: +1 888-778-4555 
Office: +1 610-395-9198 
Fax: +1 610-391-9002 
info@yourwaytransport.com 


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1. 
TABLE OF CONTENTS 
PROTOCOL SYNOPSIS .................................................................................................................................................................... 4 
LIST OF STUDY STAFF .................................................................................................................................................................. 12 
1. 
TABLE OF CONTENTS .................................................................................................................................................. 16 
LIST OF TABLES ............................................................................................................................................................................. 19 
LIST OF FIGURES ........................................................................................................................................................................... 20 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ........................................................................................................... 21 
2. 
INTRODUCTION ............................................................................................................................................................. 24 
2.1. 
Background ..................................................................................................................... 24 
2.1.1. 
Properties of Myo-Inositolhexaphosphate ................................................................... 24 
2.1.2. 
Evidence for Efficacy in Calcium-Related Diseases .................................................... 24 
2.1.3. 
Disease, Coronary Artery Calcification and Events ..................................................... 25 
2.2. 
Rationale for the Clinical Trial .......................................................................................... 26 
2.3. 
Risk-Benefit Assessment ................................................................................................. 26 
2.3.1. 
Efficacy ........................................................................................................................ 27 
2.3.2. 
Safety ........................................................................................................................... 28 
2.3.3. 
Galenics ....................................................................................................................... 31 
3. 
STUDY OBJECTIVES .................................................................................................................................................... 32 
4. 
OVERALL DESIGN AND PLAN OF THE STUDY ......................................................................................................... 33 
4.1. 
Overview .......................................................................................................................... 33 
4.2. 
Endpoints ......................................................................................................................... 34 
4.2.1. 
Primary endpoint .......................................................................................................... 34 
4.2.2. 
Secondary endpoints ................................................................................................... 34 
4.3. 
Justification of the Clinical Trial Design ........................................................................... 35 
5. 
STUDY POPULATION .................................................................................................................................................... 36 
5.1. 
Number of Patients .......................................................................................................... 36 
5.2. 
Recruitment ..................................................................................................................... 36 
5.3. 
Inclusion Criteria .............................................................................................................. 36 
5.4. 
Exclusion Criteria ............................................................................................................. 37 
5.5. 
Patient Withdrawal and Replacement .............................................................................. 37 
6. 
INVESTIGATIONAL MEDICINAL PRODUCT ............................................................................................................... 39 
6.1. 
Identity of the Investigational Medicinal Products ............................................................ 39 
6.2. 
Dose Rationale ................................................................................................................ 39 
6.3. 
Supply, Packaging, Labelling and Storage ...................................................................... 40 
6.4. 
Drug Accountability, Dispensing and Destruction ............................................................ 40 
6.5. 
Patient Identification ........................................................................................................ 40 
6.6. 
Administration of Investigational Medicinal Products ....................................................... 41 
6.7. 
Compliance ...................................................................................................................... 42 
6.8. 
Concomitant Medications ................................................................................................ 42 


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6.8.1. 
Prior and Concomitant Medication............................................................................... 42 
7. 
VARIABLES AND METHODS OF ASSESSMENT........................................................................................................ 43 
7.1. 
Safety Variables .............................................................................................................. 43 
7.1.1. 
Medical History, Demographic, and Anthropometric Information ................................ 43 
7.1.2. 
Adverse Events ............................................................................................................ 44 
7.1.3. 
Laboratory Assessments ............................................................................................. 50 
7.1.4. 
12-Lead Electrocardiograms ........................................................................................ 50 
7.1.5. 
Physical Examinations ................................................................................................. 51 
7.2. 
Haemodialysis-related Events ......................................................................................... 51 
7.3. 
Pharmacokinetic and Pharmacodynamic Parameters ..................................................... 52 
7.3.1. 
Pharmacokinetic and Pharmacodynamic Blood Sample Collection and Handling ...... 52 
7.3.2. 
Pharmacokinetic Variables .......................................................................................... 54 
7.4. 
Biomarkers ...................................................................................................................... 54 
7.5. 
Scores and Evaluations ................................................................................................... 55 
7.5.1. 
Pain Score -VAS .......................................................................................................... 56 
7.5.2. 
Lesion Score – Bates-Jensen Wound Assessment Tool ............................................. 57 
7.5.3. 
Quality of Life - Wound QOL (HRQOL) ....................................................................... 59 
8. 
STUDY CONDUCT ......................................................................................................................................................... 60 
8.1. 
Schedule and Time of Assessments ............................................................................... 60 
8.2. 
Assessments by Visit ....................................................................................................... 60 
8.2.1. 
Screening Period W-2 to Day-1 (hence the screening/recruitment period is up to 2 
weeks).......................................................................................................................... 60 
8.2.2. 
Expected Duration of the Clinical trial .......................................................................... 61 
8.2.3. 
Treatment Period W1-W12 .......................................................................................... 61 
8.2.4. 
Follow-Up Visit W13 .................................................................................................... 61 
8.2.5. 
End of Study Visit ........................................................................................................ 61 
8.3. 
Restrictions ...................................................................................................................... 62 
8.3.1. 
Contraception Requirements ....................................................................................... 62 
9. 
STATISTICAL METHODS .............................................................................................................................................. 63 
9.1. 
Clinical Trial Population ................................................................................................... 63 
9.1.1. 
Disposition of Patients ................................................................................................. 63 
9.1.2. 
Protocol Deviations ...................................................................................................... 63 
9.1.3. 
Analysis Populations .................................................................................................... 63 
9.2. 
General Considerations ................................................................................................... 63 
9.3. 
Demographic and Anthropometric Information, Baseline Characteristics, and 
Concomitant Medications ................................................................................................ 64 
9.4. 
Pharmacokinetic Analysis ................................................................................................ 64 
9.5. 
Determination of Sample Size ......................................................................................... 64 
10. 
ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS............................................................................................... 65 
10.1. 
Data Quality Assurance ................................................................................................... 65 
10.2. 
Data Collection ................................................................................................................ 65 
10.3. 
Source Documents .......................................................................................................... 65 
10.4. 
Access to Source Documents .......................................................................................... 65 


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10.5. 
Data Management ........................................................................................................... 66 
10.6. 
Archiving Clinical Trial Documents .................................................................................. 66 
10.7. 
Good Clinical Practice ..................................................................................................... 66 
10.8. 
Informed Consent ............................................................................................................ 66 
10.9. 
Protocol Approval and Amendment(s) ............................................................................. 67 
10.10. Duration of the Clinical trial .............................................................................................. 67 
10.11. Confidentiality Data Protection ........................................................................................ 67 
10.12. Other Ethical and Regulatory Issues ............................................................................... 67 
10.13. Liability and Insurance ..................................................................................................... 68 
10.14. Publication Policy ............................................................................................................ 68 
11. 
REFERENCE LIST.......................................................................................................................................................... 70 
 


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LIST OF TABLES 
Table 1 Schedule of Assessments ..................................................................................................................................................... 8 
 


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LIST OF FIGURES 
 
Figure 1 Ionised calcium concentration at the time of peak concentrations with each dose compared to baseline. ...................... 30 
Figure 2 Cartoon of the method of administration including the dialysis machine. .......................................................................... 41 
Figure 3 Cryovial sample labels for sample collections .................................................................................................................... 52 
Figure 4: VAS Analogue Scale ......................................................................................................................................................... 57 
 
 


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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
ARO 
Academic research organisation 
AST 
Aspartate aminotransferase 
BWAT 
Bates Jensen Wound Assessment Tool 
Ca 
Calcium 
CDISC 
Clinical Data Interchange Standards Consortium 
Cmax 
Maximum observed plasma concentration 
CPMP 
Committee for Proprietary Medicinal Products 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CS 
Clinically significant 
CTC-A 
Clinical Trial Center-Aachen 
CUA 
Calciphic Uremic Arteriolopathy 
CVC 
Cardiovascular calcification 
DESC 
Dose Escalation Safety Committee 
DMP 
Data Management Plan 
EC 
Independent Ethics Committee 
ECG 
Electrocardiogram 
EC50 
Effective concentration 50% 
EDTA 
Ethylenediaminetetraacetic acid 
EMA 
European Medicines Agency 
EOS 
End of Study 
ESRD 
End-stage renal disease 
EU 
European Union 
EVG 
Elastic-van-Gieson stain 
FDA 
Food and Drug Administration 
Fe 
Iron 
FU 
Follow-Up 
GCP 
Good Clinical Practice 
GFR 
Glomerular filtration rate 
GLP 
GRAS 
Good Laboratory Practice 
Generally regarded as safe 
HAP 
Hydroxyapatite 
HD 
Haemodialysis 
hERG 
human Ether-a-go-go Related Gene 


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HRQOL 
Health-Related Quality of Life questionnaire 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IMI 
Institute of Medical Informatics 
IMP 
Investigational medicinal product 
IP6 
Myo-inositolhexaphosphate 
IRB 
Investigational Review Board 
IV 
Intravenous 
MAD 
Multiple ascending dose 
MedDRA 
Medical Dictionary for Regulatory Activities 
N 
Number of patient 
NCS 
Not clinically significant 
NSAID 
non-steroidal anti-inflammatory drugs 
L 
Litre 
OTC 
Over-the-counter 
P 
Phosphorus 
PET 
Polyethylene terephthalate 
PK 
Pharmacokinetic(s) 
PRO 
PTH 
Patient-reported outcome 
Parathyroid Hormone 
PV 
Pharmacovigilance 
QT 
QT interval 
QTc 
Corrected QT interval 
QTcB 
Corrected QT interval using Bazett’s formula 
QTcF 
Corrected QT interval using Fridericia’s formula 
RDR 
Rare Disease Registries 
RWTH 
Rheinisch-Westfälische Technische Hochschule 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SCR 
Screening 
SDTM 
Standard Data Tabulation Model 
SOC 
System Organ Class 
SOP 
Standard operating procedures 
STS 
Sodium thiosulfate 
SUSAR 
Suspected unexpected serious adverse reaction 
TEAE 
Treatment-emergent adverse event 
UK 
United Kingdom 
USA 
United States of America 


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VAS 
Visual analogue scale 
WHO-DD 
World Health Organisation’s Drug Dictionary 


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2. 
INTRODUCTION 
2.1. 
Background 
SNF472 is an intravenous (IV) formulation of the hexasodium salt of myo-inositolhexaphosphate (IP6, phytate). It is 
being developed for the treatment of calciphylaxis, as well as for the prevention of cardiovascular events in patients 
with end-stage renal disease (ESRD) undergoing haemodialysis (HD). 
2.1.1. 
Properties of Myo-Inositolhexaphosphate 
Myo-inositolhexaphosphate is a naturally-occurring substance found in beans, brown rice, corn, sesame seeds, wheat 
bran, and other high-fibre foods. The calcium salt of IP6 is listed by the Food and Drug Administration (FDA) as 
generally recognised as safe (GRAS)[1]. It is highly polar and poorly absorbed when given orally. When high oral doses 
are administered, IP6 has chelating properties in the gastrointestinal lumen preventing the absorption of cations such 
as calcium, magnesium and iron [2-4].  Due to this property it has been regarded for almost 50 years as an anti-nutrient, 
because it can reduce the gastrointestinal absorption of mineral oligoelements. 
Evidence of the potential health benefits of IP6 has emerged in parallel with advances in the development of analytical 
tools for its determination in biological fluids and tissues. The physicochemical properties of IP6 in biological systems 
make it undetectable with most conventional analytical techniques. Its presence in human tissues and body fluids was 
only shown at the end of the 1990’s, after the development of sensitive assay methods[5-8]. In 1996, IP6 levels were 
shown to be present in human urine[9] and this led to the establishment of a link between IP6 and health, particularly 
with respect to calcium-related diseases, such as renal stones[10-12],  osteoporosis[13-15],  and CVC[16-18].  
When administering SNF472 to animals as an IV bolus for 28 days, no adverse effects were reported up to 7.5 mg/kg 
in rats and 10 mg/kg in dogs. At 19 and 30 mg/kg, the observed adverse effects were related to the maximum observed 
plasma concentration (Cmax). The clinical signs in animals suggest that the chelation of cations in the blood in rats 
occurs well above the therapeutic dose levels (2 to 3mg/kg). Moreover, extensive telemetry studies in dogs showed 
that doses given by bolus, which leads to QTc prolongation, can be given by slow infusion without any effects on ECG 
parameters, including QTc. QTc prolongation can be reversed giving IV calcium gluconate. To avoid bolus Cmax-related 
adverse effects, IP6 will be administered by slow IV infusion during the dialysis session. The IV route achieves higher 
plasma concentrations of IP6 than is feasible orally and avoids chelation within the gastrointestinal tract. 
2.1.2. 
Evidence for Efficacy in Calcium-Related Diseases 
Beneficial properties have been attributed to IP6 in oncology [19-23] and calcium-related diseases (e.g., prevention of 
renal lithiasis [10-12], osteoporosis [13-15], CVC [16-18], sialolithiasis [24], and dental tartar [25]. 


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Myo-inositolhexaphosphate has been shown to prevent vascular calcification in a variety of animal models [16-18].  
The in vitro and in vivo results show that SNF472 prevents the formation of hydroxyapatite [26]. 
Epidemiological data show a negative correlation between physiological IP6 levels and CVC. A high dietary intake of 
IP6 is associated with a lower incidence of aortic stenosis and aortic valve calcification [27]. 
The inhibition of pathological processes of calcification in soft tissue by IP6 is accompanied by a positive effect on 
bone. Both animal models and epidemiologic data suggest that IP6 could be an effective agent for treating osteoporosis 
by reducing bone mineral density loss. Ovariectomised Wistar rats with an IP6 enhanced diet had reduced loss of bone 
mineral density caused by oestrogen deficiency [13].  
Myo-inositolhexaphosphate has also been shown to inhibit mineralisation in vitro of MC3T3-E1 osteoblasts cultures 
[28]. The potential mechanism is through binding to growing crystals and through induction of osteopontin expression. 
This data suggest that IP6 may regulate physiological bone mineralisation by directly acting extracellularly and by 
serving as a specific signal at cellular level for the regulation of osteopontin. When incubating human mesenchymal 
stem cells (pre-osteoblasts) with IP6, bone formation activity was enhanced [29]. 
Two epidemiological studies in 1500 and 180 subjects, showed that low IP6 intake was associated with a decline in 
vertebral and femoral bone mineral density [14, 15]. A recent epidemiological study in 169 post-menopausal women 
demonstrated that high IP6 exposure over 12 months was associated with lower bone mass loss and decreased 
fracture risk (lumbar spine and femoral neck)[30]. 
Sodium phytate is also used for Technetium bone scanning (Fyton; 15 mg Na-phytate [31]). The dose prescribed varies 
from a minimum of 2.5 mg to a maximum 5.0 mg of 99mTc-phytate. This combination is used in medicine as a source 
of radiation for radiotherapy and for diagnostic purposes. Published data shows two half-lives: t½ α: 2.4-7.0 min, t½ β: 
69-105 min, with a distribution into bone and liver, and slow disappearance from liver. It is possible that this reflects 
the half-life of IP6 in humans. 
2.1.3. 
Disease, Coronary Artery Calcification and Events 
The prevalence of ESRD in the United States of America (USA) is 661,648 patients [32] and according to the European 
Renal Association/European Dialysis and Transplant Association Registry, in 2014 the estimated number of new renal 
replacement therapy patients in the 25 countries of the European Union (EU) was 71 631 [33].There are approximately 
360,000 renal replacement therapy patients in the EU, with 66% of them being treated by dialysis and the remainder 
living with a functioning graft [34]. 
Calciphylaxis is a rare disease (ORPHA280062) characterised by progressive painful necrotic skin ulcerations and 
calcification of blood vessels. It occurs mostly, but not exclusively in patients with ESRD and the mean life expectancy 
is even lower than for haemodialysis patients [35]. The prevalence rate is well below the statutory thresholds for orphan 


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diseases of 5/10,000 in the EU (European Medicines Agency) and an overall number of 200,000 patients in the USA 
(FDA). It affects 1% to 4% of the ESRD population [35]. 
2.2. 
Rationale for the Clinical Trial 
CUA patients are almost all on dialysis, except for a very small percentage who are non-uraemic. CUA has no specific 
treatment. Calciphylaxis is a life-threatening condition with a high mortality rate. The overall mortality in calciphylaxis 
patients with ESRD is 60-80%  with a 1 year survival of 45% [35, 36], whereas non-uremic calciphylaxis appears to 
have a slightly better prognosis with an overall mortality of 52% [37].  
The difference between survival curves of cases and controls was most striking in the first year and more specifically 
in the first few months after the diagnosis of calciphylaxis [38]. It is clear that the progression of calciphylaxis is highly 
aggressive with early mortality compared to HD patients without calciphylaxis. The mortality of non-uraemic 
calciphylaxis seems to be about 30% lower than in patients with uraemic calciphylaxis [36, 37]. 
The pathophysiology of CUA involves the deposition of calcium in the media of small vessels. This leads to regional, 
extremely painful ischemia leading to ulceration. The lesions tend to appear in the upper and lower limbs, although 
truncal lesions have also been described. In addition to the pain – requiring opioids to be managed – these patients 
have an increased susceptibility to infections, which is responsible for over 50% of the mortality. Empirical treatments 
available include sodium thiosulfate, hyperbaric O2, bisphosphonates, surgical debridement, and other locally 
implemented initiatives. However, these measures do not seem to improve either the course of the wound(s) or the 
high mortality rate [39-42].   SNF472, due to its innovative mechanism of inhibition of the final common pathway of 
vascular calcification, has the potential to decrease the amount of vascular calcification in these patients, hence 
shortening the time to healing of the wounds and potentially decreasing mortality rates. This study will address the 
potential of SNF472 to improve the course of the wounds seen in CUA patients. 
Further details can be found in the Investigator’s Brochure [26]. 
See Section 4.3 for justification of the clinical trial design. 
2.3. 
Risk-Benefit Assessment 
The currently available information of clinical experience with IV IP6 is based on: 
1. Technetium formulations for bone and other scans 
2. A single ascending dose study of SNF472 in healthy volunteers  
3. Both a single and repeated ascending dose study in haemodialysis patients treated for up to 28 days 
SNF472 has been extensively studied in non-clinical models for efficacy, safety, pharmacokinetics, and toxicity. The 
main toxicological finding with SNF472 in animals – at high doses only - is hypocalcaemia due to chelation of ionised 


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calcium. The symptoms and signs observed include ECG effects, particularly transitory and reversible QTc 
prolongation. This is seen at Cmax values about 100-fold higher than the expected therapeutic levels. The effect is not 
present in animals when the same bolus doses are administered by slow intravenous infusion. Moreover, SNF472 
does not block the hERG channel (Study No SNFSF2010_01 A0189 [43]). The hypocalcaemia and the associated QTc 
effect are rapidly reversed by intravenous calcium gluconate. It is expected that the risk of associated hypocalcaemia 
will be minimal in haemodialysis patients, as slow infusions ranging from 2.5 to 4 hours will be used and the plasma 
calcium concentration is controlled by the calcium content of the dialysis fluid. Furthermore, in the unlikely situation of 
hypocalcaemia symptoms and signs occurring, they can be reversed by the administration of IV calcium-gluconate. 
During the phase I studies with volunteers, single doses from 0.5 mg/kg to 12.5 mg/kg were administered 
(SNFCT2012_03 Part C). A single dose of 9 mg/kg (SNFCT2012_03 Part C) and repeated doses from one to 20 mg/kg 
were studied (SNFCT2014_03) in haemodialysis patients. In healthy volunteers, SNF472 was generally well tolerated, 
except for the occurrence of mild to moderate local infusion site irritation. Infusion site irritation is not an issue in HD 
patients, as SNF472 is injected into the HD tubing and passes through a volume of blood of at least 200 mL before 
reaching the patient’s blood vessels. 
Treatment-emergent adverse events (AEs), assessed as probably related to the IP, were infusion site pain, infusion 
site erythema, infusion site hypoaesthesia, and infusion site swelling. A single patient on the 9 mg/kg dose developed 
mild tingling of short duration twice (at 30 minutes and 2 hours) during the infusion. No treatment was required. 
Treatment-emergent AEs assessed as possibly related to the IP were injection site bruising, headache, dizziness, pain 
in extremity, lip tingling, and myalgia. 
A preliminary analysis of the SAD study suggested that infusion of 5mg/kg, 9mg/kg and 12.5 mg/kg caused increases 
in QTcB in HVs. These changes mainly occurred within the normal range and values outside the normal range were 
close to the upper limit of normal. No values were seen above 500 mSec (risk of Torsdes des Pointes). Mechanistically 
this can be explained by chelation of ionized Ca. It is also clear from limited data currently available that decreased 
ionized Ca is not a risk in HD patients due to slow infusion of SNF472, dilution of SNF472 in at least 200 cc of blood 
within dialysis machine tubing prior to entering the blood vessels, and because Ca concentrations are buffered by the 
Ca content of dialysate fluid across a semipermeable membrane. Overall, the data available suggest a favourable 
benefit/risk ratio. 
2.3.1. 
Efficacy 
Myo-inositolhexaphosphate prevents vascular calcification in non-uremic and uremic animal models. Published studies 
[16, 17, 44], as well as the non-clinical studies with SNF472 have shown that parenteral IP6 significantly prevents 
vascular calcification by between 60% and 95% in animal models. The SNF472 efficacy data obtained in animals have 
helped characterise the concentration-effect relationship and were used to predict potential doses for human clinical 


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studies. The maximum therapeutic effect was observed at either a dose of 1 mg/kg in rats in the vitamin D model or 
plasma levels in the 5000-10000 ng/mL (7.5-15 µM) range, depending on the specific model used. 
In animal models of calciphylaxis, where a dystrophic calcification in rat’s soft tissues is induced, IP6 clearly reduces 
plaque formation (calcinosis cutis) induced by KMnO4. Calcification was significantly lower in animals receiving IP6. In 
rats sacrificed two days after KMnO4 treatment calcified deposits were only found in injured tissues of non-IP6 treated 
groups (Study No EF2004_10 [45, 46]). 
IP6 has also been shown to inhibit mineralisation in vitro of MC3T3 –E1 osteoblasts cultures [28]. The potential 
mechanism is through binding to growing HAP crystals and by induction of osteopontin expression. When human 
mesenchymal stem cells (pre-osteoblasts) were incubated with IP6, bone formation activity was enhanced [29]. 
SNFCT2012_03 Pharmacodynamic Data: 
Pharmacodynamic assessments (calcification potential of plasma [47]), in healthy volunteers showed a 80% inhibition 
at 5 mg/kg SNF472, which appeared to plateau thereafter since the effects were the same for the 9 and 12.5 mg/kg 
doses.  
SNFCT2012_03 Pharmacodynamic Data: 
Pharmacodynamic assessments in haemodialysis patients showed an 80% inhibition at 9 mg/kg SNF472.  
SNFCT2014_03 Pharmacodynamic Data: 
Pharmacodynamic assessments in haemodialysis patients showed an 80% inhibition from 5 mg/kg SNF472 onwards. 
Less than 20% effect was seen at 1 mg/kg. 
 
2.3.2. 
Safety 
SNF472 was studied in rats and dogs in different toxicology and safety studies, which range from 28 days up to 3 
months of treatment.  
In the 28-day studies in rats high concentrations produced local irritation. In the 13-week studies, 15-minute daily 
intravenous administration of SNF472 in rats and dogs induced no mortality and there were no findings attributable to 
a direct systemic effect of SNF472.   
The cardiovascular and respiratory safety pharmacology was assessed in anaesthetised rats and conscious dogs (28-
day toxicology and telemetry). In rats, SNF472 did not show any clinically relevant effects on heart rate or blood 
pressure. In rats and dogs, no effects on respiratory parameters were observed. In dogs, the ECG was evaluated in a 
28-day IV (~6-minute bolus) and in a GLP telemetry study. There was a slight heart rate increase in males and females 
only at the highest dose (30 mg/kg; Cmax: 359432 ng/mL). These effects appear to be Cmax-related. In the telemetry 


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study SNF472 was administered as long infusion periods (2 hours) and short infusion times (6-minute bolus). Plasma 
SNF472, calcium, and potassium levels were evaluated. Health status, body weight, cardio-respiratory function, ECG, 
body temperature, total (serum), and free (blood) concentrations of potassium were not affected by a 2-hour infusion 
of SNF472 at 3 mg/kg, 10 mg/kg, or 30 mg/kg. QTc prolongation was observed with the 6-minute bolus at 30 mg/kg, 
but no QTc prolongation was seen with the 2-hour infusion at any of the doses. During the 2-hour infusion, plasma 
concentrations achieved similar Cmax values (318180 ng/mL) as with a bolus (although this might be an under-
estimation as it is difficult to pinpoint Cmax after a bolus injection). 
Please refer to the Investigators Brochure [26] for further toxicology data. 
SNFCT2012_03 Healthy Volunteers Safety data 
There were no SAEs, no deaths, and no withdrawals due to AEs during the study. The number of subjects with TEAEs 
(Treatment emergent adverse event) was similar for all dose groups. TEAEs were mostly mild in intensity and 3 
episodes of moderate intensity were reported for the 5.0 mg/kg SNF472 dose and 4 episodes for the 12.5 mg/kg dose. 
No clinically significant changes were observed in plasma calcium levels. Although ionised calcium levels were 
measured, several errors occurred in terms of sampling and analysis:  
• 
As a result of incorrect handling and extraction of samples, the majority of the samples could not be 
analysed.  
• 
Due to analytical errors, several results in the samples analysed were considered invalid. 
The most complete data from ionised calcium set was obtained for the 5 mg/kg dose. In the 12.5 mg/kg dose, there 
appeared to be a decrease in ionised calcium within the normal range. The baseline values for the other doses were 
limited. No formal statistical analysis could be done due to the sparse data. In an attempt to get an idea of baseline 
values in the study populations, we used the ionised calcium before the infusion of placebo or active drug was started, 
as well as the 12-hour values (8 hours after Cmax at a time when no SNF472 was detectable in the blood) and we 
compared with values obtained around tmax and per dose. Hence, the ionised calcium concentrations seem to be similar 
to the pooled baseline values with 5 mg/kg of SNF472. With the 9 mg/kg dose, the two available values seem to be at 
the lower end of the distribution of baseline values, whereas with 12.5 mg/kg dose, two of the three available values 
are below the baseline values. The data, although sparse, suggest that there possibly was a dose-related decrease in 
ionised calcium. 
There were, however, no clinical features of hypocalcaemia or clinically relevant increases in QTc observed with any 
of the three doses evaluated. SNF472 concentrations achieved with 12.5 mg/kg were around eight-fold higher than the 
anticipated therapeutic concentrations.  


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Figure 1 Ionised calcium concentration at the time of peak concentrations with each dose compared to baseline. 
Baseline values are a (placebo pre-dose and at 12 hours, b (active treatment pre-dose) and c (active treatment at 12 
hours). (mmol/L). Green line: Normal range:1.17-1.30 mmol/L. Red line: 0.5 mmol/L: possibility of tetany and potentially 
life-threatening 
The planned doses in the protocol were 0.5, 1.5, 5, and 10 mg/kg. PK simulation based on preclinical data predicted 
plasma concentrations (Cmax; ng/mL) of 3000, 10000, 30000 and 70000 respectively. After the 1st cohort (0.5 mg/kg), 
the DESC (Dose Escalation Safety Committee) decided to increase the dose to be tested in the 2nd cohort (1.5 mg/kg) 
to 5 mg/kg. This decision was based on PK results showing much lower values than the anticipated systemic exposure 
of around 2500 ng/mL as predicted by the PK model (levels were below the limit of quantification of 500 ng/mL). 
According to new PK estimations, 5 mg/kg was expected to produce the initially expected level of exposure with 1.5 
mg/kg. The Cmax with 5 mg/kg was 11571 ng/ml, which is nearly triple the anticipated EC50. Using the PK data of the 
5 mg/kg dose and the safety data after each cohort, the DESC decided to modify the following two doses to reach the 
target concentrations. The doses of 9 and 12.5 mg/kg produced SNF472 plasma levels of 24394 and 42207 ng/mL, 
respectively. 
SNFCT2012_03 and SNFCT2014_03 Haemodialysis Patients. Safety data 
The single dose study in haemodialysis patients (SNFCT2012_03) and up to 28-day MAD study in haemodialysis 
patients (SNFCT2014_03). Both have been finalised. The dose range explored in these 2 studies was between 1 mg 
and 20 mg/kg, and in the MAD 10 mg/kg was administered 3 times a week for one month.  Although unblinded, the 
data are still being analysed, the PK results suggest dose-linearity, no accumulation, and an exposure at 20 mg/kg in 
the range of 68000 ng/mL. Expected therapeutic levels are around 5000 ng/mL. The preclinical safety margin is 


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established in 127291 ng/mL. No significant safety and tolerability issues were reported. One single SAE was observed, 
not related with the drug.  
As a conclusion for Phase 1 clinical trials performed with SNF472 up to date: treatment-emergent adverse events seen 
exclusively in healthy volunteers and not in HD patients, and assessed as probably related to the investigational 
medicinal product (IMP), were infusion site pain, infusion site erythema, infusion site hypoesthesia, and infusion site 
swelling. Treatment-emergent adverse events, assessed as possibly related to the IMP, were injection site bruising, 
headache, dizziness, pain in extremity, eyelid injury, and myalgia. These effects were not seen in HD patients. A single 
SAE was recorded and was not related to treatment. No clinical significant effects were observed on vital signs, or in 
the laboratory tests.  ECGs, including the QTc interval, was fully evaluated and no clinically significant effects were 
observed.  It showed the following: 
o   QTcB prolongation in HV was found (all values were below 450 msec).  Sparse ionised calcium data 
suggested mild hypocalcaemia, correlating with QTcB 
o   QTcB prolongation in HD patients occurred with active as well as placebo treatment. It was not 
associated with hypocalcaemia and a relationship to chelation of calcium can be ruled out 
QTc changes are often seen in HD patients and can be due to the composition of the dialysis fluid, underlying 
cardiovascular disease, changes in Ca, Mg, or K, or due to medication. As HD patients showed no significant decreases 
in ionized Ca, SNF472 does not affect hERG channels and QTcB prolongations also occurred in placebos; an SNF-
related effect is therefore highly unlikely. 
 
2.3.3. 
Galenics 
SNF472 administered i.v. is 100% bioavailable. No compliance issues will be expected with the IV route in patients 
who undergo regular dialysis. 


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3. 
STUDY OBJECTIVES 
This is an open label, single arm clinical trial to investigate the effect of SNF472 in uraemic calciphylaxis patients, on 
top of standard of care. The study objective is to evaluate the effect of SNF472 on top of standard of care on promoting 
wound healing and other parameters of therapeutic response in haemodialysis patients with CUA. “Standard of care” 
of calciphylaxis is not defined by evidence or guidelines. However, experts in the field suggest a personalised 
management plan for each patient based on a list of potential measures which have recently been summarized [39, 
41]. 


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4. 
OVERALL DESIGN AND PLAN OF THE STUDY 
4.1. 
Overview 
The study will be done together with Prof. Vincent Brandenburg, MD, as the main Principal Investigator and coordinator 
of the study. To reach the study objectives, 15 evaluable CUA patients who complete the 12-week treatment period 
will be enrolled 
The primary investigator, Prof. V Brandenburg, will be responsible for the diagnosis of CUA together with the locally 
treating physician at the study site (team decision, two-pairs-of-eyes decision). The decision to include the patient into 
the study should be made based on the following criteria [48]:   
• 
The diagnosis of calciphylaxis can be made when: 
1. The following clinical features are all present, or 
2. Two of the following clinical features and typical histopathological findings are present 
• 
Clinical features: 
1. A patient on chronic haemodialysis or haemofiltration or haemodiafiltration for chronic kidney disease  
2. More than 2 painful and non-treatable skin ulcers with concomitant painful purpura 
3. Painful and non-treatable skin ulcers on the trunk, extremities, or penis with concomitant painful purpura 
• 
Histopathological findings: 
Skin biopsy is recommended only if the three clinical findings presented above are not present and will be left 
to the discretion of the treating physician. Typical histopathological findings of the skin are as follows: 
- Necrosis and ulceration of the skin with calcification of the tunica media and internal elastic membrane of 
small to medium-sized arterioles of dermis and subcutaneous fat  
- Concentric stenosis due to oedematous intimal thickening of the small to medium-sized arterioles of 
dermis and subcutaneous fat 
Intense pain as primary manifestation followed and associated with cutaneous lesions and palpation of firm calcified 
(leather-like) subcutaneous tissue surrounding the lesion is suggestive of calciphylaxis. Typically, the lesions do not 
occur at sites primarily affected by venous insufficiency or arterial malperfusion. In view of the painful character of the 
lesions, palpation is left to the discretion of the treating physician.  
The diagnosis of calciphylaxis can be supported by findings obtained from a skin biopsy. Benefits of a biopsy include 
exclusion of other conditions that can mimic calciphylaxis such as vasculitis. The characteristic histological features of 
calciphylaxis include calcification, microthrombosis, and fibrointimal hyperplasia of small dermal and subcutaneous 


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arteries and arterioles, leading to cutaneous ischemia and intense septal panniculitis. Von Kossa or Alizarin red staining 
are required to detect micro calcification. Prof Kerstin Amann, Erlangen, will be the core lab for assessing the biopsies 
[39-41].  
Performing a skin biopsy will be left to the discretion of the treating physician and will be performed following the site’s 
SOPs. In case the biopsy is performed as a routine procedure at the site, and the result is positive for CUA, the patient 
is included – as long as the “gatekeeper”, namely Prof Brandenburg, agrees with the remaining diagnostic parameters. 
If the biopsy is negative, Prof. Brandenburg will check the biopsy results and will decide if he agrees or disagrees with 
the remaining diagnostic parameters to include or not the patient.  
In order to have readable biopsies, the following requisites need to be fulfilled: 
1. site of biopsy: the biopsy should include the ulcer borders, not the necrotic core, and be deep enough to 
show deep skin layers 
2. the biopsy material should be fixed in either formalin or paraformaldehyde or glutaraldehyde  
3. paraffin blocks should be mailed to the core pathology lab (Prof K Amann, Erlangen, Germany), where 
appropriate stains such as EVG, von Kossa, etc. will be performed 
Wound treatment of calciphylaxis ulcerations will be performed according to local good clinical practice SOPs of the 
corresponding clinical site irrespective of the fact that the ulceration might be evaluated as treatment target within the 
trial. Such a wound treatment SOP might include the interdisciplinary team approach by nephrologists, dermatologists, 
(plastic) surgeons, and specialized nurses. 
4.2. 
Endpoints 
4.2.1. 
Primary endpoint   
• 
The primary lesion is the largest one – based on longitudinal and transverse measurements - and the one to 
be followed through imaging throughout the duration of the study by taking pictures of the lesion (more details 
concerning the imaging of the lesions will be addressed in the imaging manual) 
• 
A maximum of 3 lesions – including the primary one – will be thoroughly assessed during the study 
• 
Lesion score (Bates-Jensen Wound Assessment tool [49]) will be performed during Weeks 1, 2, then 4, 6, 8, 
10, 12, and EOS (FU) visit. Of note, elements of the Bates-Jensen Wound Assessment tool which imply 
probing the wound or measuring its depth are left to the discretion of the treating physician at the site and are 
not compulsory 
4.2.2. 
Secondary endpoints  
• 
Wound infection, both for the primary and the secondary lesions 


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• 
Systemic infection 
• 
Surgical treatment of the wound 
• 
Hospitalisation defined as being admitted for >24 hours 
• 
Course of the secondary lesions defined clinically as for the primary [49]  
• 
Change in pain from week 0 to 12 according to 100 mm Visual Analog Pain Scale (VAS) 
o Pain scale done at Screening, weeks 1, 2, 4, 6, 8, 10, 12, and EOS (FU) visit 
• 
Change in dose and type of pain medication assessed as a continuous variable. Name (INN), dose, and 
number of pills captured. 
• 
Wound QOL score done at Screening and weeks 1, 6, and 12  
• 
Death 
4.3. 
Justification of the Clinical Trial Design 
Preclinical data with SNF472 supports the hypothesis that the compound is able to prevent cardiovascular calcification 
(CVC). Calciphylaxis is a rare condition with a high mortality rate. It is characterised by progressive painful, necrotic, 
skin ulcerations, and calcification of blood vessels. It occurs mostly (98% of cases), but not exclusively, in patients with 
ESRD, where it is also referred to as Calciphic Uremic Arteriolopathy (CUA). “Standard of care” of calciphylaxis is not 
defined by evidence or guidelines. However, experts in the field suggest a personalised management plan, taken from 
each calciphylaxis patient a personalized selection from a homogenous list of measures to be taken which have 
recently been summarized [39, 41]. Since there is no standard of care and one-year mortality rates are about 50% -in 
a year, the study is open-label and has no placebo control arm.  
Phase 1 clinical trials with SNF472 have been completed in healthy volunteers and in patients on haemodialysis. The 
impact of renal failure and the effect of dialysis on the PK of SNF472 have been assessed, both in single and multiple 
dosing and up to one month of treatment. Calciphylaxis patients are HD patients; hence SNF472 is expected to have 
the same PK/PD and safety features. 


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5. 
STUDY POPULATION 
The clinical trial population will consist of male or female HD patients diagnosed with CUA, who are 18 years or older. 
Participants must be able to provide written informed consent and meet all the inclusion criteria and none of the 
exclusion criteria. 
The Investigator will be required to keep a record of patients who were considered for enrolment but not enrolled, 
e.g., patient screening log, according to local procedures. This information is necessary to establish that the patient 
population is selected without bias. 
5.1. 
Number of Patients 
It is planned to include 15 male or female CUA patients who complete the 12-week treatment period. 
Patients who leave the clinical trial before being entered into the study will be considered as screening failures and will 
always be replaced. Therefore, sufficient reserve patients should be recruited, where possible. Patients withdrawn after 
dosing may be replaced as needed to obtain 15 patients who complete the 12-week treatment period. 
See Section 9.5 for a discussion of sample size. 
5.2. 
Recruitment 
For this study, both non-hospitalised and hospitalised calciphylaxis patients will be recruited after obtaining written 
informed consent, with a preference for non-hospitalised patients, wherever possible. 
Patients will be approached to participate in the study during the Screening period. 
5.3. 
Inclusion Criteria 
Patients who meet the following criteria will be considered eligible to participate in the clinical trial: 
1. Patients with either newly diagnosed CUA OR recurrent CUA that has been dormant with no skin lesion 
involvement for at least 90 days from study start (new or recurrent diagnosis must be made within 5 weeks of 
study start) 
2. Patients who signed the written informed consent to participate in this clinical trial (prior to any clinical 
trial-related procedures being performed), after reading the Patient Information Sheet and Informed Consent 
Form (ICF), and who had the opportunity to discuss the clinical trial with the Investigator or designee 
3. Males or females aged ≥18  
4. Patients on maintenance haemodialysis 
5. Patients with at least a minimum level of pain on VAS scale or on pain-killers stronger than NSAIDs 


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6. Females of child-bearing potential should use a highly effective contraceptive measure throughout the study 
AND have a negative serum pregnancy test at entry. Male patients having sexual relationship in which 
pregnancy can occur should take adequate contraceptive precautions (wear a condom) (see Section 8.3.1.) 
5.4. 
Exclusion Criteria 
Patients who meet one or more of the following criteria will not be considered eligible to participate in the clinical trial: 
1. Body weight above 150 kg 
2. BMI >35 and central(abdominal) ulcers  
3. History of bisphosphonate treatment within 12 months before entering into the study 
4. Severely ill patients without reasonable expectation of survival for > 6 months according to the treating 
physician 
5. Patients with scheduled parathyroidectomy during the run-in or study period 
6. Female patients who are either intending to get pregnant or are undergoing treatment to get pregnant, as well 
as breast-feeding females 
7. Participation in another clinical trial with an experimental drug within 90 days prior the inclusion 
8. Any psychological, emotional problems, any disorders or resultant therapy that is likely to invalidate informed 
consent, or limit the ability of the patient to comply with the Clinical Trial Protocol requirements 
9. Patients who, in the opinion of the Investigator, are considered unsuitable for any other reason  
5.5. 
Patient Withdrawal and Replacement 
A patient is defined as having entered the clinical trial when he/she has provided written informed consent. A withdrawal 
is a patient who receives a study patient code and for whom treatment is prematurely terminated for any reason. 
Possible reasons for withdrawal of a subject from the clinical trial: 
• 
Subject does not fulfil inclusion criteria 
• 
AE(s) 
• 
Withdrawal of consent 
• 
Subject lost to follow-up 
• 
Protocol violation 
• 
Pregnancy  
• 
Other reasons as judged by the investigator (see also 7.1.4 12-Lead Electrocardiogram abnormalities) 
Patients may withdraw consent for participation in the clinical trial at any time without penalty and for any reason without 
prejudice to his or her future medical care. The patient does not need to give a reason for withdrawal of consent. The 


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Investigator is also free to terminate a patient’s involvement in the clinical trial at any time, if the patient’s clinical 
condition or non-compliance warrants it. The Sponsor or the Regulatory Authorities may request termination of the 
clinical trial if there are concerns about study conduct or safety.  
In all cases, the reason(s) for withdrawal and the primary reason or failure to provide a reason, must be recorded in 
the Case Report Form (CRF).  
If a patient is withdrawn, or chooses to withdraw, from the clinical trial for any reason, the Investigator must make every 
possible effort to perform the evaluations described for the End of Study Visit (see Section 8.2.5) or to verify the health 
status of the patient by calling the national death registry. Withdrawn patients may not re-enter the clinical trial. 
Entered patients who leave the clinical trial before receiving a study patient code will be considered as screening 
failures and will be replaced.  
Patients who are withdrawn from the study may be replaced at the discretion of the Sponsor and Principal Investigator. 
Replaced patients will receive the whole treatment. 
All patients who experience a clinically significant AE (in the opinion of the Investigator) which is ongoing either at the 
time of withdrawal or at the End of Study Visit, will be followed up at appropriate time intervals until the AE is resolved 
to the satisfaction of the Investigator. Since it is unpredictable how long such a follow-up will take, data from this 
follow-up generated after study finalization will be recorded by the Investigator in the source documents and reported 
to the Drug Safety and Pharmacovigilance department, but not necessarily collected in the CRF and the database. 
However, full details regarding this follow-up will be described in the Clinical Study Report. 


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6. 
INVESTIGATIONAL MEDICINAL PRODUCT 
6.1. 
Identity of the Investigational Medicinal Products 
Information regarding the dosage form, appearance, and manufacturer of the IMP are presented below: 
 
SNF472  
Code name: 
SNF472 
Description: 
Transparent 
Presentation: 
Liquid 
Strength: 
30 mg/ml or 90 mg/ml  
Dose: 
Dose will be adjusted by body weight. 
 
To simplify logistics, body weights will be divided into 4 body weight categories, in 
order to homogenise the exposure of patients to the drug. The body weight used to 
classify the subject into the four categories will be only the dry body weight from the 
Screening visit. 
 
 The dose will be as follows: 
 
Category 
Patient Body Weight 
Range (kg) 
  
Total Dose 
(mg) per 
patient 
1 
50 
65.9 
400 
2 
66 
80.9 
450 
3 
81 
110.9 
700 
4 
111 
150 
900 
  
All details of the procedure are described in the Pharmacy Manuals for each 
concentration. 
 
SNF472 will be manufactured by Patheon UK Limited and Laboratorio Reig Jofre S.A., and packaged, labelled, and 
supplied by CSM (formerly B&C) Group, where SNF472 will be stored and shipped to either the Pharmacy Services at 
the Clinical Units or directly to the Clinical Units. 
6.2. 
Dose Rationale 
The dose selected has a range of 5.6 mg SNF472/kg to 9 mg SNF472/kg depending of subject weight. This dose range 
was well tolerated in Phase 1 clinical trials (SNFCT2012_03 and SNFCT2014_03), and is selected to be the anticipated 


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therapeutic dose, reaching concentrations to be at the plateau of the PK/PD relationship (see SNFCT2014_03 CSR).  
To adjust the dose per kilogram, subjects are divided into 4 body weight categories (see Pharmacy manual for details). 
Dose levels of SNF472 from 1 to 20 mg/kg were tested in Phase1b/2 trials (SNFCT2014_03) for 1 week and 10 mg/kg 
for 1 month, without any AE/SAE related with the compound. Cmax values expected at the dose selected are not 
exceeding (6-fold below) the Cmax of 127,291 ng/mL, which was the NOAEL concentration determined in dog pre-
clinical studies. 
6.3. 
Supply, Packaging, Labelling and Storage 
The IMP at CSM (formerly B&C) will be stored in accordance to with the manufacturer’s instructions (-20ºC). The IMP 
will be labelled according to the applicable local health authority, FDA and EMA requirements. CSM Group will send 
the IMP to the Clinical Unit. All IMP shipments will be carried out on dry ice. 
All supplies of SNF472 must be stored on site at 5ºC (±3ºC). The preparation of the patient doses will be described in 
the Pharmacy Manual. There will be two Pharmacy Manuals, one for the 30 mg/ml vials and another for the 90 mg/ml 
vials. The 30 mg/ml vials are packaged in boxes of 9 vials. The 90 mg/ml vials are packaged in boxes of 3 vials. 
6.4. 
Drug Accountability, Dispensing and Destruction 
The Investigator is responsible for maintaining accurate accountability records of the IMP throughout the clinical trial. 
Each administration of the IMP will be documented in the CRF. 
The Investigator is responsible for returning all unused or partially used IMP to the Sponsor or overseeing the 
destruction of unused IMP. The IMP return or destruction will only occur after the drug accountability has been 
performed, and any discrepancies there may have been resolved by the Clinical Units. 
6.5. 
Patient Identification 
At the Screening, each patient will be identified using a unique Identification Number. 
Each patient will receive a Patient ID on Day 1 (of the Treatment Period) after eligibility for the clinical trial has been 
confirmed. The first two letters will correspond to the country where the Clinical Unit is located, the next two/three digits 
will correspond to the Clinical Unit and the last two/three digits will correspond to the patient. 
Patients who withdraw or are withdrawn from clinical trial participation for any reason, regardless of whether IMP was 
administered or not, will retain their Patient ID and the patient will not be allowed to re-enter the clinical trial.  


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6.6. 
Administration of Investigational Medicinal Products 
The IMP administration will consist of a single IV dose of SNF472 over a minimum of 2.5 and a maximum of 4-hour 
period during the patient’s dialysis session. A minimum of 2.5 h of infusion is required.  
The exact infusion starting and stopping times will be recorded in the CRF. 
The appropriate volume of the investigational product will be administered as a constant rate IV infusion using a 100 mL 
bag of saline connected directly to the dialysis machine via an IV giving set, but always BEFORE the dialysis filter. The 
constant rate IV infusion will be carried out using an infusion pump for saline bags. SNF472 should NOT be 
administered directly intravenously.  
The type of dialysis machine used will be documented in the CRF. The method of administration will be as follows: 
 
Figure 2 Cartoon of the method of administration including the dialysis machine. 
For sites belonging to the FRENOVA network please look at reference [50]. 
Any dosage interruptions will be recorded in the CRF (i.e., infusion stop and start times). In case there is an interruption 
of the infusion, once the infusion is re-started, the aim should be to deliver the whole dose, even if this takes longer 
than originally planned.  


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6.7. 
Compliance 
The Principal Investigator or designees will administer/oversee the administration of all IMPs. In addition, the following 
measures will be taken to ensure treatment compliance: 
• 
The Investigator will attempt to enrol subjects able to understand and comply with the clinical trial 
• 
The exact day and the starting and stopping IMP infusion times will be recorded in the CRF 
• 
The Investigator will maintain accountability records showing the quantities of IMPs received at the Clinical Unit 
and dispensed to each patient 
Any unused IMP, including empty, or partially used containers will be accounted for and returned to the manufacturing 
site for destruction after obtaining written Sponsor approval. 
6.8. 
Concomitant Medications 
6.8.1. 
Prior and Concomitant Medication 
Any medicinal products, prescribed, or OTC taken by a patient other than the IMPs, are considered concomitant 
medication. 
At screening, the patients’ medical history and drug history will be recorded in the CRF under the medical history and 
treatment history sections. The drug history of the patient will include all medications taken in the last 6 months prior 
to study start. After screening, all medication (along with their daily dosage, duration, and reasons for administration) 
taken by patients will be recorded in the CRF under the concomitant medication section.  
At each subsequent clinical trial visit, patients will be asked about what concomitant medications they have taken since 
the last visit. Any changes in the dose or dosing regimen of the concomitant medication must be recorded in the CRF. 


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7. 
VARIABLES AND METHODS OF ASSESSMENT 
Refer to Table 1 for information regarding when each assessment will be performed. 
For this clinical trial, a paper CRF will be utilised for data collection at the clinical sites.  Data from the CRFs will be 
entered into a clinical database using the DataFax software hosted by DF/net Research, Inc. 
At baseline and for inclusion criterion purposes, several pictures of the main wound can be taken and emailed to the 
study PI so that he can decide which one is the one to be designated as “the” main wound. In following visits, the same 
wound has to be imaged so that the course of the wound can be assessed. 
Image analysis software will be used. Each patient will have a personalised colour reference card with a unique 
barcode. This card should be placed next to the skin lesion before the image is taken, so that all wound images can 
be normalised in geometry, colour, and contrast in order to support quantitative measurements. The pictures of the 
wounds, primary, secondary, and tertiary, will be transferred to the database where they can be easily linked to their 
corresponding visit.  
7.1. 
Safety Variables 
7.1.1. 
Medical History, Demographic, and Anthropometric Information 
The medical history comprises: 
• Previous illnesses and surgical procedures 
• Family history 
• History of drug and alcohol abuse 
The treatment history will include all medication the patient has taken or is currently taking up until the Screening visit. 
The following demographic and anthropometric information will be recorded at the Screening Visit: 
• Age 
• Sex 
• Race (Caucasian, Hispanic, African-American, Asian or other) 
• Ethnicity (Latino or Hispanic, non-Latino or non-Hispanic) 
• Body weight (dry weight), without shoes (kg) (if without shoes is not possible then same conditions at each 
body weight measurement) 


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7.1.2. 
Adverse Events 
7.1.2.1. 
Management of Adverse Events 
The Investigator will carefully monitor each patient for AEs. In addition, the information on AEs will be obtained by 
regular questioning of each patient by the clinical trial staff. No leading questions should be asked. When an AE occurs, 
the Investigator will decide whether to withdraw the patient from the clinical trial and/or initiate appropriate treatment.  
In the case of any event requiring medical intervention occurring during the Treatment Period, the Investigator will 
institute general supportive measures including, where necessary, respiratory assistance and cardiopulmonary 
resuscitation. 
7.1.2.2. 
Definitions 
An adverse event (AE) is any unfavourable and unintended sign, symptom, or disease that appears or worsens in a 
subject or clinical investigation subject during the period of observation in a clinical study.  
The adverse event may be any of the following: 
- 
A new illness, 
- 
An exacerbation of a sign or symptom of the underlying condition under treatment or of a concomitant illness 
(including abnormal laboratory finding) 
- 
Unrelated to participation in the clinical study or an effect of the study medication or comparator drug, or 
- 
A combination of one or more of the above factors. 
No causal relationship with the study medication is implied by the use of the term “adverse event.” An exacerbation of 
a pre-existing condition/illness is defined as a more frequent occurrence or as an increase in the severity of the pre-
existing condition/illness during the study. Planned or elective surgical or invasive procedures for pre-existing 
conditions that have not worsened are not adverse events. However, any complication that occurs during a planned or 
elective surgery is an adverse event. (If the event fits the seriousness criteria, such as an extended hospitalisation, it 
will be considered a serious adverse event.) Conditions leading to unplanned surgical procedures may be adverse 
events. 
In order for the Sponsor to collect additional information about the clinically important laboratory or diagnostic tests 
(eg, blood, urinalysis, ECG, imaging) abnormalities, at a minimum, the following abnormalities should be captured on 
the AE CRF: 
• 
Any test result that meets the criteria for a SAE 
• 
Any test abnormality that suggests a disease and/or organ toxicity that is new or has significantly worsened 
• 
Any test abnormality that required the subject to have study medication discontinued or interrupted 


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• 
Any test abnormality that required the subject to receive specific corrective therapy, close observation, more 
frequent follow-up assessment, or further diagnostic investigation 
Laboratory test abnormalities may not be of clinical significance in the absence of: 
• 
Clinical symptoms 
• 
Change in lifestyle 
• 
Need for intervention 
Only clinically significant test abnormalities should be reported as AEs.  Determination of the clinical significance of 
test abnormalities is the responsibility of the Investigator. In particular, Grade 1 or 2 haematology, chemistry, 
abnormalities should be carefully considered for clinical relevance by the Investigator, as they are less likely to be of 
clinical significance as compared to Grade 3 or Grade 4 abnormalities.  Haematology and chemistry abnormalities 
determined to be clinically relevant will be assigned a severity rating by the Investigator.  A clinical diagnosis, rather 
than the changes in laboratory or other assessment should be recorded on the CRF as appropriate (eg, anaemia 
versus low haemoglobin value, bundle branch block rather than abnormal ECG). 
All AEs, including intercurrent illnesses, occurring during the clinical trial will be documented in the CRF. Concomitant 
illnesses that existed prior to entry into the clinical trial will not be considered AEs unless they worsen during the 
Treatment Period. Pre-existing conditions will be recorded in the CRF on the Medical History or appropriate page. 
7.1.2.3. 
Assessment of Adverse Events 
The Investigator will assess each AE according to the categories discussed in the sections below. 
7.1.2.3.1. 
Seriousness 
A SAE is defined as any untoward medical occurrence that at any dose: 
• 
Results in death 
• 
Is life-threatening; this means that the patient was at risk of death at the time of the event; it does not mean that 
the event hypothetically might have caused death if it were more severe 
• 
Requires hospitalisation or prolongation in existing hospitalisation 
• 
Results in persistent or significant disability or incapacity 
• 
 Is a congenital anomaly or a birth defect 
• 
Is an important medical event that may not result in death, be life threatening, or require hospitalization, but may 
be considered an SAE when, based upon appropriate medical judgment, it may jeopardize the subject and may 
require medical or surgical intervention to prevent one of the outcomes listed in this definition 


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Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for 
allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalisation, or development of drug 
dependency or drug abuse. 
Note that an AE or suspected adverse reaction is considered “life-threatening” for reporting as an SAE if, in the view 
of either the Investigator or the Sponsor, its occurrence places the subject at immediate risk of death.  It does not 
include an AE or suspected adverse reaction that, had it occurred in a more severe form, might have caused death. 
The following events do not meet the definition of an SAE with regard to hospitalization:  planned hospitalization for a 
condition present prior to the subject’s enrolment in the study, hospitalization of the subject for compliance/convenience 
reasons, planned hospitalization for an elective medical/surgical procedure, scheduled treatments, or routine 
check-ups, or a hospitalization or an emergency room visit lasting less than 24 hours. 
7.1.2.3.2. 
Intensity 
The Investigator will assess the severity of AEs according to the following definitions: 
• 
Grade 1 (Mild):  asymptomatic or transient, short in duration (< 1 week), no change in lifestyle, and/or no 
medications required. 
• 
Grade 2 (Moderate):  symptomatic, duration (1 to 2 weeks), alters lifestyle occasionally, medication relieves 
symptoms (may be prescription), and/or study medication is continued.   
• 
Grade 3 (Severe): prolonged symptoms, reversible, major functional impairment; prescription medications 
provide partial relief; may be hospitalized < 24 hours; temporary or permanent study medication 
discontinuation. 
• 
Grade 4 (includes Life threatening):  at risk of death; substantial disability, especially if permanent; 
hospitalized > 24 hours; permanent study medication discontinued. 
7.1.2.3.3. 
Causality 
The Investigator will assess the causality/relationship between the IMP and the AE and record that assessment in the 
CRF. The most likely cause of an AE/SAE (e.g., disease under treatment, concomitant disease, concomitant 
medication, other) will be indicated in the CRF with details of the concomitant disease, medication, or other cause. 
The causal relationship of the AE to IMP will be described in terms of: 
• 
Possible: the AE: 
- Follows a reasonable temporal sequence from administration of the IMP 


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- Could be reasonably explained by the patient’s clinical state, environmental or toxic factors or other therapies 
administered to the patient 
- Follows a known pattern of response to the IMP 
• 
Unlikely: the AE: 
- Does not follow a reasonable temporal sequence from administration of the IMP 
- Could be reasonably explained by the patient’s clinical state, environmental or toxic factors, or other 
therapies administered to the patient 
- Does not follow a known pattern of response to the IMP 
- Does not reappear or worsen upon re-challenge 
• 
Not related: 
- The AE does not meet the above criteria 
- There is sufficient information that the aetiology of the AE is not related to the IMP 
The relatedness of SAEs will also be assessed and documented on the appropriate CRF page. 
7.1.2.4. 
Recording of Adverse Events 
Adverse events will be collected from the time a patient signs the ICF until the Follow-up Visit.  
All AEs, regardless of the relationship to IMP, must be recorded in the source documents (e.g., medical record) and 
will be recorded on the appropriate CRF pages, and documents provided by the Sponsor. 
All AE reports should contain a brief description of the event, date, and time of onset, date and time of resolution, 
intensity, treatment required, relationship to IMP, action taken with the IMP, outcome, and whether the event is 
classified as serious.  
Serious adverse events should be collected for up to 30 days after the last dose of the IMP for subjects unless the 
subject has withdrawn consent. This could be collected as a phone call. 
7.1.2.5. 
Reporting of Serious Adverse Events 
All SAEs that occur during the period of observation (from the first administration of the IMP until the Follow-up Visit) 
whether considered to be associated with the IMP or not, must be reported within 24 hours after knowledge of the SAE 
by email or fax to the Pharmacovigilance Department. 


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The minimal information required for an initial report is: 
• 
Sender of report (name, address of Investigator) 
• 
Protocol number 
• 
Patient identification (Patient ID, initials, NOT patient name) 
• 
Full description of SAE 
• 
Details of the IMP 
• 
Investigator Causality assessment 
However, as far as possible all points on the SAE form should be covered in the initial report and the completed SAE 
form must be emailed to the Pharmacovigilance Department (Viglya Pharmacovigilance Dept., Email: 
pv.sanifit@viglya.com, Fax.: 0034 93 1760213). In addition, the SAE must be documented in the CRF and documents 
provided by the Sponsor. 
In case the Pharmacovigilance Department cannot be contacted (e.g., after business hours or on weekends), an 
automated reporting service is available. The required information should be faxed and a message should be left on 
the voicemail service. 
A 24-hour emergency contact will be available during the conduct of the clinical trial. For medical emergencies, the 
following phone number will be available:  
Europe: +49 241 80 80202 or +49 241 89 89575 (24h) (principal investigator) 
USA: + 1 781-392-6057 (24 h)  
After receipt of the initial report, the Pharmacovigilance Department will review the information and, if necessary, 
contact the Investigator to obtain further information for assessment of the event. The Investigator will be responsible 
for informing the local Ethics committee (EC)/ Independent Review Boards (IRB), and central IRB as per local EC/IRB 
and central IRB requirements. The Sponsor, will be responsible for informing all Regulatory Authorities and the 
Investigators (if applicable), of findings that could adversely affect the safety of subjects or impact the conduct of the 
study and will report to regulatory authorities in conformity with expedited and periodic reporting requirements. 
Details for the reporting of Suspected Unexpected Serious Adverse Reactions (SUSARs) can be found in 
Section 7.1.2.7. 


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7.1.2.6. 
Follow-up of Adverse Events 
All AEs experienced by a patient, irrespective of the suspected causality, will be monitored until the event has resolved, 
any abnormal laboratory values have returned to baseline or stabilised at a level acceptable to the Investigator and 
Medical Monitor, until there is a satisfactory explanation for the changes observed, or until the patient is lost to follow-up. 
7.1.2.7. 
Suspected Unexpected Serious Adverse Reactions  
Any AE that is serious or associated with the use of the IMP and SUSARs have additional reporting requirements, as 
described below: 
• 
If the SUSAR is fatal or life-threatening, associated with the use of the IMP, and unexpected, Regulatory 
Authorities, the EC/IRB, and Investigators will be notified within 7 calendar days after the Sponsor learns of the 
serious adverse event. Additional follow-up (cause of death, autopsy report, hospital report) information will be 
reported within an additional 8 days (15 days in total) 
• 
If the SUSAR is not fatal or life-threatening but is otherwise serious, associated with the use of the IMP, and 
unexpected, Regulatory Authorities, the EC/IRB and the Investigators will be notified within 15 calendar days after 
the Sponsor learns of the serious adverse event 
The Sponsor will also provide annual safety reports to the Regulatory Authorities and the EC responsible for the clinical 
trial. These updates will include information on SUSARs and other relevant safety findings. 
7.1.2.8. 
Periodic Independent Safety Monitoring 
An independent medical monitor will evaluate the totality of safety information collected in the trial at the following time 
points: 1) when the first 5 patients have completed a full 12 weeks of treatment; 2) when the first 10 patients have 
completed a full 12 weeks of treatment; and at End of Study. The independent medical monitor will be appointed prior 
to the first time point and will be a qualified individual who is not directly involved in study conduct and is not a direct 
employee of the Sponsor or any Principle Investigator in the study. 
7.1.2.9. 
Pregnancy  
If a female clinical trial participant or a female partner of a male clinical trial participant who has been exposed to the 
IMP becomes pregnant, the course and outcome of the pregnancy should be monitored and documented. Pregnancy 
is not an AE; however, the Investigator should inform the Sponsor immediately of the pregnancy by submitting a 
completed SAE report form (for tracking purposes) and provide any available follow up information on the Pregnancy 
Outcome Report Form, including perinatal and neonatal outcome.  Protocol required procedures for study withdrawal 
must be performed on pregnant female subject unless contraindicated by pregnancy (eg, X-ray studies).  Other 
appropriate follow-up procedures should be considered if indicated. 


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7.1.3. 
Laboratory Assessments 
The safety laboratory assessments will be performed in accordance to the Schedule of Assessments: Table 1. 
Blood samples will be collected using a standard output from the dialysis lines (Figure 2). 
The safety laboratory analyses in blood will be performed at the local clinical units in EU and will be performed at a 
central laboratory in USA, according to their validated methods. 
Haematology and Clinical Chemistry 
• 
Haematology: Haemoglobin, haematocrit, mean corpuscular volume, mean corpuscular haemoglobin, mean 
corpuscular haemoglobin concentration, erythrocyte and leucocyte count and differential (absolute and 
percentage), and platelets 
• 
Clinical chemistry (serum): Creatinine, CK, total protein, albumin, cholesterol, LDL, HDL, triglycerides, glucose, 
BUN, bilirubin, sodium, potassium, calcium, phosphate, ALP, AST, ALT, and gamma-glutamyl transferase 
• 
Clinical chemistry (serum): magnesium, iron (ferritin and transferrin) 
• 
Heavy metals (total blood; collected in sodium heparin or EDTA (dark blue)): zinc 
• 
Ionised calcium (total blood)  
• 
Hb1Ac (total blood) 
• 
PTH (plasma, EDTA): We recommend blood samples for PTH measurement should be taken into tubes containing 
EDTA, ideally between 10:00 and 16:00, and plasma separated within 24 h of venepuncture. Plasma samples 
should be stored at 4°C and analysed within 72 h of venepuncture. If plasma is not available, PTH from serum 
samples is also accepted. 
Pregnancy Test 
A serum pregnancy test will be performed at Screening, in female patients of childbearing potential, followed by a urine 
pregnancy test on a monthly basis, should urine be available. 
7.1.4. 
12-Lead Electrocardiograms 
A 12-lead ECG will be obtained with the patient supine or semi-reclined and will be performed in accordance with the 
Schedule of Assessments (Table 1). 
The Investigator will perform an overall evaluation of the ECG strips for safety purposes and the recording will be 
reported as “normal”, “abnormal not clinically significant (NCS)”, or “abnormal clinically significant (CS)”. Abnormalities 


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of clinical significance should be recorded as an AE. Cardiac intervals: PRT axis, PR, QRS, QT, RR, HR, QTcB, and 
QTcF will be measured. 
Electrocardiogram Abnormalities  
As QTc prolongation is common in ESRD patients on HD and can occur due to underlying CVC disease, haemodialysis, 
sodium thiosulfate, calcimimetics, electrolyte disturbances (Ca, Mg and K) and overdoses of SNF472, careful QTc 
assessment is essential. Any QTc interval using Bazett’s formula (QTcB) >500 ms or increase >60 ms from baseline 
in 1 or more subjects as confirmed with consecutive ECGs will be considered abnormal. It will be reported as an AE if 
the investigator considers it clinically relevant. Investigators should use their discretion to monitor the subject, apply 
appropriate management and observe until the QTcB has decreased. At the discretion of the investigator, patients with 
persistent QTc prolongation may be withdrawn from the trial. 
7.1.5. 
Physical Examinations 
The physical examinations will be performed in accordance with the Schedule of Assessments: Table 1. 
The physical examination comprises a routine medical examination. 
The routine medical examination will be recorded as “normal” or “abnormal”. 
7.2. 
Haemodialysis-related Events 
The following events are known to occur during dialysis treatments: 
• 
Hypotension 
• 
Muscle cramps 
• 
Disequilibrium syndrome 
• 
Nausea and vomiting 
• 
Headache 
• 
Chest pain 
• 
Itching 
• 
Fever and chills 
• 
Pyrogen reaction 
• 
Hypertension 
Occurrence of these events during the dialysis treatment procedure should be recorded in the CRF and indicated as 
haemodialysis-related events. If any of these events are considered to be unrelated to the hemodialysis treatment 
procedure, they should be recorded as standard adverse events. 


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7.3. 
Pharmacokinetic and Pharmacodynamic Parameters 
7.3.1. 
Pharmacokinetic and Pharmacodynamic Blood Sample Collection and Handling 
Blood samples for PK and PD analyses of SNF472 will be collected according to the Schedule of Assessments  
(Table 1).  
See separate laboratory manual instructions for detailed description of PK and PD sample collection. 
The actual date and time of each blood sample collected will be recorded. 
Blood samples will be collected using one of the lines already connected to the patient (Figure 2).  
Approximately, 4 mL of blood at pre-dose and 4 mL of blood at end of infusion will be collected into polyethylene 
terephthalate (Vacutainer) tubes containing potassium (K3) EDTA. Samples will be divided into aliquots for PK and PD 
sampling according to the laboratory manual instructions. 
Tubes will be labelled with the following minimum information: clinical study number, Patient ID, sample type, day and 
time, primary or back-up sample (see sample label, Figure 3).  
Figure 3 Cryovial sample labels for sample collections 
        
 
All samples will immediately be placed on crushed ice and centrifuged (1900g for 10 minutes at 4°C) within 30 minutes 
of collection. The resultant plasma for each time-point will be divided into aliquots according to the laboratory manual 
instructions and transferred into appropriately labelled PET tubes (e.g., 1.8 mL storage cryovials). Plasma samples 
should be kept on dry ice at the site until courier collection. Samples will be stored at -80ºC.  


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Samples for GLP PK analysis will be packed on dry ice and shipped by courier to the CSM (formerly B&C) depot for 
storage in Europe: 
 
Attention: Mathieu Denis 
CSM Europe (formerly B&C) SA 
Watson & Crick Hill 
Rue Granbonpré 11 (Gate C) 
1435 Mont-Saint-Guibert, Belgium 
Phone: +32 (0)10 237 439 
Fax: +32 (0)10 470 860 
Email: mdenis@csmondemand.com 
 
Samples for GLP PK analysis will be packed on dry ice and shipped by courier to the CSM depot for storage in USA 
from Spectra: 
 
- 
Spectra Clinical Research 
8 King Road 
Rockleigh, NJ 07628, United States 
 
- 
YOURWAY TRANSPORT BIOPHARMA SERVICES 
6681 Snowdrift Road  
Allentown, PA 18106, United States 
Toll Free: 1 888-778-4555 
Office: 1 610-395-9198 
Fax: 1 610-391-9002 
Email: info@yourwaytransport.com 
 
All USA PK samples will be sent from Allentown, USA to CSM Group in Europe (to the address above). 
 


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When requested by sponsor, all primary samples will be shipped by courier on dry ice to Envigo for PK analysis: 
Attention:  
Monica Abellan 
Study Director, Department of Bioanalytics, Metabolism and Screening  
Envigo S.A.  
Ctra. de Castellar a Sentmenat C-1415, km 29,300 
08211-Castellar del Vallès, Barcelona, Spain  
Phone: +34 937 190 361  
Fax: +34 937 299 731  
Email: monica.abellan@envigo.com  
When requested by sponsor, all back-up samples will be shipped by courier on dry ice to Laboratoris Sanifit for PD 
analysis: 
Attention: Miquel Ferrer 
Laboratoris Sanifit SL 
Europa Building, 2nd floor 
07121 Palma de Mallorca 
Spain 
Phone: +34 971 439 925 
Mobile: +34 606 118 899 
Email: miquel.ferrer@sanifit.com  
7.3.2. 
Pharmacokinetic Variables 
The following PK parameter will be assessed for SNF472:  
Cmax  
Maximum observed plasma concentration 
7.4. 
Biomarkers 
Blood samples for biomarker (BK) analysis will be collected according to the Schedule of Assessments: Table 1. 
Biomarkers will be defined and analysed at the end of the study. 
The actual date and time of each blood sample collected will be recorded. 
The 2 mL blood sample at pre-dose and end of infusion (in duplicate = 4 ml) will be collected into serum-separating gel 
PET tubes (Vacutainer) to obtain serum (as described in Table 1). All samples will be then centrifuged (1500g for 
10 minutes). The resultant serum for each time-point (in duplicate) will be divided into 2 aliquots (250 µL serum per 
aliquot each for Aliquot 1/2 and Aliquot 2/2) and transferred to 2 appropriately labelled PET tubes (e.g., 1.8 mL storage 
cryovials). Samples stored at -80ºC. 


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Serum samples for biomarker analysis will be packed on dry ice and shipped by courier at the end of the study (single 
shipment) to in Europe: 
Attention: Mathieu Denis 
CSM Europe (formerly B&C) SA 
Watson & Crick Hill 
Rue Granbonpré 11 (Gate C) 
1435 Mont-Saint-Guibert, Belgium 
Phone: +32 (0)10 237 439 
Fax: +32 (0)10 470 860 
Email: mdenis@csmondemand.com 
 
Serum samples for biomarker analysis will be packed on dry ice and shipped by courier, on the day of assessment, to 
either Spectra or Yourway Transport Biopharma Services in USA: 
- 
Spectra Clinical Research 
8 King Road 
 Rockleigh, NJ 07628, United States 
 
- 
YOURWAY TRANSPORT BIOPHARMA SERVICES 
6681 Snowdrift Road  
Allentown, PA 18106, United States 
Toll Free: 1 888-778-4555 
Office: 1 610-395-9198 
Fax: 1 610-391-9002 
Email: info@yourwaytransport.com 
7.5. 
Scores and Evaluations 
Several different scores and evaluations will be performed throughout the study (see Table 1).  
The assessment of the degree of pain a patient feels will be measured with the VAS.  
To assess the course of healing of the ulcers, the Bates Jensen Wound Assessment Tool will be used. Of note, 
elements of the Bates-Jensen Wound Assessment tool which imply probing the wound or measuring its depth are left 
to the discretion of the treating physician at the site and are not compulsory. 
Quality of life will be assessed with the Wound QoL score. 


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Images of the primary, secondary, and tertiary wounds will be taken at regular intervals and uploaded into the clinical 
database. 
7.5.1. 
Pain Score -VAS 
The Visual Analogue Scale (VAS) will be used to assess pain, as per the patient. A VAS is a measurement instrument 
that aims to measure a characteristic or attitude that is believed to range across a continuum of values and cannot 
easily be directly measured. For example, the amount of pain that a patient feels ranges across a continuum from none 
to an extreme amount of pain.  
Operationally, a VAS is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end, as 
illustrated in 
 
Figure 4The patient marks on the line the point that he feels represents his perception of his current status. The VAS 
score is determined by measuring in millimetres from the left hand end of the line to the point that the patient marks 
[51]. 


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Figure 4: VAS Analogue Scale 
7.5.2. 
Lesion Score – Bates-Jensen Wound Assessment Tool 
The site investigator will use the Bates Jensen Wound Assessment Tool (BWAT) to assess the course of the lesion. 
BWAT is a measuring instrument used to assess and monitor healing in pressure ulcers and other chronic wounds[49]. 
It is not, however, specific for CUA. It uses a numerical scale to rate wound characteristics from best to worst possible. 
It consists of 15 items, two of which (location and shape) are not scored. Scored items are: 
• 
Size 
• 
Depth 
• 
Edges 
• 
Undermining or pockets 
• 
Necrotic tissue type 
• 
Necrotic tissue amount 
• 
Exudate type 
• 
Exudate amount 
• 
Surrounding skin colour 
• 
Peripheral tissue oedema 
• 
Peripheral tissue induration 
• 
Granulation tissue 
• 
Epithelialization 


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Each item should be scored from 1 to 5, with 1 being the best for that attribute.  
Of note, elements of the Bates-Jensen Wound Assessment tool which imply probing the wound or measuring its depth 
are left to the discretion of the treating physician at the site and are not compulsory. The BJWAT total score will be 
calculated using a standard methodology for any missing values. Additionally, scores for the component items will be 
assessed longitudinally.  Improvement or worsening will be assessed in the total score and the individual component 
scores. 
7.5.2.1. 
Image Acquisition Process 
Pictures will be taken from the patient’s lesions at the visits detailed in the Schedule of Assessments Table 1. 
At baseline and for inclusion criterion purposes, as per the site investigator, several pictures of the primary lesion 
should be taken in order for the PI (Dr Brandenburg) to decide which image is the best quality image, to include in the 
database, as the primary lesion. Thereafter, all other pictures of the primary lesion should be taken in the same way 
(light, angle, etc.) as the baseline one so that the course of the wound can be assessed. Color reference cards with an 
individual barcode (unique patient identifier) which will be recorded into the CRF and optimized for automatic detection 
and reading should be placed next to the lesion before any image is taken. 
Similar rules apply for the secondary and tertiary lesions. 
All pictures will be uploaded into the database. The pictures will be linked to their corresponding visit. 
7.5.2.2. 
Image Analyses 
Lesion images will be analysed using the following methods. 
1.       Two reviewers will independently perform a two-step review of the lesion images: 
a.       The first step is a patient-level analysis in which the baseline and final images for each patient are de-
identified with respect to order and are randomly labeled as image A or image B. Each reviewer will 
compare the images to assess whether image A is worse, image B is worse, or if there is no difference 
between images A and B.  If there is discordance between the reviewers’ assessments, the reviewers 
will discuss the case together to attempt concordance. 
b.       The second step is a review of all patient images taken as baseline and every two weeks during the 
12-week trial. Each on-treatment analysis will be compared to baseline and scored as worsened, 
improved, or no change. The aggregated categorical scores across all patients for each time point 
will be correlated with the aggregate BWAT total score for each corresponding time point. If there is 
discordance between the reviewers’ assessments, the reviewers will discuss the case together to 
attempt concordance.  


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2.       The patient images will be color calibrated and analysed using JMP (a SAS product) to produce an RGB (Red 
Blue Green) score.  The RGB scores will be used to calculate image changes over the course of each patient’s 
study participation. 
 
7.5.3. 
Quality of Life - Wound QOL (HRQOL) 
The Wound-QoL questionnaire measures the disease-specific, health-related quality of life of patients with chronic 
wounds. It consists of 17 items on impairments which are always assessed in retrospect to the preceding seven days. 
The Wound-QoL is completed by the patient [52]. The Wound-QoL will be available in the specific language of each 
participating country for this study (English and Spanish) to ensure that each patient will understand all questions. All 
the information (questions/answers) will be entered into the CRF.  The global score and subscale scores will be 
calculated programmatically in accordance with the scoring rules. The source data (paper) will be faxed / emailed to 
the sponsor and the original kept in the Investigator Files (TMF).  


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8. 
STUDY CONDUCT 
8.1. 
Schedule and Time of Assessments 
The Schedule of Assessments to be performed for each part of the clinical trial is described in Table 1. 
The following priority order will be in effect when more than one assessment is required at a particular time-point, with 
PK blood sampling being performed nearest to the specified time: 
1. 
Lesion and pain score 
2. 
Blood samples for safety assessments 
3. 
12 Lead ECG 
4. 
PK and biomarker blood sampling 
5. 
HRQOL score (wound QOL) 
8.2. 
Assessments by Visit 
The Schedule of Assessments to be performed for each part of the clinical trial can be found in Table 1. 
8.2.1. 
Screening Period W-2 to Day-1 (hence the screening/recruitment period is up to 2 weeks) 
Potential patients for the inclusion in the clinical trial will be informed about the study and asked to attend the Screening 
Visit within 14 days before receiving the first dose of IMP. The Investigator has to confirm that patients are on standard 
of care as per the site’s SOPs. Written informed consent will be obtained from all patients before any screening 
procedures are performed. Patients will be fully informed of their responsibilities, of all the procedures expected to be 
performed in the clinical trial, the possible risks, disadvantages and potential benefits of being dosed with SNF472 and 
their rights while participating in the clinical trial. They will have the opportunity to ask questions and have time to 
consider participation. If the patient wishes to participate in the clinical trial, they will be asked to sign and date the ICF. 
The Screening Visit will be carried out and a 12-Lead ECG, will be taken, demographic, including body weight (dry 
weight) and anthropometric data, physical examination, medical history and treatment history (prior medication) data. 
Safety laboratory assessments (including clinical chemistry, haematology and a serum pregnancy test) will be taken 
from the routine safety laboratory analysis whenever possible.  
The patient will be asked to draw the level of pain experienced on the VAS. 
Patients will be considered eligible to participate in the clinical trial if they successfully complete the Screening Visit, 
meet all the inclusion criteria, and the lesion is considered to fulfil CUA requirements, as per Dr Vincent Brandenburg. 


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Patients can start treatment at any point in time during the initial 2-week period at the PI’s discretion or if the PI decides 
that the patient is not adequately responding to the SOC. 
8.2.2. 
Expected Duration of the Clinical trial 
The maximum expected duration for an individual patient of the clinical trial, including Screening and Follow-up, will be 
approximately 15 weeks.  
8.2.3. 
Treatment Period W1-W12 
All eligible patients will receive SNF472 during their haemodialysis sessions. SNF472 will be administered at each 
dialysis session for the entire duration of the study. The duration of infusion of SNF472 will range from 2.5 h up to 
maximum time on dialysis, which would be 4 h. SNF472 should NOT be administered directly intravenously. SNF472 
should NOT be administered concomitantly with STS, should STS be used. In case both drugs would be administered 
to the patient, the administration of SNF472 should be stopped 30 minutes before the end of the dialysis session to 
allow the STS infusion to take place in the last 30 minutes of the session. 
In the event of Fe+ administration, the infusion of SNF472 should be stopped BEFORE starting the Fe+ infusion. 
For other assessments please check Table 1. 
8.2.4. 
Follow-Up Visit W13 
All patients will undergo a physical examination, a 12-lead ECG, and be assessed for resolution of pending AEs and 
SAEs. In addition, safety laboratory assessments will be performed and the pain and lesion scores will be assessed. 
8.2.5. 
End of Study Visit 
Patients who withdraw consent or are withdrawn from the clinical trial should, if possible, have an End of Study Visit. 
This visit should take place as soon as possible after the patient has withdrawn consent or has withdrawn from the 
clinical trial. The assessments and procedures scheduled for the Follow-Up Visit should be performed at the End of 
Study Visit. 


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8.3. 
Restrictions 
8.3.1. 
Contraception Requirements 
The use of highly effective contraception methods to prevent pregnancy, of a female participant or a female partner of 
a male participant, from the day of dosing and for 3 months after the follow-up visit, is necessary.  
•       Male patients: 
o   Male patient who have not had a vasectomy and have a female partner of childbearing potential, must 
use a condom with spermicide when having heterosexual intercourse, from the time the consent form 
is signed until 3 months after the last dose of study drug 
o   If the male patient’s partner is of childbearing potential or if she has had a tubal ligation without having 
had her ovaries taken out and she is taking a hormonal contraceptive, she may choose to continue 
taking the hormonal contraceptive but it is strongly recommended to add 1 non-hormonal method of 
contraception (i.e., male condom with spermicide, female condom, diaphragm with spermicidal jelly 
or a cervical cap). We strongly recommend the partner, must use reliable forms of contraception 
during the study and for 3 months after the last dose of study drug 
•       Highly effective contraceptive methods are: 
o Combined (estrogen and progesterone containing) oral, intravaginal or transdermal contraceptive 
associated with inhibition of ovulation + condom with spermicide 
o Progesteron-only oral, injectable or implantable hormonal contraception associated with inhibition of 
ovulation + condom with spermicide 
o   Intra uterine device (IUD) + condom with spermicide 
o   True abstinence: When this is in line with the patient´s preferred and usual lifestyle. Periodic 
abstinence (e.g., calendar, ovulation, symptothermal (monitoring of your body temperature), post-
ovulation methods), and withdrawal are NOT acceptable methods of contraception. 
o   Male sterilisation (with the appropriate post-vasectomy documentation of the absence of sperm in the 
ejaculate). 
•       Female patients must be in one of the cases described below:  
o   Absence of menstruation for 12 consecutive months (menopause) and the doctor confirms they are 
postmenopausal 
o   Both ovaries and uterus have been removed by surgery 
o   Cannot get pregnant due to having ovarian problems (confirmed by a doctor) 
o   If of childbearing potential, the female patient and their partner have to use highly effective forms of 
contraception (see above) during the study and for 3 months after the last dose of study drug 
 


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9. 
STATISTICAL METHODS 
All statistical analyses and programming of tables, figures, and listings will be performed by SYNTAX FOR SCIENCE 
S.L. (Parc Bit, 07121 Mallorca, Spain) using the latest available version of SAS® (SAS Institute Inc., Cary, North 
Carolina, USA).  
Before database lock, a Statistical Analysis Plan (SAP) will be issued as a separate document, providing detailed 
methods for the analyses outlined below. 
Any deviations from the planned analyses as mentioned in detail in the SAP will be described and justified in the final 
integrated Clinical Study Report.  
9.1. 
Clinical Trial Population  
9.1.1. 
Disposition of Patients 
Disposition data will be listed and summarised overall. A listing of withdrawals will also be presented including the 
primary reason for withdrawal. 
9.1.2. 
Protocol Deviations 
Deviations from the Clinical Trial Protocol, including deviations of inclusion/exclusion criteria will be assessed as “minor” 
or “major” in agreement with the Sponsor, prior to database lock. 
9.1.3. 
Analysis Populations 
Safety population: 
All patients who receive at least 1 dose of IMP will be included in the safety 
population.  
Efficacy Population:  
All patients who receive at least 75% of SNF472 doses and for whom at least 
baseline and Week 12/EOS images are readable will be part of the Efficacy 
Population. 
9.2. 
General Considerations  
All efficacy (ulcer size, Bates-Jensen Wound tool assessments, pain scale, and wound QoL), PK and safety parameters 
as well as population characteristics will be listed and described using summary statistics. Descriptive statistics (n, 
mean, standard deviation, median, minimum, and maximum) will be calculated for each quantitative variable (unless 
otherwise stated). Frequency counts (number of subjects [n] and percentages) will be made for each qualitative 
variable. 
All listings will be sorted by patient number, time-point, and parameter (if applicable). 


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9.3. 
Demographic and Anthropometric Information, Baseline Characteristics, and Concomitant 
Medications 
Demographic data will be listed and summarised. 
Medical history data will be listed and summarised. 
Prior medications are defined as those taken until the time of the first IMP administration. Concomitant medications are 
defined as those taken at the time of or after the first IMP administration. 
Prior and concomitant medication will be coded according to the latest available version of the World Health 
Organisation’s Drug Dictionary (WHO-DD) and the Anatomical Therapeutic Chemical classification system. Prior and 
concomitant medication will be listed separately. 
9.4. 
Pharmacokinetic Analysis 
The plasma SNF472 PK parameter, Cmax, will be calculated, individual and mean.  
9.5. 
Determination of Sample Size 
Based on recent historical data from a U.S. large dialysis provider organization, approximately 25% of calciphylaxis 
skin lesions are considered to be improved over a 3-6 month period (data unpublished; personal communication). A 
total of 15 subjects who complete 12-week of treatment was determined necessary to show with 80% power that the 
percentage of subjects for which the primary ulcer is totally or partially healed after 12 weeks of treatment is greater 
than 25%. For these calculations, it was assumed that the percentage of totally or partially healed subjects for SNF472 
will be 60%. 


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10. 
ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS 
10.1. 
Data Quality Assurance 
The Sponsor or designee will conduct Clinical Unit visits to, inspect the facilities, and to ensure that all the clinical study 
procedures are followed as per protocol. 
The Investigator must prepare and maintain adequate and accurate case histories designed to record all observations 
and other data pertinent to the clinical trial for each clinical trial patient. All information recorded in the CRF for this 
clinical trial must be consistent with the patient’s source documentation. 
10.2. 
Data Collection 
Paper CRFs will be distributed to the clinical sites.  Once the CRFs are source data verified, the originals are sent to 
the sponsor. The sponsor digitizes the CRFs for data entry. The data from the digitized CRFs will be entered into a 
database using DataFax software hosted by DF/net Research, Inc.   
Once the original CRFs are sent to the sponsor, all data additions, changes or corrections will be captured on the query 
reports. 
The responsible Clinical Monitor will check source data during the monitoring visits to the Clinical Unit. The Investigator 
will ensure that the data collected are accurate, complete and legible.  
All clinical work conducted under this Clinical trial Protocol will follow Good Clinical Practice (GCP) principles [54]. 
10.3. 
Source Documents 
All data obtained during the clinical trial should be promptly recorded in the CRF, as is described in section 10.2.  
The CRF entries for each patient will be checked against source documents by the monitor. Instances of missing or 
uninterpretable data will be discussed with the Investigator for resolution. 
10.4. 
Access to Source Documents 
During the course of the clinical trial, a Monitor will make Clinical Unit visits to review Clinical Trial Protocol compliance, 
assess IMP accountability and ensure that the clinical trial is being conducted according to pertinent regulatory 
requirements. CRF entries will be verified against source documents. The review of medical records will be handled 
confidentially to ensure clinical trial patient anonymity. 
Checking of CRF entries for completeness and clarity and verifying with source documents, will be required to monitor 
the clinical trial for compliance with GCP and other regulations. Moreover, Regulatory Authorities of certain countries 
and ECs/IRBs may wish to carry out source data inspections on-site, and the Sponsor’s Clinical Quality Assurance 


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Group may wish to carry out audits. Direct access to source data will be required for these inspections and audits; they 
will be carried out giving due consideration to data protection and patient confidentiality. The Investigator assures the 
Sponsor of the necessary support at all times. 
10.5. 
Data Management 
Data management activities will be performed by DF/net Research, Inc. 
A data management plan (DMP) will describe the work- and data-flow within this clinical trial. Versions for the computer 
systems and the coding will be defined in the DMP. 
10.6. 
Archiving Clinical Trial Documents 
According to International Conference on Harmonisation (ICH) guidelines, essential documents should be retained for 
a minimum of 2 years after the last approval of a marketing application in an ICH region and until there are no pending 
or contemplated marketing applications in an ICH region or at least 2 years have elapsed since the formal 
discontinuation of clinical development of the IMP. However, these documents should be retained for a longer period 
if required by the applicable legal requirements. 
10.7. 
Good Clinical Practice 
The procedures set out in this Clinical trial Protocol are designed to ensure that the Sponsor and the Investigator abide 
by the principles of the ICH guidelines on GCP[54], and the Declaration of Helsinki (Version 1996)[55]. The clinical trial 
will also be carried out in keeping with national and local legal requirements. 
10.8. 
Informed Consent 
Before each patient is enrolled in the clinical trial, written informed consent will be obtained from the patient according 
to the local regulatory and legal requirements. The Patient Information Sheet and ICF must be signed and dated; one 
copy will be handed to the patient and the Investigator will retain a copy as part of the clinical trial records. The 
Investigator will not undertake any investigation specifically required for the clinical trial until written consent has been 
obtained. The terms of the consent and when it was obtained must also be documented in the CRF. 
The Investigator must ensure that the patient is given full and adequate oral and written information about the nature, 
purpose, possible risk and benefit of the clinical trial. Patients must also be notified that they are free to withdraw from 
the clinical trial at any time without prejudice to future care. The patient should be given the opportunity to ask questions 
and allowed time to consider the information provided. 
If a Clinical Trial Protocol Amendment is required, the Patient Information Sheet and ICF may need to be revised to 
reflect the changes to the Clinical Trial Protocol. If the Patient Information Sheet and ICF are revised, they must be 


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reviewed and approved by the responsible EC/IRB, and signed by all patients subsequently enrolled in the clinical trial 
as well as those currently enrolled in the clinical trial. 
10.9. 
Protocol Approval and Amendment(s) 
Before the start of the clinical trial, the Clinical Trial Protocol and other relevant documents will be approved by the 
EC/IRB/Regulatory Authorities in accordance with local legal requirements. The Sponsor must ensure that all ethical 
and legal requirements have been met before the first patient is enrolled in the clinical trial. 
This Clinical Trial Protocol should be followed exactly. To alter the Clinical Trial Protocol, amendments must be written, 
which must be released by the responsible staff and receive EC/IRB/Regulatory Authority approval prior to 
implementation (as appropriate). 
Administrative changes may be made without the need for a substantial Clinical Trial Protocol Amendment, but will 
also be mentioned in the integrated Clinical Study Report. All Clinical Trial Protocol Amendments will be distributed to 
all Clinical Trial Protocol recipients, with appropriate instructions. 
10.10. Duration of the Clinical trial 
The maximum expected duration of participation for an individual patient, including Screening and Follow-up, will be 
approximately 15 weeks. 
10.11. Confidentiality Data Protection 
All clinical trial findings and documents will be regarded as confidential. The Investigator and members of his research 
team must not disclose such information without prior written approval from the Sponsor. The Investigator shall permit 
access to subject’s records and source documents for the purpose of monitoring, auditing or inspection by Sanifit, 
authorized representatives of Sanifit, regulatory authorities and IRB/IEC’s only. 
The anonymity of participating patients must be maintained. Patients will be specified on documents by their patient 
number, initial or birth date, not by name. Documents that identify the patient (e.g., the signed Patient Information Sheet 
and ICF) must be maintained in confidence by the Investigator. 
10.12. Other Ethical and Regulatory Issues 
If a safety issue of clinical relevance is identified, from review of any data, then the Sponsor will issue prompt notification 
to all parties ‒ Investigator and EC/IRB/Regulatory Authorities. 
A safety issue of clinical relevance is one that has a relevant impact on the course of the clinical trial or program 
(including the potential for suspension of the clinical trial program or amendments to the Clinical Trial Protocol) or 
warrants immediate update of the Patient Information Sheet and ICF. 


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10.13. Liability and Insurance 
The Sponsor will take out reasonable third party liability insurance cover in accordance with all participating countries 
(Spain, UK, and USA) legal requirements. The civil liability of the Investigator, the persons instructed by him and the 
hospital, practice or institute in which they are employed and the liability of the Sponsor with respect to financial loss 
due to personal injury and other damage that may arise as a result of the carrying out of this clinical trial are governed 
by the applicable laws and GCP guidelines. 
The Sponsor will arrange for patients participating in this clinical trial to be insured against financial loss due to personal 
injury caused by the pharmaceutical products being tested or by medical steps taken in the course of the clinical trial. 
The method and manner of compensation to patients should comply with applicable regulatory requirement(s). 
Wherever applicable, patient’s insurance is available at Chubb Insurance Company of Europe SE under the insurance 
policy number 99494900 (USA), 99494898 (Spain), and 994948899 (UK). 
10.14. Publication Policy 
The sponsor recognizes the fundamental obligation of the institution for publication of nature, purpose and result of the 
work performed.  
With regard to a publication about the substance SNF472 the Institution, upon Sponsor’s previous written consent, 
shall have the right to publish or present the results of the Study conducted under this Agreement, including Study Data 
after providing a copy of the proposed publication to the Sponsor at least thirty (30) days prior to submission for 
publication or disclosure and at least ten (10) days prior to submission for Abstracts. If the Sponsor believes that the 
manuscript contains any of its Confidential Information or subject matter that is patentable or otherwise protected by 
IP rights, the sponsor can exceptionally demand a delay of the publication to maximum 90 days after submission of 
the manuscript, if this is necessary for the protection of intellectual property. The notification will include specific details 
to be amended from the manuscript in mutual understanding. The approval shall not be unreasonably denied and the 
scientific content may not be changed. If no objection is received in writing within the above mentioned period, the 
Party seeking disclosure will be free to publish the manuscript or other form of disclosure as submitted to the Sponsor. 
Upon termination or expiry of this Agreement, the provisions of article 10 from the contract between Aachen University 
and Laboratoris Sanifit shall still remain in force. The Sponsor retains the right to nominate authors in any publication 
at its sole discretion, provided they contributed in the conception, design, execution, follow-up and/or discussion of 
results of the study.  
The Institution shall grant, and shall cause the Coordinating Investigator and the German Principle Investigators to 
grant, the Sponsor a worldwide, royalty-free, non-exclusive license to reproduce and distribute copies of any Publication 
relating to the Study in which the Institution, the Principal Investigator, or any other Study Staff member retains the 


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copyright. The Institution will publicly acknowledge in each Publication the Sponsor’s contribution as follows: “Data 
used in preparation of this manuscript were obtained with support of Laboratoris Sanifit (plus Address)”.  
The institution can publish all data which are collected regardless of the substance SNF472 (for example, but not finally: 
Calciphylaxis Foreground, Imaging systems or methods etc.) without prior submission and approval by the sponsor. 


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11. 
REFERENCE LIST 
1. 
http://www.accessdata.fda.gov/scripts/fdcc/?set=SCOGS. 
2. 
Davies, N.T. and S.E. Olpin, Studies on the phytate: zinc molar contents in diets as a determinant of Zn 
availability to young rats. Br J Nutr, 1979. 41(3): p. 590-603. 
3. 
Forbes, R.M., H.M. Parker, and J.W. Erdman, Jr., Effects of dietary phytate, calcium and magnesium levels 
on zinc bioavailability to rats. J Nutr, 1984. 114(8): p. 1421-5. 
4. 
Pallauf, J., et al., Supplemental sodium phytate and microbial phytase influence iron availability in growing 
rats. J Trace Elem Med Biol, 1999. 13(3): p. 134-40. 
5. 
March, J.G., B.M. Simonet, and F. Grases, Determination of phytic acid by gas chromatography-mass 
spectroscopy: application to biological samples. J Chromatogr B Biomed Sci Appl, 2001. 757(2): p. 247-55. 
6. 
March JG, S.B., Grases F, Salvador A., Indirect determination of phytic acid in urine. Anal. Chim. Acta, 1998. 
367: p. 63-68. 
7. 
Grases F, P.J., Isern B, Prieto RM., Determination of myo-inositol hexakisphosphate (phytate) in urine by 
inductively coupled plasma atomic emission spectrometry (ICP-AES). Anal. Chim. Acta., 2004. 510: p. 41-43. 
8. 
Perelló J, I.B., Muñoz JA, Valiente M, Grases F., Determination of phytate in urine by high performance liquid 
chromatography – mass spectrometry. Chromat., 2004. 60: p. 265-268. 
9. 
Grases F, L.A., Determination of phytic acid in urine by ICP atomic emission spectrometry. Anal. Lett., 1996. 
29: p. 1193-9. 
10. 
Grases, F., et al., Urinary phytate in calcium oxalate stone formers and healthy people--dietary effects on 
phytate excretion. Scand J Urol Nephrol, 2000. 34(3): p. 162-4. 
11. 
Curhan, G.C., et al., Dietary factors and the risk of incident kidney stones in younger women: Nurses' Health 
Study II. Arch Intern Med, 2004. 164(8): p. 885-91. 
12. 
Conte, A., et al., Urinary lithogen risk test: usefulness in the evaluation of renal lithiasis treatment using 
crystallization inhibitors (citrate and phytate). Arch Esp Urol, 1999. 52(3): p. 305-10. 
13. 
Grases, F., et al., Effect of tetracalcium dimagnesium phytate on bone characteristics in ovariectomized rats. 
J Med Food, 2010. 13(6): p. 1301-6. 
14. 
Lopez-Gonzalez, A.A., et al., Phytate (myo-inositol hexaphosphate) and risk factors for osteoporosis. J Med 
Food, 2008. 11(4): p. 747-52. 
15. 
Lopez-Gonzalez, A.A., et al., Phytate levels and bone parameters: a retrospective pilot clinical trial. Front 
Biosci (Elite Ed), 2010. 2: p. 1093-8. 
16. 
Grases, F., et al., Phytate (Myo-inositol hexakisphosphate) inhibits cardiovascular calcifications in rats. Front 
Biosci, 2006. 11: p. 136-42. 
17. 
Grases, F., et al., Effect of crystallization inhibitors on vascular calcifications induced by vitamin D: a pilot 
study in Sprague-Dawley rats. Circ J, 2007. 71(7): p. 1152-6. 
18. 
Van den Berg CJ, H.L., Stanbury SW. , Inositol phosphates and phytic acid as inhibitors of biological 
calcification in the rat. Clin. Sci., 1972. 43: p. 377-383. 
19. 
Midorikawa, K., et al., Protective effect of phytic acid on oxidative DNA damage with reference to cancer 
chemoprevention. Biochem Biophys Res Commun, 2001. 288(3): p. 552-7. 
20. 
Reddy, B.S., Prevention of colon carcinogenesis by components of dietary fiber. Anticancer Res, 1999. 
19(5A): p. 3681-3. 
21. 
Graf, E. and J.W. Eaton, Dietary suppression of colonic cancer. Fiber or phytate? Cancer, 1985. 56(4): p. 
717-8. 
22. 
Shamsuddin, A.M., I. Vucenik, and K.E. Cole, IP6: a novel anti-cancer agent. Life Sci, 1997. 61(4): p. 343-54. 
23. 
Gupta, K.P., J. Singh, and R. Bharathi, Suppression of DMBA-induced mouse skin tumor development by 
inositol hexaphosphate and its mode of action. Nutr Cancer, 2003. 46(1): p. 66-72. 
24. 
Grases F, S.C., Simonet BM, Costa-Bauzá., Sialolithiasis: mechanism of calculi formation and etiologic 
factors. A. Clin. Chim. Acta., 2003. 334(1-2): p. 131-6. 
25. 
Grases, F., et al., Anticalculus effect of a triclosan mouthwash containing phytate: a double-blind, randomized, 
three-period crossover trial. J Periodontal Res, 2009. 44(5): p. 616-21. 


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Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
Final V4  
Page 71 of 72 
                               11 Apr 2017 
 
Laboratoris Sanifit S.L. Phone/Fax: +34 971 439 925 info@sanifit.com www.sanifit.com 
PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
26. 
Investigator’s Brochure for SNF472, 2012. 
27. 
Grau A, F.-P.C., Grases F, Sanchis P, Perelló J, Isern B, Costa-Bauzá A, Vidal L, Moranta E, Aceña M, Caldés 
O, Bonnin O, García-Raja A, Bethencourt A., Relación entre el fitato y calcificaciones valvulares cardíacas. 
Estudio de campo para diseño de un ensayo clínico en la estenosis aórtica, in IV Congreso de la Sociedad 
Balear de Cardiología2005: Palma de Mallorca (Mallorca). 
28. 
Addison, W.N. and M.D. McKee, Inositol hexakisphosphate inhibits mineralization of MC3T3-E1 osteoblast 
cultures. Bone, 2010. 46(4): p. 1100-7. 
29. 
Arriero MdM, R.J., Perelló J, Monjo M. , Differential response of MC3T3-E1 and human mesenchymal stem 
cells to inositol hexakisphosphate. Cell Physiol. Biochem., In press. 
30. 
Lopez-Gonzalez, A.A., et al., Protective effect of myo-inositol hexaphosphate (phytate) on bone mass loss in 
postmenopausal women. Eur J Nutr, 2013. 52(2): p. 717-26. 
31. 
Fyton-Summary of Product Characteristics, IZOtop, Editor 2002. 
32. 
http://www.usrds.org/2015/view/v2_01.aspx. 2015. 
33. 
Noordzij, M., et al., Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual 
Report. Clin Kidney J, 2014. 7(2): p. 227-38. 
34. 
Lameire, N., et al., Chronic kidney disease: a European perspective. Kidney Int Suppl, 2005(99): p. S30-8. 
35. 
JR, N. Calciphylaxis - http://www.emedicine.com/derm/byname/calciphylaxis. 
36. 
Schlieper, G., et al., Sodium thiosulfate in the treatment of calcific uremic arteriolopathy. Nat Rev Nephrol, 
2009. 5(9): p. 539-43. 
37. 
Nigwekar, S.U., et al., Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol, 
2008. 3(4): p. 1139-43. 
38. 
Mazhar, A.R., et al., Risk factors and mortality associated with calciphylaxis in end-stage renal disease. 
Kidney Int, 2001. 60(1): p. 324-32. 
39. 
Brandenburg, V.M., et al., Calcific uraemic arteriolopathy: a rare disease with a potentially high impact on 
chronic kidney disease-mineral and bone disorder. Pediatr Nephrol, 2014. 29(12): p. 2289-98. 
40. 
Brandenburg, V.M., M. Cozzolino, and S. Mazzaferro, Calcific uremic arteriolopathy: a call for action. Semin 
Nephrol, 2014. 34(6): p. 641-7. 
41. 
Nigwekar, S.U., et al., Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis, 2015. 66(1): p. 
133-46. 
42. 
Goel, S.e.a., Treatment of severe metastatic calcification and calciphylaxis in dialysis patients. Int J Nephrol, 
2011(Feb 24). 
43. 
IP6Na6: Effect on HERG Tail Currents recorded from Stably Transfected HEK 293 cells, 2010, b-Sys. 
44. 
Moorthi, R.N. and S.M. Moe, CKD-mineral and bone disorder: core curriculum 2011. Am J Kidney Dis, 2011. 
58(6): p. 1022-36. 
45. 
Evaluation on the effects of an IP6 diet in the treatment of rat dystrophic calcification in soft tissues, 2004, 
Universitat de les Illes Balears. 
46. 
Grases, F., et al., Dietary myo-inositol hexaphosphate prevents dystrophic calcifications in soft tissues: a pilot 
study in Wistar rats. Life Sci, 2004. 75(1): p. 11-9. 
47. 
Perelló J, S.C., Joubert PH, et al. First-time-in-human phase 1 clinical trial in healthy volunteers with SNF472, 
a novel inhibitor of vascular calcification. 2015. 
48. 
Hayashi, M., Calciphylaxis: diagnosis and clinical features. Clin Exp Nephrol, 2013. 17(4): p. 498-503. 
49. 
B, S.C.a.B.-J., Wound care: a collaborative practice manual for health professionals, 2011, Lippincott Williams 
and Wilkins p. 144-154. 
50. 
K2 Hemodialysis Machine Operator’s Manual Rev. H2008-2014: Fresenius USA Inc. 
51. 
Gould, D., et al., Examining the validity of pressure ulcer risk assessment scales: developing and using 
illustrated patient simulations to collect the data. J Clin Nurs, 2001. 10(5): p. 697-706. 
52. 
Augustin M, B.K., Herberger K, Protz K, Goepel L, Wild T, Blome C, Use of the WoundQoL instrument in 
routine practice: Feasibiliy, validity and development of an implementation tool. Wound Medicine, 2014. 5: p. 
4-8. 


Laboratoris Sanifit 
SNFCT2015_04 
Clinical Trial Protocol Incorporating Amendment 3 
CONFIDENTIAL 
 
Final V4  
Page 72 of 72 
                               11 Apr 2017 
 
Laboratoris Sanifit S.L. Phone/Fax: +34 971 439 925 info@sanifit.com www.sanifit.com 
PARC BIT. Europa Building. 07121 Palma de Mallorca. Spain 
53. 
Deserno, T.M., et al., Integrated image data and medical record management for rare disease registries. A 
general framework and its instantiation to the German Calciphylaxis Registry. J Digit Imaging, 2014. 27(6): p. 
702-13. 
54. 
Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95), T.E.A.f.t.E.o.M. Products, Editor 2002. p. 
1-59. 
55. 
Declaration of Helsinki. Recommendations Guiding Physicians in Biomedical Research involving Human 
Patients, W.M.A. (WMA), Editor Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, 
and amended by the 29th WMA General Assembly, Tokyo, Japan, October 1975, 35th WMA General 
Assembly, Venice, Italy, October 1983, 41st WMA General Assembly, Hong Kong, September 1989, 48th 
WMA General Assembly, Somerset West, Republic of South Africa, October 1996. 
 
 

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Statistical Analysis Plan 
 
1. TITLE PAGE 
Study Title: 
Phase 2 Open Label Single Arm Repeat Dose Study to Assess the Effect 
of SNF472 on Wound Healing in Uraemic Calciphylaxis Patients 
Sponsor: 
Laboratoris Sanifit  
Prepared by: 
Syntax for Science 
Protocol Number: 
SNFCT2015-04 
Protocol Version: 
V4 (Incorporating Amendment 3) 
Protocol Date: 
11/APR/2017 
 
 
Document Version: 
V1 FINAL 
Document Date: 
31/JAN/2018 
Authors: 
 
Juan Vicente Torres 
Sebastià Barceló 
Confidentiality Statement 
This confidential document is the property of the Sponsor. No unpublished information contained 
herein may be disclosed without prior written approval from the Sponsor. Access to this document 
must be restricted to relevant parties. 


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THIS PAGE IS INTENCIONALLY LEFT BLANK 
 
 
 
 


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TABLE OF CONTENTS 
1. 
TITLE PAGE........................................................................................................................... 1 
2. 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ........................................ 6 
3. 
VERSION HISTORY ............................................................................................................. 7 
4. 
INTRODUCTION ................................................................................................................... 8 
5. 
STUDY OBJECTIVES AND ENDPOINTS ......................................................................... 8 
5.1 
Study objectives .................................................................................................................. 8 
5.2 
Endpoints ............................................................................................................................ 8 
5.2.1 
Primary endpoint ......................................................................................................... 8 
5.2.2 
Secondary endpoints ................................................................................................... 8 
6. 
STUDY DESIGN ..................................................................................................................... 9 
6.1 
General study design and plan ............................................................................................ 9 
6.2 
Visits schedule .................................................................................................................... 9 
6.3 
Study population ............................................................................................................... 12 
6.3.1 
Inclusion Criteria ....................................................................................................... 12 
6.3.2 
Exclusion Criteria ...................................................................................................... 12 
6.3.3 
Criteria for subject withdrawal .................................................................................. 13 
6.4 
Sample size ....................................................................................................................... 13 
6.5 
Randomization and blinding ............................................................................................. 13 
6.6 
Study methods .................................................................................................................. 13 
6.6.1 
Bates-Jensen Wound Assessment Tool (BWAT) ..................................................... 13 
6.6.2 
Independent Image Review ....................................................................................... 14 
6.6.3 
Pain Visual Analog Scale (VAS) .............................................................................. 14 
6.6.4 
Wound Quality of Life (Wound-QoL) ...................................................................... 14 
7. 
SEQUENCE OF PLANNED ANALYSES .......................................................................... 15 
7.1 
Interim analysis................................................................................................................. 15 
7.2 
Final analysis .................................................................................................................... 15 
8. 
STATISTICAL METHODS................................................................................................. 15 
8.1 
General considerations ..................................................................................................... 15 
8.2 
Analysis populations......................................................................................................... 16 
8.2.1 
All Subjects ............................................................................................................... 16 
8.2.2 
Safety Analysis Set.................................................................................................... 16 
8.2.3 
Efficacy Analysis Set ................................................................................................ 16 
8.2.3.1 
Intention to Treat Set ......................................................................................... 16 
8.2.3.2 
Per Protocol Set.................................................................................................. 16 


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8.2.4 
PK Analysis Set ......................................................................................................... 16 
8.3 
Covariates and subgroups ................................................................................................. 17 
8.4 
Missing data ...................................................................................................................... 17 
8.5 
Censored Subjects............................................................................................................. 18 
8.6 
Multi-centre studies .......................................................................................................... 18 
8.7 
Multiple testing ................................................................................................................. 18 
8.8 
Baseline values ................................................................................................................. 18 
8.9 
Reporting conventions ...................................................................................................... 19 
8.9.1 
General reporting conventions .................................................................................. 19 
8.9.2 
Statistical summary conventions ............................................................................... 19 
9. 
STATISTICAL ANALYSIS ................................................................................................. 20 
9.1 
Baseline and other relevant data ....................................................................................... 20 
9.1.1 
Subject disposition .................................................................................................... 20 
9.1.2 
Protocol deviations .................................................................................................... 20 
9.1.3 
Analysis sets .............................................................................................................. 20 
9.1.4 
Demographics and other baseline characteristics...................................................... 20 
9.1.5 
Medical History ......................................................................................................... 20 
9.1.6 
Prior and Concomitant medications .......................................................................... 21 
9.1.7 
Treatment exposure and compliance ......................................................................... 21 
9.2 
Efficacy Analysis .............................................................................................................. 22 
9.2.1 
Primary endpoint ....................................................................................................... 22 
9.2.2 
Secondary endpoints ................................................................................................. 22 
9.2.2.1 
Change from baseline in BWAT total and component scores by visit .............. 22 
9.2.2.2 
The previous analysis will also be done for the secondary and tertiary lesions if 
there is enough data. Change from baseline in imaging score by visit ............................... 23 
9.2.2.3 
Change from baseline in the Pain Visual Analog Scale (VAS) by visit ............ 23 
9.2.2.4 
Change from baseline in total and subscales of wound QoL score by visit ...... 23 
9.2.2.5 
Potential Wound Complications ........................................................................ 24 
9.2.3 
Hospitalization and Death ......................................................................................... 24 
9.2.4 
Exploratory Analyses ................................................................................................ 24 
9.2.4.1 
Absolute change in BWAT total score between Week 12 and Follow-up for all 
lesions. 
24 
9.2.4.2 
BWAT vs VAS correlation. ............................................................................... 24 
9.3 
Safety analyses ................................................................................................................. 25 
9.3.1 
Adverse Events .......................................................................................................... 25 
9.3.2 
Clinical Laboratory Evaluations................................................................................ 25 


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9.3.3 
ECG, Physical examination and Body weight .......................................................... 26 
9.4 
Pharmacokinetics .............................................................................................................. 27 
9.4.1 
Pharmacokinetic Parameters ..................................................................................... 27 
9.4.2 
Accumulation ............................................................................................................ 28 
9.4.3 
End of infusion PK concentration vs BWAT correlation ......................................... 28 
9.4.4 
End of infusion PK concentration vs VAS correlation ............................................. 28 
9.5 
Pharmacodynamics ........................................................................................................... 29 
9.5.1 
% PD Inhibition ......................................................................................................... 29 
9.5.2 
% PD Inhibition vs BWAT correlation ..................................................................... 29 
9.5.3 
% PD Inhibition vs VAS correlation ......................................................................... 29 
9.6 
PK/PD modelling .............................................................................................................. 29 
9.7 
Subgroup analysis ............................................................................................................. 30 
9.7.1 
BWAT ....................................................................................................................... 30 
9.7.2 
VAS ........................................................................................................................... 30 
10. SUMMARY OF CHANGES FROM THE PROTOCOL .................................................. 30 
11. REFERENCES ...................................................................................................................... 32 
12. APPENDICES ....................................................................................................................... 33 
 
 


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2. LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
AE 
Adverse event 
BWAT 
Bates Jensen Wound Assessment Tool 
Cmax 
Maximum observed plasma concentration 
CS 
Clinically significant 
CUA 
Calciphic Uremic Arteriolopathy 
CRF 
Case Report Form 
ECG 
Electrocardiogram 
EOS 
End of Study 
FU 
Follow-Up 
ICF 
Informed Consent Form 
ICH 
International Council on Harmonisation 
IMP 
Investigational medicinal product 
IV 
Intravenous 
N 
Number of subjects 
NSAID 
non-steroidal anti-inflammatory drugs 
L 
Litre 
PK 
Pharmacokinetic(s) 
PTH 
Parathyroid Hormone 
QT 
QT interval 
QTc 
Corrected QT interval 
QTcB 
Corrected QT interval using Bazett’s formula 
QTcF 
Corrected QT interval using Fridericia’s formula 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SCR 
Screening 
SOC 
System Organ Class 
VAS 
Visual analog scale 
 


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3. VERSION HISTORY  
 
Version 
Date 
Status 
1 
31/JAN/2018 
FINAL 
AUTHORS  
Name 
Function 
Date 
Signature 
Juan Vicente Torres 
Statistician 
 
 
 
Sebastià Barceló Bauzà 
Statistician 
 
 
 
APPROVAL 
A signature below confirms that this statistical analysis plan meets the analysis requirements for 
Protocol SNFCT2015-04.  
Syntax for Science 
Name 
Function 
Date 
Signature 
Marta Rodriguez 
Head of Biometry 
 
 
 
Sponsor 
Name 
Function 
Date 
Signature 
Rekha Garg, MD, MS 
Sr. VP, Regulatory 
Affairs and Safety 
 
 
Alex Gold, MD 
Chief Medical Officer 
 
 
Carolina Salcedo 
Chief Scientific 
Officer 
 
 
 
 


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4. INTRODUCTION 
This document describes the statistical methods and data presentations to be used in summarizing 
and analyzing the data for Protocol SNFCT2015-04.  Background information is provided for the 
overall study design and objectives.  The reader is referred to the study protocol and case report 
forms (CRFs) for details of study conduct and data collection. 
5. STUDY OBJECTIVES AND ENDPOINTS 
5.1 Study objectives 
The objective of this study is to evaluate the safety and efficacy of SNF472 on top of standard of 
care on promoting wound healing and other parameters of therapeutic response in haemodialysis 
subjects with calciphylaxis (calcific uraemic arteriolopathy, CUA). 
5.2 Endpoints 
5.2.1 Primary endpoint 
• The primary endpoint is the absolute change in BWAT total score between baseline (Week 1) 
and Week 12 for the primary lesion (the largest one).  
5.2.2 Secondary endpoints  
Wound healing: 
• Absolute change from baseline in BWAT total and component scores by visit for the primary 
lesion, secondary lesion, and tertiary lesions. 
• Qualitative change from baseline in imaging score by visit for the primary lesion, secondary 
lesion, and tertiary lesions. 
 
Pain: 
• Absolute change from baseline by visit in the Pain Visual Analog Scale (VAS). 
 
Quality of Life: 
• Absolute change from baseline at Weeks 6 and 12 in global score and subscales of wound QoL 
score. 
 
Wound and disease complications: 
• Presence/absence of new wound infection at any time post baseline 
• Presence/absence of new systemic infection at any time post baseline 
• Surgical treatment of the wound at any time post baseline 
• Requires or prolongs hospitalization  
• Death 


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6. STUDY DESIGN 
6.1 General study design and plan 
It is an open-label single-arm clinical trial. Up to 15 CUA subjects will be enrolled, treated, and 
followed over a 12-week period to assess the safety and efficacy of SNF472 for the treatment of 
CUA. 
6.2 Visits schedule 
 


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Table 001 Visits Schedule 
 
SCR 
TREATMENT PERIOD 
FU 
Week -2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lesions Overview 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Images Collection 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Visit  
X 
X X X X X X X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X 
Body Weight 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Biopsy (if performed by site)1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
ECG  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
ECG (pre dose & end of infusion)  
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
Safety Laboratory Assessments2 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
PTH 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Potassium, Magnesium, Iron  
(ferritin/transferrin) and Zinc  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Potassium, Magnesium, Iron 
(ferritin/transferrin) and Zinc (predose & end 
of infusion)* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
Ionised Calcium  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
                                                 
1 Biopsy is not an inclusion criterion, but if performed the report and analysis will be documented 
2 These data sets will be used from the routine monthly blood analysis performed on each patient 
 


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SCR 
TREATMENT PERIOD 
FU 
Week -2, -1 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
Day 
 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
1 
3 
5 
 
Ionised Calcium (predose & end of infusion) 
 
X 
X 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
X 
X 
 
Pregnancy Test3 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Treatment History (prior medication)4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CUA Diagnosis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment (Intravenous SNF472)6 
 
X X X X X X X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
 
Wound QoL Score 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Pain Score (VAS scale) 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Lesion Score (BJWAT) 
 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
Biomarkers 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Plasma PK and PD sampling (predose & end of 
infusion)* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
Concomitant Medication 
 
X X X X X X X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X 
Adverse Events 
 
X X X X X X X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X X 
X 
X 
End of Study Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
                                                 
3 Pregnancy test is to be serum at baseline and urine monthly thereafter 
4 Prior medication includes medications within 6 months of study start 
5 The inclusion/exclusion criteria will be assessed for each patient at Screening – final entry into the study depends on confirmation by the PI, Dr VB 
6 A Treatment Period includes 3 dialysis sessions/week x 12 weeks (36 treatments) 


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6.3 Study population 
6.3.1 Inclusion Criteria 
Patients who meet the following criteria will be considered eligible to participate in the clinical 
trial: 
1. Patients with either newly diagnosed CUA OR recurrent CUA that has been dormant 
with no skin lesion involvement for at least 90 days from study start (new or 
recurrent diagnosis must be made within 5 weeks of study start) 
2. Patients who signed the written informed consent to participate in this clinical trial 
(prior to any clinical trial-related procedures being performed), after reading the 
Patient Information Sheet and Informed Consent Form (ICF), and who had the 
opportunity to discuss the clinical trial with the Investigator or designee 
3. Males or females aged ≥18  
4. Patients on maintenance haemodialysis 
5. Patients with at least a minimum level of pain on VAS scale or on pain-killers 
stronger than NSAIDs 
6. Females of child-bearing potential should use a highly effective contraceptive 
measure throughout the study AND have a negative serum pregnancy test at entry. 
Male patients having sexual relationship in which pregnancy can occur should take 
adequate contraceptive precautions (wear a condom).  
6.3.2 Exclusion Criteria 
Patients who meet one or more of the following criteria will not be considered eligible to 
participate in the clinical trial: 
1. Body weight above 150 kg 
2. BMI >35 and central (abdominal) ulcers  
3. History of bisphosphonate treatment within 12 months before entering into the study 
4. Severely ill patients without reasonable expectation of survival for > 6 months 
according to the treating physician 
5. Patients with scheduled parathyroidectomy during the run-in or study period 
6. Female patients who are either intending to get pregnant or are undergoing treatment 
to get pregnant, as well as breast-feeding females 
7. Participation in another clinical trial with an experimental drug within 90 days prior 
the inclusion 
8. Any psychological, emotional problems, any disorders or resultant therapy that is 
likely to invalidate informed consent, or limit the ability of the patient to comply 
with the Clinical Trial Protocol requirements 
9. Patients who, in the opinion of the Investigator, are considered unsuitable for any 
other reason 


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6.3.3 Criteria for subject withdrawal 
A subject is defined as having entered the clinical trial when he/she has provided written informed 
consent. A withdrawal is a subject who receives a study subject code and for whom treatment is 
prematurely terminated for any reason. 
Possible reasons for withdrawal of a subject from the clinical trial: 
• Adverse Event(s) 
• Subject lost to follow-up 
• Withdrawal of consent 
• Pregnancy 
• Death 
• Other (specify)  
6.4 Sample size 
Given the exploratory purpose of the study, the sample size will not be recalculated.  
The original sample size justification was:  
Based on recent historical data from a U.S. large dialysis provider organization, approximately 
25% of calciphylaxis skin lesions are considered to be improved over a 3-6-month period (data 
unpublished; personal communication). A total of 15 subjects was determined necessary to show 
with 80% power that the percentage of subjects for which the primary ulcer is totally or partially 
healed after 12 weeks of treatment is greater than 25%. For these calculations, it was assumed 
that the percentage of totally or partially healed subjects for SNF472 will be 60%. 
6.5 Randomization and blinding 
This was an open-label, single-arm study with no randomization. Efforts to minimize assessment 
bias were implemented by including an independent review of the images. A protocol for the 
review and scoring of the images was produced. 
6.6 Study methods 
6.6.1 Bates-Jensen Wound Assessment Tool (BWAT) 
The Bates-Jensen Wound Assessment Tool (BWAT) score is collected through a questionnaire of 
13 items, which are evaluated individually with a score of 1 to 5. BWAT is summarized by a total 
score which is calculated by adding up the scores of all individual items. Therefore, the total score 
ranges from 13 to 65 and can be only calculated if all items are answered. However, for the purpose 
of this analysis missing items were imputed as described in Section 8.4. Note that the BWAT 
contains two extra variables to indicate the location and shape of the lesion that are not used for 
the calculation of the total score. 


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6.6.2 Independent Image Review 
Standardized lesion images were evaluated by two independent reviewers. The independent 
reviewers evaluated all images and assessed the evolution of the lesions compared to Week 1 by 
indicating if the lesion improved, worsened or did not change.  
The assessment was performed in two separate steps in the following order: 
1. Blinded Review: reviewers compared Week 1 to Week 12 on a blinded manner without 
knowing the order of the visits. 
2. Unblinded Review: reviewers assessed the evolution of the lesions (primary, secondary, and 
tertiary) for all visits comparing them to Week 1.  
 
For any discordant scores, the evaluators had to discuss and try to find agreement.  In situations 
where concordance could not be reached, the worst result will be used for the analysis. 
6.6.3 Pain Visual Analog Scale (VAS) 
A VAS is a measurement instrument that aims to measure a characteristic or attitude that is 
believed to range across a continuum of values and cannot easily be directly measured. 
6.6.4 Wound Quality of Life (Wound-QoL) 
The Wound-QoL measures the disease-specific, health-related quality of life of subjects with 
chronic wounds. It consists of 17 items on impairments which are always assessed in retrospect to 
the preceding seven days. Answers to each item are coded with numbers (0='not at all' to 4='very 
much').  
A Wound-QoL global score on overall disease-specific quality of life is computed by averaging 
all items. A global score can only be computed if at least 75% of the items have been answered 
(i.e., at least 13 in 17 items are valid). Otherwise, the global score will be considered missing. 
In addition, subscales of the Wound-QoL can be calculated representing different dimensions of 
disease specific quality of life by averaging the respective items. A subscale can only be computed 
if no more than 1 item of the subscale is missing.  
The items are assigned to subscales as follows: 
• Subscale 'Body': Items #1 to #5 
• Subscale 'Psyche': Items #6 to #10 
• Subscale 'Everyday life': Items #11 to #16 
 
Item #17 does not belong to any of the subscales. 
 
 


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7. SEQUENCE OF PLANNED ANALYSES 
7.1 Interim analysis 
An interim analysis is planned when approximately 50% subjects have completed 12 weeks of 
treatment. The objective of this interim analysis is to determine whether the study should continue 
to enroll subjects, given the difficulty in finding qualifying subjects. The interim analysis will also 
be used to help inform the design of future clinical trials in this population. 
7.2 Final analysis 
The final analysis will be performed when all subjects have finished the study and the database 
has been successfully locked.  
8. STATISTICAL METHODS 
8.1 General considerations 
Data will be analyzed by Syntax for Science personnel. Statistical analyses will be reported with 
tables, figures, and subject data listings and presented in rich text format and pdf. Output 
specifications for all tables, listings and figures will be in conformance with guidelines specified 
by the International Council on Harmonisation (ICH E3). In general, continuous variables in 
demographic and baseline characteristics will be summarized by displaying: n (non-missing 
sample size), mean, standard deviation (SD), standard error (SE), median, quartiles, maximum and 
minimum. The frequency and percentages (based on the non-missing sample size) of observed 
levels will be reported for all categorical measures. Percentages will be calculated out of the total 
number of subjects in the analysis set or the nonmissing sample size, as appropriate. 
Numerical efficacy variables will be summarized displaying n, mean, 95% confidence interval, 
median, SD, SE, quartiles, minimum, maximum.  
Time-to-event variables will be calculated and analyzed in days if not specified otherwise. 
All summary tables will be structured in a column and will be annotated with the total population 
size relevant to that table/treatment, including any missing observations.  
Differences within groups will be assessed using paired t-test or Wilcoxon test as considered 
appropriate. 
No inferential statistics will be applied to baseline characteristics and safety variables unless 
specified otherwise. 
In general, all data recoded in this study will be listed, sorted by site and subject, and when 
appropriate by visit number (or assessment date). A description of the content and format of all 
planned listings is provided in the Appendix, Section 12.2. 
Report summaries will be generated using validated SAS® software, version 9.3 or higher, on a 
PC platform. Additional validated software may be used to generate analyses, as needed.  
All SAS programs that create outputs or supporting analysis datasets will be validated by a second 
statistical programmer or biostatistician. At a minimum, validation of programs will consist of a 


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review of the program log, review of output or dataset format and structure, and independent 
review of all outputs. 
8.2 Analysis populations 
8.2.1 All Subjects 
Subjects included in the study who have signed informed consent and received at least one dose 
of SNF472. 
8.2.2 Safety Analysis Set  
Subjects included in the study who have signed informed consent and received at least one dose 
of SNF472.  
8.2.3 Efficacy Analysis Set 
The definitions given in the protocol about the efficacy analysis sets were considered very 
restrictive, therefore two new analysis sets for efficacy have been defined: 
8.2.3.1 
Intention to Treat Set 
Subjects who have received at least one dose of SNF472 and for whom at least one post-baseline 
efficacy measurement is obtained. 
8.2.3.2 
Per Protocol Set  
The Per Protocol Set includes all subjects who receive at least 75% of SNF472 doses and who did 
not violate the protocol in a way that might affect the evaluation of the effect of the study drug on 
the primary endpoint. 
Major and minor protocol violations will be identified and documented by the Sponsor.   
8.2.4 PK Analysis Set  
All subjects who receive at least 1 dose of SNF472 and for whom either of the primary PK 
parameters (Cmax) can be calculated. Further analysis sets might be defined if considered 
appropriate to assess the sensitivity of the PK results, e.g., subjects without any major protocol 
deviation thought to interfere with the absorption, distribution, metabolism, and excretion of the 
compound to be measured. 
 
The following table indicates the correspondence between the above defined analysis sets and the 
planned statistical analysis: 
Planned analysis / Analysis sets 
All Subjects* 
Safety* 
Intention 
to treat 
Per 
Protocol 
PK 


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Disposition, Protocol Deviations 
and Analysis Sets 
X 
 
 
 
 
Baseline and disease 
characteristics 
 
X 
 
 
 
Previous and Concomitant 
medications 
 
X 
 
 
 
Treatment compliance and 
exposure 
 
X 
 
 
 
Primary endpoint 
 
 
X 
X 
 
Secondary endpoints 
 
 
X 
 
 
Safety variables 
 
X 
 
 
 
PK analysis 
 
 
 
 
X 
PD/Biomarker analysis 
 
 
 
 
X 
Subgroup analysis 
 
 
X 
 
 
All subject listings 
X 
 
 
 
 
* Includes all patients who received at least 1 dose. 
8.3 Covariates and subgroups 
The primary efficacy endpoint will be summarized by various subgroups of interest based on 
baseline and demographic categories including age (e.g., < 65 years of age and > 65 years of age), 
gender, race, and country, and based on certain medications (e.g. STS: sodium thiosulfate). 
Summaries by subgroup will only be produced if there are at least 2 subjects in the category of 
interest. Otherwise, categories might be grouped as appropriate. 
8.4 Missing data 
This section provides a general description about methods used to impute missing data. Specific 
details for imputed variables will be given in Section 9.2. 
Missing imputation will be only applied for the primary and key secondary endpoints, i.e. BWAT, 
VAS and Wound QoL. The main analysis will be based on Multiple Imputation (MI). Sensitivity 
analyses will be conducted to assess the robustness of the results with regards to handling of 
missing data. The following methods will be applied: Last Observation Carried Forward (LOCF), 
and Observed Cases (OC) (Molenberghs & Kenward, 2007). 
 
Multiple Imputation 
Multiple imputation was selected as the method for imputing missing data as the natural 
progression of calciphylaxis skin lesions under standard of care treatment varies considerably 
[Nigwekar et al, 2013]. Rather than making assumptions under the LOCF method that may either 
be too optimistic or conservative relative to the natural progression of skin lesions under standard 


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of care treatment, multiple imputation uses all available data for a given variable to impute for 
missing data. Missing data will be imputed 100 times to generate 100 complete data sets, using the 
MI SAS procedure (using Markov Chain Monte Carlo (MCMC) for continuous variables or the 
Fully Conditional Specification (FCS) Discriminant analysis for categorical variables). The 
absolute change from baseline at Week 12 will be then derived from observed and imputed data at 
this time point. The 100 complete data sets will be then analyzed using a paired t-test, and the 
MIANALYZE procedure will be used to generate valid statistical inferences by combining results 
from the 100 analyses using Rubin’s formulae. 
The number of imputations (100) will be informally verified by replicating sets of 100 imputations 
and checking whether the combined results are stable. If not stable, the number of imputations will 
be increased and informally checked as above, and thus until stable estimates are obtained. 
The imputation model will include: 
• The endpoint values from all non-missing scheduled weeks.  
• The endpoint values from other items within the same scale, if applicable. 
 
LOCF 
This analysis imputes the last measured value of the endpoint to all subsequent evaluations. In case 
of missing data at baseline, the missing value will be imputed using the first available visit, i.e., 
First Observation Carried Backward, FOCB. 
 
Observed Cases 
The analysis under this scenario will be conducted without any missing data imputation. 
8.5 Censored Subjects 
Subject 16001 had a surgical closure of the primary lesion at Week 11. This subject’s efficacy data 
was censored for the timepoints after the surgical procedure, and will be treated as missing.  
8.6 Multi-centre studies 
This is a multicenter study, with sites enrolling subjects in the USA, UK and Spain with each site 
enrolling 1 -2 subjects. Efficacy data collected from all study centers will be pooled for data 
analysis. 
8.7 Multiple testing 
There will be no adjustments for multiple comparisons in this proof of concept study.  
8.8 Baseline values 
Baseline is considered the value collected at the Day 1 Week 1 visit. If Day 1 Week 1 value is 
missing, the Screening value will be used as baseline. If neither a Day 1 Week 1 or Screening value 


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is available, then the baseline value will be imputed according to the MI and LOCF methods 
described in Section 8.4.  
Some analyses will be also presented comparing pre-dose and post-dose effects. Unless otherwise 
specified, post-dose and pre-dose comparisons will be done using data from the same study day. 
8.9 Reporting conventions 
8.9.1 General reporting conventions 
All tables, figures and data listings will be presented in landscape orientation. Legends will be 
used for all figures with more than one variable or item displayed. Figure lines should be wide 
enough to see the line after being copied.  
All tables, figures, and listings,  (TFLs) will have the name of the relevant SAS program (output 
name), the author, and a run time stamp on the bottom of each output. 
Titles should contain the following information:  
• Output number.  
• Description of the data that is being summarized. 
• Type of analysis performed, covariates used (if applicable).  
• Analysis set. 
8.9.2 Statistical summary conventions 
For tables, sample sizes for each population will be presented as totals in the column header 
(N=xx), where appropriate. Sample sizes shown with summary statistics are the number (n) of 
subjects with non-missing values at a visit.  
Summaries for categorical variables will include all categories (even if some categories are empty). 
All summaries for continuous variables will include: N, mean, and SD. Other summaries (e.g. SE, 
median, quartiles, range, 95% intervals, CV or %CV) will be used as appropriate. All percentages 
should be rounded and reported to a single decimal place (xx.x%). If percentages are reported as 
integers, percentages greater than 0% but <1% will be reported as <1%, whereas percentages 
greater than 99% but <100% will be reported as >99%. A percentage of 100% will be reported as 
100%. No value of 0% should be reported. Any computation of percent that results in 0% is to be 
reported as a blank. P-values will be reported with up to three decimal places with a leading zero 
(0.001). P-values <0.001 will be reported as <0.001. Summaries for continuous variables will be 
presented with the same number of decimal places as originally provided in the CRF. 


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9. STATISTICAL ANALYSIS 
9.1 Baseline and other relevant data 
9.1.1 Subject disposition 
The number of subjects who were enrolled, completed each visit, and discontinued, and reasons 
for discontinuation will be summarized (Shell T - 1). 
9.1.2 Protocol deviations 
Deviations from the Clinical Study Protocol will be collected by the monitors, including deviations 
of inclusion/exclusion criteria will be assessed and categorized by the Sponsor. The number of 
subjects with protocol deviations (any, major, minor and by deviation) will be summarized 
descriptively (Shell T - 2). All the collected information regarding protocol deviations will be 
listed. 
9.1.3 Analysis sets 
The number of subjects included and excluded in each analysis set will be described (Shell T - 3). 
Subjects excluded from any analysis set will be listed including: analysis set from which it is 
excluded, and the reasons for exclusion (Shell T - 3). 
9.1.4 Demographics and other baseline characteristics 
The following variables will be summarized (Shell T - 4):  
Demographics: Age, Sex, Race, Ethnicity, Weight, Height, and BMI as recorded at the Screening 
visit. BMI will be presented as a continuous variable and for the following categories: “<20”, “20-
25”, and “>25”. 
Disease characteristics: Intense Pain (Yes/No), VAS score, Firm calcified (Yes/No/NA), 
cutaneous lesions (Yes/No), Skin biopsy (Yes/No/Scheduled/Not done), Results of the biopsy 
(Yes/No/Not applicable/To be redone).  
History of drug and alcohol abuse: Alcohol Consumption (Yes/No), total units of alcohol 
consumed weekly, and Drug Consumption (Yes/No), recorded in the Medical History CRF 
section. 
9.1.5 Medical History 
The following tables will be created (Shell T - 4):  
General: contains a Yes/No variable for each domain: Hemodialysis, Heart, Vascular System, 
Parathyroid, Diabetes, Kidney Diseases, Fractures, Liver Diseases, Other Diseases. For each 
domain we will consider as “Yes” if the subject has any non-negative (i.e. excluding No, UNK 
and missings) answer for at least one question related with the domain and “No” in the other cases. 


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The data related with each domain will be summarized and listed. The information summarized 
will be presented only for the subjects who has a “Yes” in the General table, but all subjects’ 
information will be listed. 
For each domain, the following variables will be summarized: 
Hemodialysis: Ca-Conc, URR and Kt/V.  
Heart: NYHA Stage, CHD, Heart failure, LVEF, MI, Bypass Surgery and PTCA.  
Vascular System: PAD and Stage Fontaine.  
Parathyroid: PTX, and Method.  
Diabetes: Diabetes, Type, and Insulin dependent.  
Kidney Disease: Renal insufficiency, CKD, Origin, Renal hypert., Metab. Acid., Osteopathy, 
Anemia, and 2nd HPT.  
Additional Diseases, Fractures: Occurrence by each Location.  
Additional Diseases, Liver Diseases: Occurrence by each Condition.  
Additional Diseases, Other: Primary HPT, Malignant, and Rheumatic.  
9.1.6 Prior and Concomitant medications 
Prior and concomitant medications will be tabulated and listed for the safety analysis set. 
Prior medications are defined as those taken from 6 months prior to Screening until the time of the 
first treatment dose administration. Concomitant medications are defined as those taken at the time 
of or after the first treatment dose administration.  
Prior and concomitant medication will be coded according to the World Health Organization's 
Drug Dictionary (WHO-DDE) and the Anatomical Therapeutic Chemical (ATC) classification 
system. 
Prior and concomitant medications will be summarized separately by ATC Name and Preferred 
Term indicating the number of subjects and percentage (Shell T - 5). When calculating the use of 
prior/concomitant medications, each subject will only be counted once and any repetitions of 
medications will be ignored; the denominator will be the total population size. 
A separate table will be presented for Pain Medications. Pain medication will be defined from the 
list of Concomitant Medications, according to coding specified by the study sponsor which should 
be merged with the Concomitant Medications dataset by Drug Record Number and Sequence 1. 
9.1.7 Treatment exposure and compliance 
The extent of exposure to SNF472 will be characterised according to the number of subjects 
exposed, the duration of exposure, and the dose to which they were exposed.  
The following data will be summarized descriptively for the total treatment period and by week 
(Shell T-6): 
• Treatment duration (days) defined as the total number of days between the first and the last 
infusion dates (inclusive). 


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• Treatment exposure (infusions) defined as the number of infusions with the study drug of at 
least 1 hour that were administered to a subject. 
• Compliance (%) defined as the total number of infusions administered to a subject divided by 
the total number of planned infusions, i.e, 3 administrations x 12 weeks of treatment = 36. 
• Dose (mg) presented as a categorical variable indicating the number and percentage of subjects 
presented on the different planned dose levels (400, 450, 700, and 900 mg). 
• Total dose (mg) (an estimation of the total dose) 
• Dialysis duration (minutes) defined as the time in minutes registered between the start of the 
dialysis start and it end. 
• Infusion duration (minutes) defined as the time in minutes registered between the start of the 
infusion and its end. 
• Number of infusions with any interruptions counting the number of infusions per subject 
where the question "Infusion interruptions" is Yes. 
•  Ca in Dialysate Bath presented as a categorical variable. 
 
9.2 Efficacy Analysis 
9.2.1 Primary endpoint 
The primary endpoint is the absolute change in BWAT total score between baseline (Week 1) and 
Week 12 for the primary lesion (the largest one).  
Absolute change from baseline will be calculated as differences in the total score from Week 1 to 
Week 12. Descriptive statistics will be presented. Differences between the two visits will be 
analyzed using a Paired Student’s T-Test. (Shell T-7)  
Missing imputation will be done on the item level. For the imputation of baseline missing item 
scores FOCB will be used for LOCF imputation method if any subsequence item score is available, 
else the score will be imputed by 3. For the multiple imputation method the baseline values will 
be imputed by 3. The main analysis will be done using Multiple Imputation, and supported by the 
different sensitivity analysis as specified in Section 8.4. A forest plot summarizing these results 
will be produced presenting the estimated change from Week 1 to Week 12 and its 95% confidence 
interval for the different imputation methods (Shell F - 1). 
9.2.2 Secondary endpoints 
9.2.2.1 
Change from baseline in BWAT total and component scores by visit 
BWAT Score is collected at Week 1, Week 2, Week 4, Week 6, Week 8, Week 10, Week 12 and 
Follow-up. Differences in absolute and relative change from baseline will be also presented. 
Differences from baseline will be tested using a Paired Student’s T-Test. (Shell T-7). Additionally, 
a figure presenting the evolution (mean, and 95% confidence interval) of the total score and 


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individual items by visit will be presented (Shell F-2). This analysis will be done using Observed 
Cases. 
9.2.2.2 
The previous analysis will also be done for the secondary and tertiary 
lesions if there is enough data. Change from baseline in imaging score by visit 
Image evaluation will be summarized separately for the blinded and unblinded reviews. 
Percentages for each category and their exact 95% confidence interval (Clopper-Pearson) will be 
presented. Imputation methods will not be used for this score. 
9.2.2.3 
Change from baseline in the Pain Visual Analog Scale (VAS) by visit 
Absolute change from baseline will be calculated as differences in the total score from Week 1 to 
Week 12. Descriptive statistics will be presented. Differences between the two visits will be 
analyzed using a Paired Student’s T-Test. (Shell T-7)  
The Week 1 to Week 12 analysis will be done using Multiple Imputation, and supported by the 
different sensitivity analysis as specified in Section 8.4. A forest plot summarizing these results 
will be produced presenting the estimated change from baseline and 95% confidence interval for 
the different imputation methods. These analysis will also be done for the PP population. 
 
Additionally, the VAS Score is collected at Screening, Week 1, Week 2, Week 4, Week 6, Week 
8, Week 10, Week 12 and Follow-up. VAS scores will be summarized by visit. Differences in 
absolute and relative change from Week 1 to each visit will be presented descriptively. Finally, 
differences in absolute change from Week 12 to Follow-up will be summarized. Statistically 
significant differences from the reference values will be tested using a Paired Student’s T-Test 
(Shell T-7). Additionally, a figure presenting the evolution (mean, and 95% confidence interval) 
of the VAS score by visit will be presented (Shell F-2). This analysis will be done using Observed 
Cases. 
9.2.2.4 
Change from baseline in total and subscales of wound QoL score by visit 
Missing values (e.g., missing visits, visits with more than 25% of the items missing, or subscales 
with more than one item missing) will be imputed. Missing imputation will be done on a 
subscale level. Absolute change from Week 1 to Week 12 will be done using Multiple 
Imputation, by each subscale and global score and supported by the different sensitivity analysis 
as specified in Section 8.4. A forest plot summarizing these results will be produced presenting 
the estimated change from baseline and 95% confidence interval for the different imputation 
methods (Shell F-1). 
Wound Quality of Life was collected at Week 1, Week 6 and Week 12. Differences in percent and 
absolute change from Week 1 to each visit by each subscale and in the global score will be analyzed 
using a Paired Student’s T-Test (Shell T-7). Means and 95% confidence interval will be presented 
graphically by visit for the global score and subscales (Shell F-2). This analysis will be done using 
Observed Cases. 


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9.2.2.5 
Potential Wound Complications 
Sponsor will review all AEs to identify potential wound complications (eg., wound infections, 
systemic infections, wound complications, surgical treatments of the wound). 
9.2.3 Hospitalization and Death 
Hospitalizations will be identified from the list of Adverse Event for which Seriousness has been 
reported as “Requires or prolongs hospitalization”.  
The number and percentage Hospitalizations will be will be summarized by System Organ Class 
and Preferred Term presenting the number of events, the number of subjects and percentage (Shell 
T-5).  
Deaths will be identified from the list of adverse events, for which Seriousness has been reported 
as “Results in death” or Outcome has been reported as ”Death” or Primary Reason for Premature 
Termination has been reported as “Death” on the End of Study CRF section. 
The number and percentage of deaths will be computed and will be summarized by System Organ 
Class and Preferred Term (Shell T-5).  
9.2.4 Exploratory Analyses 
9.2.4.1 
Absolute change in BWAT total score between Week 12 and Follow-up 
for all lesions.  
The absolute change in BWAT total score of the primary lesion between Week 12 and Follow-up 
will be summarized using the missing imputation method specified for the primary endpoint.  
The same analysis will also be done for the secondary and tertiary lesions if there is enough data. 
9.2.4.2 
BWAT vs VAS correlation.  
Correlation between VAS and BWAT (absolute and relative) change from baseline to Week 12 
will be assessed:  
• Absolute VAS change from baseline vs absolute BWAT change from baseline 
• Relative VAS change from baseline vs relative BWAT change from baseline 
 
Correlation will be assessed graphically by means of linear regression analysis where VAS and 
BWAT will be considered as dependent and independent variables, respectively. Linear regression 
parameters, correlation estimate and their 95% confidence intervals will be presented. 
 


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9.3 Safety analyses 
9.3.1 Adverse Events 
AEs will be summarized presenting the number of events, the number of subjects and percentage. 
When calculating the incidence of AEs, or by seriousness sub-classification, each subject will only 
be counted once and any repetitions of AEs will be ignored; the denominator will be the total 
population size. In case of repetition of an AE the worse seriousness will be considered. 
An overview table (Shell T-5) will be prepared showing the number of subjects (percentage of 
subjects, and events) with: 
• Adverse Events  
• Adverse Events by relationship to SNF472 
• Adverse Events leading to drug discontinuation 
• Serious Adverse Events 
• Adverse Events leading to death 
 
In addition, frequency tables (Shell T-5) will be prepared for: 
• Adverse Events by System Organ Class and Preferred Term 
• Adverse Events by Preferred Term in Decreasing Order of Incidence  
• Adverse Events by System Organ Class and CTCAE Grade 
• Adverse Events by System Organ Class and Relationship to SNF472 
• Adverse Events Leading to Discontinuation of SNF472 by System Organ Class 
• Serious Adverse Events by System Organ Class and Preferred Term 
9.3.2 Clinical Laboratory Evaluations 
Summary tables will be presented in groups of related parameters: 
• Haematology 
• Clinical Chemistry 
• Parathyroid Hormone 
• Potassium, magnesium, iron (ferritin/transferrin) and zinc 
• Ionised Calcium 
• Pregnancy test 
Analyses are conducted for the laboratory data using SI units. 
Haematology and Clinical chemistry data will be collected at Screening, Week 1, Week 6, Week 
12 and Follow-up. Absolute change from baseline values for each parameter will be summarized 
descriptively.   (Shell T-7).  
Parathyroid Hormone data will be collected at Week 1 and Week 12. Absolute change from 
baseline values for each parameter will be summarized descriptively.   (Shell T-7).  


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Potassium, magnesium, iron (ferritin/transferrin) and zinc data will be collected at Screening, 
Week 1 (pre and post-dose), Week 12 (pre and post-dose) and Follow-up. Differences in absolute 
change from the pre-dose measurement of each visit to the post-dose measurement of the same 
visit, and the differences in absolute change from Baseline to all measures will be summarized 
(Shell T-7).  
Ionised Calcium data will be collected at Screening, Weeks 1, 2, 4, 6, 8, 10 and 12 (pre and post-
dose), and Follow-up. Differences in absolute change from the pre-dose measurement of each visit 
to the post-dose measurement of the same visit, and the differences in absolute change from 
Baseline to all measures will be summarized (Shell T-7).  
Pregnancy test data will be collected at Screening, Week 1, Week 4, Week 8 and Week 12. The 
following variables will be summarized: Done/ not done, if any, reason for not done.  Sample type 
and results by visit (Shell T-6). 
9.3.3 ECG, Physical examination and Body weight 
Electrocardiograms are collected at Screening, Week 1 (pre-dose and end of infusion), Week 6 
(pre-dose and end of infusion), Week 12 (pre-dose and end of infusion) and Follow-up. The 
following variables are collected: RR interval, PRT axis, PR interval, QRS complex, QT interval, 
QTcB, QTcF, Heart rate and ECG Assessment, including clinical evaluation. 
Differences in absolute change from the pre-dose to post-dose within the same visit, and the 
differences in absolute change from Week 1 day 1 pre-dose to all the following pre-dose 
measurements will be summarized (Shell T-7).  
Following the recommendation of the guidance ICH E14, the following additional analyses on 
QTc for both Bazett’s and Fridericia’s formulas will be done: 
• number of subjects with QTc interval > 450 ms 
• number of subjects with QTc interval > 480 ms 
• number of subjects with QTc interval > 500 ms 
• number of subjects with QTc interval increases from predose > 30 ms  
• number of subjects with QTc interval increases from predose > 60 ms 
The previous parameters will be measured at any point during the study after the first drug infusion 
(Shell T-4). In addition, the same parameters will be summarized by visits Week 1 day 1, Week 6 
day 1 and Week 12 day 5 for pre-dose and post-dose time-points (Shell T-6). The tables will be 
also presented for QT. 
Shift tables on the ECG clinical assessment will be produced to present: 
• Change from baseline on the pre-dose assessments to Week 6 and Week 12 (Shell T-9) 
• Change from pre-dose to post-dose within infusion days at weeks 1, 6 and 12 (Shell T-10)  
 
RR, QTcB and QTcF will be re-calculated using the following formulas, if it is possible: 
 


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Physical examination was collected at Screening and Follow up Visit and it will be summarized 
and listed by subject, time-point and body system including the following information: parameter, 
assessment and clinical significance (Shell T-6). 
Body weight was collected at Screening, Week 6 and Follow up Visit and it will be listed by 
subject and time-point including the following information: date, weight without shoes, Height 
without shoes and BMI. 
 
9.4 Pharmacokinetics  
The PK analysis will be summarized, listed and printed for the PK analysis set.  
Plasma samples collected, at Week 1 and Week 12, pre and end of infusion will be used for PK 
assessment. The end of the infusion is the approximate time of Cmax.  
All concentration values below the LLQ and samples with no reportable value occurring prior to 
dosing will be replaced by “0”. For tabulation, graphical representation and calculation purposes, 
all samples LLQ or with no reportable value observed after the drug administration will be set to 
missing. 
Blood samples for the quantitation by LC-MS/MS of SNF472 will be taken on 2 different days at 
pre-dose and at the end of the infusion time on day 1 (Week 1), and on Week 12. Infusion should 
be performed during 2.5 to 4 hours at constant rate.  The following parameters will be calculated: 
• Actual infusion time (Tinf) will be calculated as the difference between the actual clock 
time of the end of infusion time (EOI) and the actual clock time of the start of the infusion 
(SOI), i.e., Tinf = EOI - SOI. The actual infusion time will be expressed in minutes. 
• Actual sampling time will be calculated as the difference between the sample collection 
actual clock time and the clock time of dosing starts.  The actual sampling times will be 
expressed in minutes.  
9.4.1 Pharmacokinetic Parameters 
The plasma concentrations of SNF472 obtained at predose and at the end of the infusion time 
(EOI) will be reported. EOI corresponds to the maximum (peak) plasma concentration during the 
dosing interval (Cmax), based on data from previous clinical studies. Standard pharmacokinetic 
parameters will not be calculated due to the lack of experimental points in the plasma 
concentration-time profile of SNF472. 
 
Descriptive statistics of the pharmacokinetic parameters will be presented by visit and timepoint 
and will contain the following information: 
 


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• SNF472 dose:  
 
 
expressed in mg 
• 
Tinf:  
 
 
 
 
actual infusion time. Expressed in minutes 
• 
Actual sampling time  
 
actual sampling time. Expressed in minutes 
• Pre-dose plasma levels: 
 
expressed in ng/mL or as below of the lower 
limit of quantification (BLQ). 
• 
End of infusion plasma levels (Cmax) 
expressed in ng/mL 
 
Individual data will be flagged for exclusion if actual time differs significantly from scheduled 
time. In those cases when the actual infusion time and actual sampling time at the end of the 
infusion differs significantly from the protocol time will be excluded from statistics, based on the 
pharmacokinetist criteria. 
PK data will be listed by subject, visit and time-point. In addition, the same information listed 
using all time-points will be reported in a figure (Shell F-2).  
On a case by case basis, it may be necessary to exclude individual infusion time values and 
concentration values because they are erroneous or abnormal. Any excluded data should be flagged 
in the individual data listings and the reason for exclusion should also be documented. If the 
exclusion has a meaningful impact on the overall interpretation of the results, then it should be 
discussed. Planned infusion and sampling times may be used as a replacement for unknown or 
missing actual times, based on the pharmacokinetist criteria.  
9.4.2 Accumulation 
Given the short half-life of SNF472, no accumulation of SNF472 plasma concentration is 
expected. Accumulation effects from Week 1 to Week 12 will be assessed on the Cmax by 
comparing the difference between the two visits. Accumulation will be declared if the 90% CI of 
the difference does not include the value 0. 
9.4.3 End of infusion PK concentration vs BWAT correlation  
Correlation between End of Infusion PK Concentration vs Increase in  BWAT Total Score from 
Week 1 to Week 12 will be assessed graphically by means of linear regression analysis where 
BWAT and EoI PK concentration will be considered as dependent and independent variables, 
respectively. Linear regression parameters, correlation estimate and their 95% confidence intervals 
will be presented. 
9.4.4 End of infusion PK concentration vs VAS correlation  
Correlation between End of Infusion PK Concentration vs Increase in  Pain Score (VAS) from 
Week 1 to Week 12 will be assessed graphically by means of linear regression analysis where VAS 
and EoI PK concentration will be considered as dependent and independent variables, respectively. 
Linear regression parameters, correlation estimate and their 95% confidence intervals will be 
presented. 
 


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9.5 Pharmacodynamics 
Plasma samples collected, at Week 1 and Week 12 pre and post-dose (around the Tmax for the 
post-dose measurement), from all subjects, will be used for exploratory pharmacodynamic (PD) 
assessment by using an in vitro test to assess the propensity for hydroxyapatite (HAP) crystal 
formation in plasma (see Protocol CT2015-04.2).  
9.5.1 % PD Inhibition  
The PD assessment will be performed by Laboratorios Sanifit and sent to Syntax for Science for 
analysis. The readout of the assay is a % inhibition of the propensity for hydroxyapatite crystal 
formation per each subject and visit. 
The percent inhibition of  HAP crystallization will be summarized by visit. In addition, the same 
information will be listed by all subjects and all timepoints together with the PK.  
9.5.2 % PD Inhibition vs BWAT correlation  
Correlation between % PD Inhibition vs Increase in  BWAT Total Score from Week 1 to Week 12 
will be assessed graphically by means of linear regression analysis where BWAT and % PD 
Inhibition will be considered as dependent and independent variables, respectively. Linear 
regression parameters, correlation estimate and their 95% confidence intervals will be presented. 
9.5.3 % PD Inhibition vs VAS correlation  
Correlation between % PD Inhibition vs Increase in  Pain Score (VAS) from Week 1 to Week 12 
will be assessed graphically by means of linear regression analysis where VAS and % PD 
Inhibition will be considered as dependent and independent variables, respectively. Linear 
regression parameters, correlation estimate and their 95% confidence intervals will be presented. 
 
9.6 PK/PD modelling 
PK/PD modeling links the drug plasma concentration with an efficacy metric, and it is performed 
to guide in the design for future studies. 
The % inhibition of  HAP crystallization and the Cmax will be used to calculate a PK/PD 
correlation between both parameters at Week 1, Week 12 and combining both visits.  
 
 


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9.7 Subgroup analysis 
Subgroup analysis will be summarized for the ITT analysis set. Subgroups will be based on 
baseline and demographic categories including age (e.g., < 65 years of age and > 65 years of age), 
gender, race, and country, and use of STS (sodium thiosulfate).  
9.7.1 BWAT 
Subgroup analysis will be done for the absolute change in BWAT total score between baseline 
(Week 1) and Week 12 for the primary lesion as specified in Section 8.3. Missing imputation will 
be done as specified in Section 9.2.1. 
9.7.2 VAS 
Subgroup analysis will be done for the absolute change in VAS total score between Week 1 and 
Week 12 as specified in Section 8.3. Missing imputation will be done as specified in Section 
9.2.2.4. 
VAS responder analysis for STS subgroup will be done by each imputation method summarizing 
the percentage of reduction of VAS from Week 1 to Week 12 (Shell T-8). Percentage of reduction 
will be calculated as follows: 
Percentage of reduction = -100*(Week 12 VAS score - Week 1 VAS score) / (Week 1 VAS score) 
The following categories will be used: 
• Worsening (negative percentage of reduction) 
• >=0 and <30 
• >=30 
• % not available (Week 1 VAS score = 0) 
• Missing W12 value 
 
10. SUMMARY OF CHANGES FROM THE PROTOCOL 
5.2 The protocol did not provide details about the methods used for the analysis of the study 
endpoints, nor at which timepoints. The primary endpoint was assessed comparing Week 1 to 
Week 12. Whereas, secondary endpoints were assessed comparing baseline to all subsequent 
visits. Differences from baseline were tested using a Paired Student’s T-Test. Last Observation 
Carried Forward (LOCF) and Multiple Imputation (MI) was used to treat missing data.  
5.2.2 “Change in dose and type of pain medication assessed as a continuous variable. Name (INN), 
dose, and number of pills captured” was not done but the use of pain medications will be discussed 
in the CSR. 
6.3.3 Criteria for subject withdrawal - For criteria for withdrawal, data are presented for subjects 
who received at least one dose of study medication.  Subjects who did not meet entry criteria are 
presented as screen failures. 


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8.2.2 Efficacy Analysis Set. The efficacy analysis set has been divided in Intention to Treat and 
Per Protocol sets.  
 
 
 
 


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11. REFERENCES 
• Nigwekar S et al (2003). Sodium Thiosulfate Therapy for Calcific Uremic Arteriolopathy. Clin 
J Am Soc Nephrol, Vol 8. 
• Molenberghs, G. and Kenward, M. G. (2007). Missing Data in Clinical Studies. Wiley. 
• ICH E3 (1995) - Structure and content of clinical study reports. Step4. 
• ICH E14 (2005) - The clinical evaluation of QT/QTc interval prolongation and 
proarrhythmic potential for nonantiarrhythmic drugs. Step 4. 
 


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12. APPENDICES 
The appendices contain a list of Tables, Figures, and Listings to be produced, as well as their 
corresponding shells.