bmj open · for peer review only protocol for a randomised controlled, open label trial of ex-vivo...

For peer review only

Protocol for a Randomised controlled, open label trial of Ex-vivo Normothermic Perfusion versus Static Cold Storage in

Donation after Circulatory Death Renal Transplantation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012237

Article Type: Protocol

Date Submitted by the Author: 10-Apr-2016

Complete List of Authors: Hosgood, Sarah; University of Cambridge, Dept of Surgery Saeb-Parsy, Kourosh; University of Cambridge, Dept of Surgery Wilson, Colin; Freemans Hospital, Transplantation

Callaghan, Christopher; Guy's and St Thomas's, Transplantation Collett, Dave; NHS Blood and Transplant, Statistics and Clinical Audit Nicholson, Michael; University of Cambridge, Dept of Surgery

<b>Primary Subject Heading</b>:

Surgery

Secondary Subject Heading: Renal medicine

Keywords: Transplant medicine < INTERNAL MEDICINE, Renal transplantation < NEPHROLOGY, TRANSPLANT SURGERY

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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A Protocol of a Randomised controlled, open label trial of Ex-vivo Normothermic

Perfusion versus Static Cold Storage in Donation after Circulatory Death Renal

Transplantation

1

Sarah A Hosgood, 1

Kourosh Saeb-Parsy, 2

Colin Wilson, 3

Christopher Callaghan, 4

Dave

Collett, 1

Michael L Nicholson.

1

University of Cambridge, Department of Surgery, Addenbrooke’s Hospital, Level 9. Hill’s

Road. Cambridge CB2 OQQ 2

Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, Tyne and Wear NE7

7DN 3

Guy’s & Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT 4

NHS Blood and Transplant Fox Den Road, Stoke Gifford, Avon, Bristol BS34 8RR

Correspondence

Dr Sarah Hosgood

University of Cambridge,

Department of Surgery,

Addenbrooke’s Hospital,

Level 9.

Hill’s Road.

Cambridge

CB2 OQQ

Tel 01223 762002

Email [email protected]

Trial Registration Number: SRCTN15821205

Protocol Version 1.1 Date: 4th

November 2015

Funder: Kidney Research UK (SP/MEKC/1/2014)

Sponsor: University of Cambridge and University Hospitals of Cambridge Foundation Trust

Cambridge CB2 OQQ. Mr Stephen Kelleher Tel 01223 596472.

Email: r&[email protected]

Role of Sponsor

• Central data collection and verification of SAEs. Reporting safety information

and checking for (annually) and notifying PIs of updates to the Reference

Safety Information for the trial.

Contributors

The study protocol was derived by (MLN, SAH, KSP, CW and CC). MLN wrote the original

draft which was reviewed and revised by all the co-authors. DC performed the statistics.

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Abstract

Introduction

Ex-vivo normothermic perfusion (EVNP) is a novel technique that reconditions the kidney

and restores renal function prior to transplantation. Phase I data from a series of EVNP in

donation after circulatory death (DCD) and extended criteria donor (ECD) kidneys has

established the safety and feasibility of the technique in clinical practice.

Methods and analysis

This is a UK based phase II multicentre randomized controlled trial to assess the efficacy of

EVNP compared to the conventional static cold storage technique in DCD kidney

transplantation. Four hundred patients receiving a kidney from a DCD donor (Category III,

controlled) will be recruited into the study. On arrival at the transplant centre, kidneys will be

randomized to receive either EVNP (n = 200) or remain in static cold storage (n = 200).

Kidneys undergoing EVNP will be perfused with an oxygenation packed red cell solution at

near body temperature for 60 minutes prior to transplantation. The primary outcome measure

will be determined by rates of delayed graft function (DGF) defined as the need for dialysis

in the first week post-transplant. Secondary outcome measures include graft function in the

first 7 days post-transplant, duration of DGF, rates of primary non function, patient and graft

survival at 1 year, complications, rates of acute rejection and length of hospital stay. The

level of fibrosis and inflammation will also be measured using tissue, blood and urine

samples.

Ethics and dissemination

The study has been approved by the NHS Health Research Authority Research Ethics

Committee. The results are expected to be published in 2020.

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Strengths and Limitations

• This is a large multicentre randomized controlled trial. It will provide evidence of the

effect of ex-vivo normothermic perfusion on early graft function in DCD kidney

transplantation.

• The secondary objectives will allow us to examine of the impact of EVNP on rates of

acute rejection and longer-term graft function and survival.

• Tissue, blood and urine samples will enable a more in depth analysis of the effects of

EVNP on ischaemia reperfusion

• The limitation of this study is the lack of blinding. Due to the nature of the technique

and in order to report safety outcomes, it is not possible to blind the surgical team to

the allocation of the kidney.

• Delayed graft function defined as dialysis within the first week of transplantation is

subjective. However, it is the best accepted measure of early graft function.

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Introduction

Kidney transplantation continues to be limited by a shortage of organ donors. In response to

this there has been an increase in the use of kidneys from marginal donors and a significant

proportion of transplant kidneys are now provided by donation after circulatory death (DCD)

donors 1. DCD kidneys inevitably sustain a warm ischaemic insult prior to retrieval and 50-

60% of these kidneys have delayed graft function (DGF) after transplantation 1. DGF is

associated with an increased risk of acute rejection, longer in-patient stay and therefore

greater cost, and may also reduce allograft survival 1-7

. Moreover, when compared to

standard criteria donors, DCD kidneys are three times more likely to be declined for

transplantation due to concerns over their quality 8, 9

.

Organ preservation has traditionally relied on hypothermic techniques based on the principle

that refrigeration reduces cellular metabolism and tissue oxygen requirements. The problem

is that in the anoxic hypothermic environment anaerobic cellular respiration continues, albeit

at a slow pace. Oxidative phosphorylation is uncoupled and mitochondrial ATP production

by chemiosmosis ceases 10

. ATP continues to be generated at a much slower rate by

substrate-based phosphorylation in the glycolytic pathway. This leads to depletion of

intracellular ATP stores. Anaerobic respiration generates lactic acid leading to worsening

intracellular acidosis and eventually loss of cell viability 10

. The initial warm ischaemic

injury sustained by DCD kidneys makes them less tolerant of cold ischaemic injury during

hypothermic preservation 11, 12

.

Normothermic perfusion techniques offer an alternative form of organ preservation and

resuscitation that has the potential to limit some of the effects of hypothermic preservation

techniques 13

. Ex-vivo normothermic perfusion (EVNP) is a novel technique that may help to

recondition ischaemically injured kidneys prior to transplantation 13

. The aim of EVNP is to

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restore metabolism and function to the kidney prior to transplantation by circulating a warm

oxygenated red cell based solution through the kidney.

EVNP has recently been introduced into clinical practice for kidneys from marginal donors

13-17. The early experience of renal transplantation after EVNP shows that the technique is

feasible, safe and may improve early graft function.

This study will investigate the effect of 60 minutes EVNP in kidneys from DCD donors

compared to the traditional technique of static cold storage

The primary outcome measure will be delayed graft function (DGF) defined as the need for

dialysis in the first 7 days post-transplantation. Secondary outcome measures will include

more sensitive measures of renal function over the first 7 days post-transplant, length of

hospital stay, graft and patient survival at 1 year and rates of acute rejection. Fibrosis,

inflammatory markers and urinary biomarkers will also be examined in tissue, blood and

urine.

Methods

Study type

A randomised controlled, open label trial of the effect of EVNP on initial graft function in

donation after circulatory death kidney transplantation. Figure 1 summaries the design of the

trial.

Eligibility

Patients will be eligible for the trial if they meet the following criteria; patients undergoing a

DCD kidney transplantation (Maastricht Categories III & IV); the donor and recipient must

be ≥ 18 years and it must be the patient’s 1st or 2

nd kidney transplant.

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Written informed consent will be taken from all patients included in the trial by a qualified

member of the study team. Patients will not be eligible if the donor or recipient is under the

age of 18 years, the DCD donor is in Maastricht Categories I & II, patients receiving a 3rd

or

subsequent kidney transplant, patients receiving multi-organ transplants e.g. simultaneous

pancreas-kidney transplantation, patients receiving dual kidney transplants, paediatric en-bloc

kidney transplants or kidneys that have been preserved by hypothermic machine perfusion.

There will be four participating centres in the UK; Cambridge (lead), Newcastle, Guy’s and

Edinburgh.

Randomisation

Patients will be allocated at random in a 1:1 ratio to either static cold storage (CS) plus 1 hour

of EVNP (n = 200) or CS (n = 200) only. A patient information sheet will be given to

potential recruits on admission for DCD kidney transplantation and written informed consent

will then be obtained. Randomisation will be performed after the transplant recipient and

kidney have both arrived in the transplanting centre and a final decision to proceed with

transplantation has been made by a member of the study team. The randomisation will be

performed on a web based system (sealedenvelope) which uses a computer generated

randomisation sequence. In cases where paired kidneys from the same donor are transplanted

in the same centre, one kidney from the pair will be randomly allocated to CS and the other to

EVNP. In these cases the randomisation will also determine which kidney (right or left) will

be transplanted first. Due to the nature of the trial, no-one is blinded to treatment allocation.

Multiple vessels

DCD kidneys with multiple renal arteries will not be excluded from the trial as EVNP is

technically possible in such kidneys. Nonetheless, EVNP may prove to be very difficult in

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kidneys with particularly complex vascular anatomy. If such a kidney is randomised to

EVNP then the local investigator may decide to use CS alone. Nonetheless, the recipient will

be analysed in the EVNP arm of the study in line with the intention to treat basis. As per

protocol analysis will also be performed to assess the effects of the actual preservation

method.

Kidney retrieval

All kidneys will be retrieved by UK national retrieval teams. Following in situ flushing of the

abdominal organs with hyperosmolar citrate solution or University of Wisconsin (UW)

solution, kidneys will be removed and then placed individually in preservation solution and

packed in ice. The perfusion solution used will be recorded.

Ex-vivo normothermic perfusion

The EVNP circuit has been designed using paediatric cardiopulmonary bypass technology

(Medtronic, Watford, UK) and consists of a centrifugal blood pump (Bio-pump 560), a heat

exchanger, a venous reservoir (Medtronic), 1/4 inch PVC tubing and an Affinity membrane

oxygenator (Medtronic). The hardware includes a speed controller, a TX50P flow transducer

and a temperature probe (Cole-Parmer, London, UK). Two infusion pumps are also

incorporated into the system.

Perfusate

The circuit will be primed with perfusate solution (Ringer’s solution, Baxter Healthcare,

Thetford, Norfolk, UK) and one unit of O Positive or O Negative packed red cells from the

blood bank. Manntiol 10% (Baxter Healthcare), dexamethasone 8 mg (Organon Laboratories,

Cambridge, UK) and heparin (CP Pharmaceuticals, Wrexham, UK) will be added to the

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perfusate. Sodium bicarbonate 8.4% (Fresenius Kabi, Cheshire, UK) will be added to

normalize the pH. A nutrient solution (Synthamin 17, Baxter Healthcare) with sodium

bicarbonate 8.4%, insulin (Novo Nordisk, Denmark) and multivitamins (Cernevit, Baxter

Healthcare) will be infused into the circuit at a rate of 20 mL/h. Prostacyclin 0.5 mg (Flolan,

Glaxo-Wellcome, Middlesex, UK) will be infused into the arterial arm of the circuit at a rate

of 5 mL/h and glucose 5% (Baxter Healthcare) at 5 mL/h. Ringer’s solution will be used to

replace urine output mL for ml.

Perfusion Chamber

Kidneys undergoing EVNP will be placed in a custom designed sterile perfusion chamber

and the renal artery and vein will be cannulated and primed with cold 0.9% sodium chloride.

Perfusion Parameters

Kidneys will be perfused at a set mean arterial pressure (75 mmHg). The plasma-free red

cell-based perfusate will be circulated from the venous reservoir through the centrifugal

pump into the membrane oxygenator, where it is oxygenated and also warmed to 35-36◦C. It

will then flow through the arterial limb of the circuit to the renal artery. Venous return from

the renal vein will be fed back into the reservoir.

Renal blood flow (RBF) will be monitored continuously during EVNP. Intra-renal resistance

(IRR) will be calculated (mean arterial pressure/RBF) every 5 min until the end of perfusion.

The total urine output will be recorded. Blood gas analysis will be used to measure the acid

base balance pre and post EVNP.

Post-perfusion

After EVNP, kidneys will be flushed with approximately 500 mL of cold (4◦C) hyperosmolar

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citrate (HOC, Baxter Healthcare, UK) to remove the perfusate and then placed back in ice

until transplanted. Prior to transplantation the arterial Carrel patch may have to be excised

along with a short segment of vein in order to remove the cannula ligature sites.

EVNP Assessment Scoring (Table 1)

An assessment score will be recorded for all kidneys undergoing EVNP but will not be used

to make decisions about the suitability of kidneys for transplantation 13

.

Transplantation

This will be performed using standard techniques. Anaesthesia will be given according to

local protocols. Kidneys will be transplanted into either iliac fossa with anastomosis of the

artery to either the common, external or internal iliac arteries. The vein will be anastomosed

to either the common or the external iliac vein. The ureteric anastomosis will be performed

as an extravesical onlay over a double J stent.

Immunosuppressive therapy

All centres will use similar immunosuppressive protocols as follows: Patients will receive

20mg of basiliximab i.v. pre-transplant and 20mg i.v. on postoperative day 4. Patients will

receive a bolus of methylprednisolone i.v. at induction of anaesthesia using a dosage

according to local practice. The post-transplant oral prednisolone regimen will also be

according to local practice.

Patients may be treated with either tacrolimus or cyclosporine according to local protocols.

There will be no restriction on the formulation of the prescribed calcineurin inhibitors.

Tacrolimus will be prescribed to achieve target trough levels of 3-12 ng/ml. Cyclosporin will

be prescribed to achieve target trough levels of 100-250 ng/ml. The first dose of calcineurin

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inhibitor may be given pre- or post-operatively. All patients will receive mycophenolate as

either mycophenolate mofetil (Cellcept) at a starting dose of at least 1g/day or mycophenolate

sodium (Myfortic) starting at a dose of at least 720mg/day.

Anti-microbial and anti-thrombotic prophylaxis will be given according to local protocols. It

is expected that patients will also receive prophylaxis against Pneumocystis jiroveci

pneumonia, oral candidiasis and cytomegalovirus (Valganciclovir for 100 days in CMV +ve

donor to CMV –ve recipient transplants).

Outcomes

Primary outcome measure

The primary outcome measure is delayed graft function (DGF) defined as the need for

dialysis in the first 7 days post-transplantation 18

.

Secondary outcome measures

The secondary outcome measures include incidences of primary non-function (PNF) defined

as the permanent lack of allograft function from the time of transplantation. This will include

graft losses due to irreversible rejection and vascular thrombosis. The cause of graft loss will

be recorded. The duration of DGF in days. Functional DGF (fDGF) defined as <10% fall in

serum creatinine for 3 consecutive days in the first week post-transplant. Creatinine reduction

ratio day 2 (CRR2 = creatinine day 1 – creatinine day 2/ creatinine day 1) and Creatinine

reduction ratio day 5 (CRR 5 = pre-transplant creatinine - creatinine day 5/ pre-transplant

creatinine) 19

. Length of hospital stay, rates of biopsy-proven acute rejection rate and

measures of renal function (serum creatinine and eGFR) at 1, 3, 6 and 12 months post-

transplant. Patient survival (time from transplant to death) and allograft survival (time from

transplant to graft loss or return to dialysis) will be recorded. The EVNP score will be

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calculated for each kidney undergoing EVNP (Table 1). Arterial and venous samples will be

collected during perfusion and used to measure oxygen consumption, acid base balance and

concentrations of sodium, potassium, glucose, lactate and calcium. Concentrations of sodium,

potassium will also be measured in the urine at the end of EVNP.

Renal fibrosis

One of the commonest causes for graft failure after transplantation is the development of

chronic allograft nephropathy 20

. The aim of this study is to determine if EVNP can slow the

progression of fibrosis. Biopsies of the kidney will be taken pre-transplant and after 3

months. Biopsies will be fixed in formalin and paraffin embedded cut sections of the graft

with be stained with sirius red (stains for collagen III). The degree of fibrosis will be

quantified using computerised digital image analysis.

Injury markers

Ischaemia reperfusion injury is a leading cause of early graft dysfunction. The aim of this

study is to determine if EVNP can reduce the amount inflammation and injury after

transplantation. Blood and urine samples will be collected pre and post-transplant and used to

measure inflammation [inflammatory cytokines Interleukin-6 (IL-6), Tumour Necrosis Factor

alpha, (TNF-α), Interleukin- 8 (Il-8)] and kidney injury [neutrophil gelatinase-associated

lipocalin (NGAL), Liver fatty acid binding protein (L-FABP)]. Further biopsies of the kidney

will be taken and snap frozen in liquid nitrogen pre-implantation and 30 minutes post-

transplant (analysis to be determined).

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Sample storage

Samples will be stored in the clinical and research laboratories within the participating

centres. Samples will be coded and donor identifiable material will only be available to the PI

and the research team at the participating centres. Samples are appropriately labelled in

accordance with the trial procedures to comply with the 1998 Data Protection Act. Biological

samples collected from participants as part of this trial will be transported, stored, accessed

and processed in accordance with national legislation relating to the use and storage of human

tissue for research purposes and such activities shall at least meet the requirements as set out

in the 2004 Human Tissue Act and the 2006 Human Tissue (Scotland) Act.”

On completion of the trial samples will be disposed of in accordance with the Human Tissue

Authority’s Code of Practice.

Statistics

Sample size determination

The trial size was calculated with respect to the primary end-point, which is delayed graft

function defined as the requirement for dialysis in the first 7 days post-transplantation. Based

on 5 years of data from the three participating centres, the overall rate of DGF in DCD kidney

transplants is 50%. In a pilot series of kidney transplants from extended criteria donors, 18

kidneys undergoing CS followed by 1 hour of EVNP were compared to a historical control

group of 47 ECD transplants after CS alone. The DGF rates were 1/18 (6%) in the EVNP

group compared to 17/47 (36%) in the CS group 14

.

Using a fixed sample size study, with interim analyses after 125 and 250 patients have been

enrolled and reached 365 days post-transplant, a total of 376 patients receiving a DCD kidney

(Maastricht category III & IV controlled donors) will be required to detect a 30% relative

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reduction in DGF (from 50 to 35%) with a power of 80% and a statistical significance of α =

0.05. To allow for study withdrawal rate of 6%, a total of 400 patients will be recruited.

Interim Analysis

Two interim analyses will be performed during the study period. The first of these will be

after 125 patients have received a transplant and reached 7 days post-transplant and the

second after 250 patients have been recruited (and have received a transplant and reached 7

days post-transplant).

Analysis population and principles

The population used for efficacy analyses will be an intent to treat population including all

eligible randomised patients. This will be the primary analysis for the trial. Characteristics of

all randomised patients will be tabulated by arm of the trial to describe the cohort.

The primary and secondary outcome will also be analysed per protocol.

Analysis of primary and secondary outcomes

The analyses will be described in detail in a full Statistical Analysis Plan. This section

summarises the main issues. A full statistical analysis plan will be drawn up prior to the first

interim analysis.

Primary analysis

The number of patients whom experience delayed graft function between the two groups will

be compared using a logistic regression model adjusting for cold ischemic time and donor

age.

Secondary outcomes

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Primary non-function: The number of patients experiencing primary non-function in each

arm will be compared using a Fisher’s exact text. The cause of graft loss will be tabulated by

arm. The duration of DGF in days will be summarised using the Kaplan Meier estimate of the

duration of DGF for all those who experienced DGF and compared using a log rank test.

The number of participants whom experience functional DGF: The number of patients in

each arm will be compared using a Fisher’s exact test. The Creatinine reduction ratio day 2

and day 5 will be compared by arm using a two sample t-test. The length of hospital stay

defined from admission to discharge will be estimated using the Kaplan Meier method, with

deaths in hospital censored, and compared between arms using the log-rank test.

Biopsy-proven acute rejection rate; the number of patients in each arm will be compared

using a Fisher’s exact test. Longitudinal changes in serum creatinine and eGFR will be

separately assessed at 1, 3, 6 and 12 months post-transplant and mean values compared using

two-way ANOVA with repeated measures for patients in each arm of the trial. Any

difference between arms in the way serum creatinine and eGFR changes over time will also

be assessed using this model. Patient survival (time from transplant to death) and Allograft

survival (time from transplant to graft loss or return to dialysis) will be analysed using a

Kaplan-Meier estimate of the probability of an event after 12 months and a log rank test.

Time to graft loss or return to dialysis will be modelled.

Analysis Population and Missing Data

Normally if a patient experiences DGF, they would remain in hospital for a minimum of 7

days. Hence for pragmatic reasons, if a patient is discharged from the hospital prior to 7 days

post-transplant and the patient is known to be alive at 7 days post-transplant, then such

patients will be imputed to have not experienced DGF. Some patients may also withdraw

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consent, be withdrawn or die during the conduct of the trial. In either of these cases, it is

impossible to know whether such patients are either less or more likely to experience DGF

had they not experienced early censoring. Sensitivity analyses will be performed to account

for this.

Safety outcomes

Incidences of acute rejection, renal artery or renal vein thrombosis, complications of the renal

transplant biopsy and the number of hospital admission for any recognised complication of

renal transplantation and immunosuppression will be summarised by arm.

The University of Cambridge and Cambridge University Hospital NHS Foundation Trust will

be the sponsor for this study. A Trial Steering Committee will meet 6 monthly to review the

trial, monitor recruitment rates to consider protocol amendments and provide advice. A Trial

Management Group will be responsible for the ethics committee application and the

production of reports and the day to day running of the trial. A data monitoring committee

will consist of three independent members with expertise in renal transplantation, clinical

trials and statistics. They will meet at least annually to review data, primarily concentrating

on patient safety.

Data handling

A data will be collected prospectively and recorded on the electronic case report forms. The

data will be monitored by the trial manager and audited each month. Each participant will be

allocated a unique study number and will be identifiable by this number throughout the

course of the study. This number will be used on all documentation and during analysis of the

results. Tissue, blood and urine samples will be coded with a unique number. Any data that

is transferred will be carried out under the NHS Code of Practice on Confidentiality.

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Ethical Considerations

The study protocol and trial documents including the consent form and participant

information sheet have been approved by the NHS Health Research Authority East of

England, Cambridge Central Research Committee (15/EE/0356). Approval has also been

granted by the NHS Research & Development (R&D) department and will be sought at each

participating centre. Substantial amendments will require ethical review. Amendments will

also need to be reviewed and accepted by the NHS R&D departments before they can be

implemented in practice at sites.

Insurance of negligent or non-negligent harm will be covered under the University's clinical

trial policy.

There are no conflicts of interest for the PIs or members of the study team.

Dissemination

The results of the study will be submitted for peer review for publication in a scientific

journal. The results of the study will also be presented at national and international meetings.

Acknowledgements

This study was supported by Kidney Research UK, the Cambridge National Institute for

Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and

Transplant Research Unit in Organ Donation and Transplantation at the University of

Cambridge in collaboration with Newcastle University and in partnership with NHS Blood

and Transplant (NHSBT). The views expressed are those of the authors and not necessarily

those of the NHS, the NIHR, the Department of Health or NHSBT.

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3: van der Vliet JA, Warle MC, Cheung CL, Teerenstra S, Hoitsma AJ. Influence of

prolonged cold ischemia in renal transplantation. Clin Transplant 2011; 25: E612–E616.

4: Snoeijs MG, Winkens B, Heemskerk MB, et al. Kidney transplantation from donors after

cardiac death: A 25-year experience. Transplantation 2010; 90: 1106–1112.

5: Yarlagadda SG, Coca SG, Formica RN, Jr, Poggio ED, Parikh CR. Association between

delayed graft function and allograft and patient survival: A systematic review and meta-

analysis. Nephrol Dial Transplant 2009; 24: 1039–1047.

6: Rao PS, Ojo A. The alphabet soup of kidney transplantation: SCD, DCD, ECD–

fundamentals for the practicing nephrologist. Clin J Am Soc Nephrol 2009; 4: 1827–1831.

7: Quiroga I, McShane P, Koo DD, et al. Major effects of delayed graft function and cold

ischaemia time on renal allograft survival. Nephrol Dial Transplant 2006; 21: 1689–1696.

8: Dare AJ, Pettigrew GJ, Saeb-Parsy K. Preoperative assessment of the deceased-donor

kidney: from macroscopic appearance to molecular biomarkers. Transplantation 2014 Apr

27;97(8):797-807.

9: Callaghan CJ, Harper SJ, Saeb-Parsy K, Hudson A, Gibbs P, Watson CJ, et al. The discard

of deceased donor kidneys in the UK. Clin Transplant 2014 Mar;28(3):345-353.

10: Nourbakhsh N, Singh P. Role of renal oxygenation and mitochondrial function in the

pathophysiology of acute kidney injury. Nephron Clin Pract. 2014;127(1-4):149-52

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11: Summers DM, Johnson RJ, Allen J, Fuggle SV, Collett D, Watson CJ, Bradley JA.

Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac

death in the UK: a cohort study. Lancet. 2010 Oct16;376(9749):1303-11.

12: Summers DM, Johnson RJ, Hudson A, Collett D, Watson CJ, Bradley JA. Effect of donor

age and cold storage time on outcome in recipients of kidneys donated after circulatory death

in the UK: a cohort study. Lancet. 2013 Mar 2;381(9868):727-34.

13: Hosgood SA, Nicholson ML. First in Man Renal Transplantation after Ex Vivo

Normothermic Perfusion. Transplantation 2011 Aug 11.

14: Nicholson ML, Hosgood SA. Renal transplantation after ex vivo normothermic perfusion:

the first clinical study. Am J Transplant 2013 May;13(5):1246-1252.

15: Hosgood SA, Nicholson ML. The first clinical case of intermediate ex vivo normothermic

perfusion in renal transplantation. Am J Transplant 2014 Jul;14(7):1690-1692.

16: Hosgood SA, Nicholson ML. Ex vivo normothermic perfusion of declined human

kidneys after inadequate in situ perfusion. Am J Transplant 2014 Feb;14(2):490-491.

17: Hosgood SA, Barlow AD, Hunter JP, Nicholson ML. Ex-vivo normothermic perfusion -

an innovative technology for quality assessment of marginal donor kidney transplants. 2015

Br J Surg. 2015 Oct;102 (11):1433-40.

18: Mallon DH, Summers DM, Bradley JA, Pettigrew GJ. Defining delayed graft function

after renal transplantation: simplest is best. Transplantation. 2013 Nov 27;96(10):885-9.

19: Vilar E, Varagunam M, Yaqoob MM, Raftery M, Thuraisingham R. Creatinine reduction

ratio: a useful marker to identify medium and high-risk renal transplants. Transplantation.

2010 Jan 15;89(1):97-103.

20: Boor P, Floege J. Renal allograft fibrosis: biology and therapeutic targets. Am J

Transplant. 2015 Apr;15(4):863-86. doi: 10.1111/ajt.13180. Epub 2015 Feb 17. Review.

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EVNP Score

Macroscopic appearance Points

Excellent perfusion with global and even pink appearance 1 point

Moderate perfusion with some areas of patchy or mottled perfusion 2 points

Poor perfusion with a globally mottled and purple appearance 3 points

Mean Renal Blood Flow (ml/min/100g) <50ml/min/100g 1 point


Total Urine Output (ml) <43ml/hr 1 point

Total Urine Output (ml) >43ml/hr 0 point

Table 1: Ex-vivo normothermic perfusion (EVNP) score. Scores for macroscopic appearance,

renal blood flow and urine output will be added to yield an overall assessment score ranging

from 1 (the highest quality) to 5 (the lowest quality).

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Figure 1: Trial Design

Inclusion criteria 1. Patients undergoing DCD kidney

transplantation (Maastricht III & IV)

2. DCD donor age ≥ 18 years

3. Transplant recipients aged ≥ 18 years

4. Patients undergoing a1st or 2nd kidney

transplant

5. Patients who have given written informed

consent

Exclusion criteria 1. DCD donors <18 years old

2. DCD (Maastricht I & II)

3. Patients receiving a 3rd

or

subsequent kidney transplant

4. Patients receiving multi-organ

transplants e.g. simultaneous

pancreas-kidney transplantation

5. Patients receiving dual kidney

transplants

6. Paediatric en-bloc kidney

transplants

7. Organ preservation by

hypothermic machine perfusion

Donation after Circulatory Death Kidney

Patient information sheet and informed consent

Arrival of kidney

Randomisation

Sealed envelope

Single kidney Pair of kidneys

EVNP CS

Randomisation EVNP/CS

• Left or right kidney

• Transplanted 1st or 2nd

EVNP Protocol and

Assessment score

Biopsy and Transplantation

Primary Outcome Measures (recorded

on the eCRF)

1: Delayed graft function (DGF) defined

as the need for dialysis in the first 7 days

post-transplantation.

Secondary Outcome Measures (recorded

on the eCRFs) 1: Primary non-function (PNF)

2: Duration of DGF in days

3: Functional DGF (fDGF)

4: Creatinine reduction ratio day 2

5: Creatinine reduction ratio day 5

6: Length of hospital stay

7: Biopsy-proven acute rejection rates.

8: Serum creatinine and eGFR at 1, 3, 6 and

12 months.

9: Patient survival (time from transplant to

death).

10: Allograft survival (time from transplant

to graft loss or return to dialysis)

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EVNP Normothermic Perfusion Trial

Patient Information Sheet Version 1.1 4th November 2015

Page 1 of 5

Pre-Transplant Patient Information Sheet

You are being invited to take part in a research study. Before you decide, it is important for

you to understand why the research is being done and what it will involve. Please take time

to read the following information carefully and discuss it with others if you wish. Ask us if

there is anything that is not clear or if you would like more information. Take time to decide

whether or not you wish to take part.

Study Title: Ex-vivo Normothermic Perfusion Trial

Summary

We would like to assess whether a new technique of kidney preservation can improve early

graft function compared to the standard cold storage technique.

1 What is the purpose of the study?

When kidneys are removed from an organ donor they are normally stored on ice until they

are ready to be transplanted. A kidney can be preserved safely at a low temperature in

these conditions. However, there is some degree of deterioration and the longer they are

left in this condition the more they deteriorate (rather like food that is kept in the fridge).

We have developed a technique that may improve the quality of the kidney. This involves

placing the kidney on a machine and passing a warmed, oxygen-rich solution containing red

blood cells through it for about one hour. Under these conditions the kidney can start to

function again and produce urine. This improves the condition of the kidney and may

improve function after transplantation.

2 How is this study designed?

This study will assess the technique of warming a kidney and compare it to the standard

cold storage technique that is commonly used. Kidneys will be randomly assigned to receive

either the warming technique or standard cold storage.

3 Why have I been invited?

The kidney you are being offered is a suitable match for you. It is a kidney from a donation

after circulatory death donor and meets the criteria for entry into the trial.

4 Do I have to take part?

It is completely your choice whether you want to take part. If you decline to be included in

the study the kidney will undergo the standard cold storage technique of preservation with

no intervention.

5 What will happen to me if I take part?

You will be prepared for surgery in the normal way. Standard practice involves keeping the

transplant kidney under cold storage in ice until the time of the transplant operation. If you

consent to take part in this trial then your kidney will be randomly assigned to either

standard practice or to having warm perfusion for one hour immediately before the kidney

is transplanted. Should there be any problem with the warm perfusion procedure then the

kidney can be quickly removed from the perfusion machine and returned to cold storage in

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ice before transplantation. This failsafe position has not been required so far in our first 40

cases.

During the transplant operation we will also take a small tissue biopsy from the kidney 30

minutes after it has been transplanted. Although there is a small risk of causing bleeding

from the kidney biopsy site (<5%) your surgeon will be able to repair the bleeding site if this

happens.

6 What do I have to do?

After your transplant you will receive the normal standard care but will also be asked to

provide a few additional blood and urine samples for analysis. Your participation in this

study will not affect the way you are followed up after a transplant. The normal follow up

involves clinical visits at least twice a week for six weeks and then weekly for a further six

weeks.

At three months after your transplant we will plan to perform a routine needle biopsy of the

kidney to look for scarring. This would help us with our research but it is not compulsory.

Needle biopsies have a good safety record but there is a small risk (less than 1%) of

significant bleeding.

After three months you will be seen either in Cambridge or your local centre. The length

between clinical visits will be gradually extended after the first three months.

7 What are the alternatives for treatment?

If you decide not to take part in the trial the kidney will not receive any intervention and will

be transplanted as normal.

8 What are the possible disadvantages and risks of taking part?

There are no potential side effects to you. This technique of perfusion is applied to the

kidney only, before it is transplanted. There is a small risk that the kidney might be damaged

during the assessment and therefore could not be transplanted. This has not happened in

our experience of 40 cases so far but it remains as a potential risk. Although your kidney

may be deemed suitable for transplantation it is a kidney from a marginal donor and we

know that this increases the rate of delayed graft function. This means that it may take

some time for the kidney to start to function fully. There is also a small risk that the kidney

will never function.

9 What are the possible benefits of taking part?

This trial is being performed because we are uncertain whether or not warm perfusion

improves the outcome of kidney transplantation. Our experience so far suggests that using

this technique to recondition the kidney can result in better postoperative function. It is

also possible however that warm perfusion worsens the outcome of a kidney transplant.

10 What happens when the research study stops?

At the end of the research study you will continue to be followed up for your kidney

transplant either at Addenbrooke’s Hospital or at your local renal hospital.

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10 What if new information becomes available?

If new information becomes available your Transplant Consultant might consider it to be in

your best interests to withdraw you from the study. He/she will explain the reasons and

arrange for your care to continue.

12 What will happen if I do not want to carry on with the study?

You will be given normal care after the kidney transplant. If you withdraw from the study we

will ask permission to use the data collected up to your withdrawal.

13 What will happen to the samples I give?

All urine, blood and tissue samples requested following renal transplantation, either

routinely or because of a clinical need, will be tested or disposed of according to normal

hospital policies and procedures. We will keep a small amount of these samples within the

Hospital in a secured area for analysis at a later date. Once analysed, these will be disposed

of according to normal hospital policy. Tissue samples will also be kept within the hospitals

pathology department.

14 What will happen to the results of the research study?

The results of the research will be published in specialist journals in order to inform other

transplant doctors around the world. You will not be identified in any report or publication.

You will be able to get a copy of the results by asking the kidney doctors in the follow up

clinic.

15 Will my General Practitioner/Family Doctor (GP) be involved?

Participation in this trial will not affect your treatment and follow-up by your GP after

discharge from the hospital.

16 Who is organising the research?

The research is being organised by doctors at the Cambridge Transplant Unit. The trial is

funded by Kidney Research UK and approximately 400 patients will be recruited.

17 Who has reviewed the study?

The study has been reviewed by the transplant doctors in Cambridge, Kidney Research UK

and the Local Research Ethics Committee.

18 Will my taking part in this study be kept confidential?

We will follow ethical and legal best practice and all information about you will be handled

confidentially. If you join the study, some parts of your medical records and the data

collected for the study will be looked at by authorised persons from the research team. They

may also be looked at by representatives of the regulatory authority or by those responsible

for research and development audit (for monitoring the quality of the research). All have a

duty of confidentiality to you as a research participant and will do their best to meet this

duty. Our procedure for handling, processing, storage and destruction of data will match the

Data Protection Act 1998. Your name will not be disclosed outside the hospital. The data

collected will be stored and retained securely for 10 years and it will also be disposed of

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securely. You have the right to check the accuracy of data held about you and correct any

errors.

19 What if there is a problem?

Any complaint about the way you have been dealt with during the trial or any possible harm

you might suffer will be addressed. If you have any concerns about any aspect of this trial

you should speak to your trial doctor who will do their best to answer your questions.

In the event that something does go wrong and you are harmed by taking part in the

research and this is due to someone’s negligence then you may have grounds for a legal

action for compensation against Cambridge University Hospitals NHS Foundation Trust or

the University of Cambridge. The normal National Health Service complaints mechanisms

will still be available to you (if appropriate). The University has obtained insurance, which

provides no-fault compensation i.e. for non-negligent harm, you may be entitled to make a

claim for this.

Obtaining further information

If you have any questions or concerns about any aspect of this study, you should ask to

speak to the researchers who will do their best to answer your questions or to Professor

Michael Nicholson (01223 339221).

Complaints and Independent Advice

If you wish to speak to an independent body about any concerns or complaints about any

aspect of the way you have been approached or treated during this trial, you can do this

through the Addenbrooke’s Kidney Patient’s Association or the Patient Advice and Liaison

Service (PALS) at Addenbrooke’s Hospital. The formal NHS complaints procedure is also

available to you. Details can be obtained through the hospital.

Complaints

If you remain unhappy and wish to complain formally, you can do this through the NHS

complaints procedure.

NHS based research

If you are harmed by taking part in this research project, there are no special compensation

arrangements. If you are harmed due to someone’s negligence, then you may have grounds

for a legal action but you may have to pay for it. Regardless of this, if you wish to complain,

or have any concerns about any aspect of the way you have been approached or treated

during the course of this study, the normal National Health Service complaints mechanisms

will be available to you.

Contacts for further information

A) General information about research can be found on www.nres.org.uk;

www.addenbrookes.nhs.uk; or www.instituteofclinicalresearch.org.uk

B) For specific information about this research project, contact Professor Michael Nicholson,

01223 339221.

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C) For advice on whether you should participate in the study, contact either Professor

Michael Nicholson on 01223 339221, or one of the other transplant doctors on G5 on 01223

217306.

D) For independent advice you can also contact the Patient Advice and Liaison Service

(PALS) on 01223 216 756, email [email protected]

E) Addenbrooke’s Kidney Patient’s Association email [email protected]

Thank you for reading this information sheet and for considering taking part in this study. If

you agree to take part you will be given a copy of this information sheet and a signed copy

of your consent form to keep.

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Patient consent form v1.1 EVNP DCD Trial 4th Nov 2015 Page 1

Patient Consent Form

Patient Identification Number:

Ex-vivo Normothermic Perfusion Kidney Trial

1. I confirm that I have read and understood the information sheet for the above study. I

have had the opportunity to consider the information, ask questions and have had these

answered satisfactorily.

Initial

2. I understand that my participation is voluntary and that I am free to withdraw at any time

without giving any reason, without my medical care or legal rights being affected.

Initial

3. I understand that relevant sections of my medical notes and data collected during the

study, may be looked at by individuals from the Cambridge University Hospitals NHS

Foundation Trust, where it is relevant to my taking part in this research. I give permission

for these individuals to have access to my medical records.

Initial

4. I agree for the storage and analysis of my serum, urine and kidney biopsy samples. I

understand that these samples may be kept for analysis at a later date.

Initial

5. I agree to take part in the above study.

Initial

Name of Participant ……………………………………………………………………………………………….

Signature………………………………………………………………… Date………………………………

Name of Person Taking Consent ………………………………………………………………………………

Signature………………………………………………………………… Date………………………………

Name of Principal Investigator: Professor Michael Nicholson (Consultant Transplant Surgeon)

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1

SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and

related documents*

Section/item ItemNo

Description

Administrative information

Title 1 Descriptive title identifying the study design, population, interventions,

and, if applicable, trial acronym

Trial registration 2a Trial identifier and registry name. If not yet registered, name of

intended registry

2b All items from the World Health Organization Trial Registration Data

Set

Protocol version 3 Date and version identifier

Funding 4 Sources and types of financial, material, and other support

Roles and

responsibilities

5a Names, affiliations, and roles of protocol contributors

5b Name and contact information for the trial sponsor

5c Role of study sponsor and funders, if any, in study design; collection,

management, analysis, and interpretation of data; writing of the report;

and the decision to submit the report for publication, including whether

they will have ultimate authority over any of these activities

5d Composition, roles, and responsibilities of the coordinating centre,

steering committee, endpoint adjudication committee, data

management team, and other individuals or groups overseeing the

trial, if applicable (see Item 21a for data monitoring committee)

Introduction

Background and

rationale

6a Description of research question and justification for undertaking the

trial, including summary of relevant studies (published and

unpublished) examining benefits and harms for each intervention

6b Explanation for choice of comparators

Objectives 7 Specific objectives or hypotheses

Trial design 8 Description of trial design including type of trial (eg, parallel group,

crossover, factorial, single group), allocation ratio, and framework (eg,

superiority, equivalence, noninferiority, exploratory)

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Methods: Participants, interventions, and outcomes

Study setting 9 Description of study settings (eg, community clinic, academic hospital)

and list of countries where data will be collected. Reference to where

list of study sites can be obtained

Eligibility criteria 10 Inclusion and exclusion criteria for participants. If applicable, eligibility

criteria for study centres and individuals who will perform the

interventions (eg, surgeons, psychotherapists)

Interventions 11a Interventions for each group with sufficient detail to allow replication,

including how and when they will be administered

11b Criteria for discontinuing or modifying allocated interventions for a

given trial participant (eg, drug dose change in response to harms,

participant request, or improving/worsening disease)

11c Strategies to improve adherence to intervention protocols, and any

procedures for monitoring adherence (eg, drug tablet return,

laboratory tests)

11d Relevant concomitant care and interventions that are permitted or

prohibited during the trial

Outcomes 12 Primary, secondary, and other outcomes, including the specific

measurement variable (eg, systolic blood pressure), analysis metric

(eg, change from baseline, final value, time to event), method of

aggregation (eg, median, proportion), and time point for each

outcome. Explanation of the clinical relevance of chosen efficacy and

harm outcomes is strongly recommended

Participant

timeline

13 Time schedule of enrolment, interventions (including any run-ins and

washouts), assessments, and visits for participants. A schematic

diagram is highly recommended (see Figure)

Sample size 14 Estimated number of participants needed to achieve study objectives

and how it was determined, including clinical and statistical

assumptions supporting any sample size calculations

Recruitment 15 Strategies for achieving adequate participant enrolment to reach

target sample size

Methods: Assignment of interventions (for controlled trials)

Allocation:

Sequence

generation

16a Method of generating the allocation sequence (eg, computer-

generated random numbers), and list of any factors for stratification.

To reduce predictability of a random sequence, details of any planned

restriction (eg, blocking) should be provided in a separate document

that is unavailable to those who enrol participants or assign

interventions

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Allocation

concealment

mechanism

16b Mechanism of implementing the allocation sequence (eg, central

telephone; sequentially numbered, opaque, sealed envelopes),

describing any steps to conceal the sequence until interventions are

assigned

Implementation 16c Who will generate the allocation sequence, who will enrol participants,

and who will assign participants to interventions

Blinding

(masking)

17a Who will be blinded after assignment to interventions (eg, trial

participants, care providers, outcome assessors, data analysts), and

how

17b If blinded, circumstances under which unblinding is permissible, and

procedure for revealing a participant’s allocated intervention during

the trial

Methods: Data collection, management, and analysis

Data collection

methods

18a Plans for assessment and collection of outcome, baseline, and other

trial data, including any related processes to promote data quality (eg,

duplicate measurements, training of assessors) and a description of

study instruments (eg, questionnaires, laboratory tests) along with

their reliability and validity, if known. Reference to where data

collection forms can be found, if not in the protocol

18b Plans to promote participant retention and complete follow-up,

including list of any outcome data to be collected for participants who

discontinue or deviate from intervention protocols

Data

management

19 Plans for data entry, coding, security, and storage, including any

related processes to promote data quality (eg, double data entry;

range checks for data values). Reference to where details of data

management procedures can be found, if not in the protocol

Statistical

methods

20a Statistical methods for analysing primary and secondary outcomes.

Reference to where other details of the statistical analysis plan can be

found, if not in the protocol

20b Methods for any additional analyses (eg, subgroup and adjusted

analyses)

20c Definition of analysis population relating to protocol non-adherence

(eg, as randomised analysis), and any statistical methods to handle

missing data (eg, multiple imputation)

Methods: Monitoring

Data monitoring 21a Composition of data monitoring committee (DMC); summary of its role

and reporting structure; statement of whether it is independent from

the sponsor and competing interests; and reference to where further

details about its charter can be found, if not in the protocol.

Alternatively, an explanation of why a DMC is not needed

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21b Description of any interim analyses and stopping guidelines, including

who will have access to these interim results and make the final

decision to terminate the trial

Harms 22 Plans for collecting, assessing, reporting, and managing solicited and

spontaneously reported adverse events and other unintended effects

of trial interventions or trial conduct

Auditing 23 Frequency and procedures for auditing trial conduct, if any, and

whether the process will be independent from investigators and the

sponsor


Research ethics

approval

24 Plans for seeking research ethics committee/institutional review board

(REC/IRB) approval

Protocol

amendments

25 Plans for communicating important protocol modifications (eg,

changes to eligibility criteria, outcomes, analyses) to relevant parties

(eg, investigators, REC/IRBs, trial participants, trial registries, journals,

regulators)

Consent or assent 26a Who will obtain informed consent or assent from potential trial

participants or authorised surrogates, and how (see Item 32)

26b Additional consent provisions for collection and use of participant data

and biological specimens in ancillary studies, if applicable

Confidentiality 27 How personal information about potential and enrolled participants will

be collected, shared, and maintained in order to protect confidentiality

before, during, and after the trial

Declaration of

interests

28 Financial and other competing interests for principal investigators for

the overall trial and each study site

Access to data 29 Statement of who will have access to the final trial dataset, and

disclosure of contractual agreements that limit such access for

investigators

Ancillary and

post-trial care

30 Provisions, if any, for ancillary and post-trial care, and for

compensation to those who suffer harm from trial participation

Dissemination

policy

31a Plans for investigators and sponsor to communicate trial results to

participants, healthcare professionals, the public, and other relevant

groups (eg, via publication, reporting in results databases, or other

data sharing arrangements), including any publication restrictions

31b Authorship eligibility guidelines and any intended use of professional

writers

31c Plans, if any, for granting public access to the full protocol, participant-

level dataset, and statistical code

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Appendices

Informed consent

materials

32 Model consent form and other related documentation given to

participants and authorised surrogates

Biological

specimens

33 Plans for collection, laboratory evaluation, and storage of biological

specimens for genetic or molecular analysis in the current trial and for

future use in ancillary studies, if applicable

*It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013

Explanation & Elaboration for important clarification on the items. Amendments to the

protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT

Group under the Creative Commons “Attribution-NonCommercial-NoDerivs 3.0 Unported”

license.

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Appendix 1 and 2



A Protocol for a Randomised controlled, open label trial of Ex-vivo Normothermic Perfusion versus Static Cold Storage

in Donation after Circulatory Death Renal Transplantation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012237.R1

Article Type: Protocol

Date Submitted by the Author: 02-Aug-2016

Complete List of Authors: Hosgood, Sarah; University of Cambridge, Dept of Surgery Saeb-Parsy, Kourosh; University of Cambridge, Dept of Surgery Wilson, Colin; Freemans Hospital, Transplantation

Callaghan, Christopher; Guy's and St Thomas's, Transplantation Collett, Dave; NHS Blood and Transplant, Statistics and Clinical Audit Nicholson, Michael; University of Cambridge, Dept of Surgery

<b>Primary Subject Heading</b>:

Surgery

Secondary Subject Heading: Renal medicine

Keywords: Transplant medicine < INTERNAL MEDICINE, Renal transplantation < NEPHROLOGY, TRANSPLANT SURGERY


BMJ Open on A

ugust 17, 2021 by guest. Protected by copyright.

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1

A Protocol of a Randomised controlled, open label trial of Ex-vivo Normothermic

Perfusion versus Static Cold Storage in Donation after Circulatory Death Renal

Transplantation

1

Sarah A Hosgood, 1

Kourosh Saeb-Parsy, 2

Colin Wilson, 3

Christopher Callaghan, 4

Dave

Collett, 1

Michael L Nicholson.

1

University of Cambridge, Department of Surgery, Addenbrooke’s Hospital, Level 9. Hill’s

Road. Cambridge CB2 OQQ 2

Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, Tyne and Wear NE7

7DN 3

Guy’s & Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT 4

NHS Blood and Transplant Fox Den Road, Stoke Gifford, Avon, Bristol BS34 8RR

Correspondence

Dr Sarah Hosgood

University of Cambridge,

Department of Surgery,

Addenbrooke’s Hospital,

Level 9.

Hill’s Road.

Cambridge

CB2 OQQ

Tel 01223 762002

Email [email protected]

Trial Registration Number: ISRCTN15821205

Protocol Version 1.1 Date: 4th

November 2015

Funder: Kidney Research UK (SP/MEKC/1/2014)

Sponsor: University of Cambridge and University Hospitals of Cambridge Foundation Trust

Cambridge CB2 OQQ. Mr Stephen Kelleher Tel 01223 596472.

Email: r&[email protected]

Role of Sponsor

• Central data collection and verification of SAEs. Reporting safety information

and checking for (annually) and notifying PIs of updates to the Reference

Safety Information for the trial.

Contributors

The study protocol was derived by (MLN, SAH, KSP, CW and CC). MLN wrote the original

draft which was reviewed and revised by all the co-authors. DC performed the statistics.

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Abstract

Introduction

Ex-vivo normothermic perfusion (EVNP) is a novel technique that reconditions the kidney

and restores renal function prior to transplantation. Phase I data from a series of EVNP in

extended criteria donor (ECD) kidneys has established the safety and feasibility of the

technique in clinical practice.

Methods and analysis

This is a UK based phase II multicentre randomized controlled trial to assess the efficacy of

EVNP compared to the conventional static cold storage technique in DCD kidney

transplantation. Four hundred patients receiving a kidney from a DCD donor (Category III

and IV, controlled) will be recruited into the study. On arrival at the transplant centre,

kidneys will be randomized to receive either EVNP (n = 200) or remain in static cold storage

(n = 200). Kidneys undergoing EVNP will be perfused with an oxygenation packed red cell

solution at near body temperature for 60 minutes prior to transplantation. The primary

outcome measure will be determined by rates of delayed graft function (DGF) defined as the

need for dialysis in the first week post-transplant. Secondary outcome measures include

incidences of primary non-function (PNF), the duration of DGF, functional DGF (fDGF)

defined as <10% fall in serum creatinine for 3 consecutive days in the first week post-

transplant, creatinine reduction ratio day 2 and day 5, length of hospital stay, rates of biopsy-

proven acute rejection, serum creatinine and eGFR at 1, 3, 6 and 12 months post-transplant

and patient and allograft survival. The EVNP assessment score will be recorded and the level

of fibrosis and inflammation will also be measured using tissue, blood and urine samples.


The study has been approved by the NHS Health Research Authority Research Ethics

Committee. The results are expected to be published in 2020.

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Strengths and Limitations

• This is a large multicentre randomized controlled trial. It will provide evidence of the

effect of ex-vivo normothermic perfusion on early graft function in DCD kidney

transplantation.

• The secondary objectives will allow us to examine of the impact of EVNP on rates of

acute rejection and longer-term graft function and survival.

• Tissue, blood and urine samples will enable a more in depth analysis of the effects of

EVNP on ischaemia reperfusion

• The limitation of this study is the lack of blinding. Due to the nature of the technique

and in order to report safety outcomes, it is not possible to blind the surgical team to

the allocation of the kidney.

• Delayed graft function defined as dialysis within the first week of transplantation is

subjective. However, it is the best accepted measure of early graft function.

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Introduction

Kidney transplantation continues to be limited by a shortage of organ donors. In response to

this there has been an increase in the use of kidneys from marginal donors and a significant

proportion of transplant kidneys are now provided by donation after circulatory death (DCD)

donors 1. DCD kidneys inevitably sustain a warm ischaemic insult prior to retrieval and 50-

60% of these kidneys have delayed graft function (DGF) after transplantation 1. DGF is

associated with an increased risk of acute rejection, longer in-patient stay and therefore

greater cost, and may also reduce allograft survival 1-7

. Moreover, when compared to

standard criteria donors, DCD kidneys are three times more likely to be declined for

transplantation due to concerns over their quality 8, 9

.

Organ preservation has traditionally relied on hypothermic techniques based on the principle

that refrigeration reduces cellular metabolism and tissue oxygen requirements. The problem

is that in the anoxic hypothermic environment anaerobic cellular respiration continues, albeit

at a slow pace. Oxidative phosphorylation is uncoupled and mitochondrial ATP production

by chemiosmosis ceases 10

. ATP continues to be generated at a much slower rate by

substrate-based phosphorylation in the glycolytic pathway. This leads to depletion of

intracellular ATP stores. Anaerobic respiration generates lactic acid leading to worsening

intracellular acidosis and eventually loss of cell viability 10

. The initial warm ischaemic

injury sustained by DCD kidneys makes them less tolerant of cold ischaemic injury during

hypothermic preservation 11, 12

.

Normothermic perfusion techniques offer an alternative form of organ preservation and

resuscitation that has the potential to limit some of the effects of hypothermic preservation

techniques 13

. Ex-vivo normothermic perfusion (EVNP) is a novel technique that may help to

recondition ischaemically injured kidneys prior to transplantation 13

. The aim of EVNP is to

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restore metabolism and function to the kidney prior to transplantation by circulating a warm

oxygenated red cell based solution through the kidney.

EVNP has recently been introduced into clinical practice for kidneys from marginal donors

13-17. The early experience of renal transplantation after EVNP shows that the technique is

feasible, safe and may improve early graft function.

This study will investigate the effect of 60 minutes EVNP in kidneys from DCD donors

compared to the traditional technique of static cold storage

The primary outcome measure will be delayed graft function (DGF) defined as the need for

dialysis in the first 7 days post-transplantation. Secondary outcome measures will include

more sensitive measures of renal function over the first 7 days post-transplant, length of

hospital stay, graft and patient survival at 1 year and rates of acute rejection. Fibrosis,

inflammatory markers and urinary biomarkers will also be examined in tissue, blood and

urine.

Methods

Study type

A randomised controlled, open label trial of the effect of EVNP on initial graft function in

donation after circulatory death kidney transplantation. Figure 1 summaries the design of the

trial.

Eligibility

Patients will be eligible for the trial if they meet the following criteria; patients undergoing a

DCD kidney transplantation (Maastricht Categories III & IV); the donor and recipient must

be ≥ 18 years and it must be the patient’s 1st or 2

nd kidney transplant.

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Written informed consent will be taken from all patients included in the trial by a qualified

member of the study team. Patients will not be eligible if the donor or recipient is under the

age of 18 years, the DCD donor is in Maastricht Categories I & II, patients receiving a 3rd

or

subsequent kidney transplant, patients receiving multi-organ transplants e.g. simultaneous

pancreas-kidney transplantation, patients receiving dual kidney transplants, paediatric en-bloc

kidney transplants or kidneys that have been preserved by hypothermic machine perfusion.

There will be four participating centres in the UK; Cambridge (lead), Newcastle, Guy’s and

Edinburgh.

Randomisation

Patients will be allocated at random in a 1:1 ratio to either static cold storage (CS) plus 1 hour

of EVNP (n = 200) or CS (n = 200) only. A patient information sheet will be given to

potential recruits on admission for DCD kidney transplantation and written informed consent

will then be obtained (Appendix 1 and 2). Randomisation will be performed after the

transplant recipient and kidney have both arrived in the transplanting centre and a final

decision to proceed with transplantation has been made by a member of the study team. The

randomisation will be performed on a web based system (sealedenvelope) which uses a

computer generated randomisation sequence. In cases where paired kidneys from the same

donor are transplanted in the same centre, one kidney from the pair will be randomly

allocated to CS and the other to EVNP. In these cases the randomisation will also determine

which kidney (right or left) will be transplanted first. Due to the nature of the trial, no-one is

blinded to treatment allocation.

Multiple vessels

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DCD kidneys with multiple renal arteries will not be excluded from the trial as EVNP is

technically possible in such kidneys. A cannula that preserves the carrel patch or a graft

reconstruction using donor vessels will be used where possible. Nonetheless, EVNP may

prove to be very difficult in kidneys with particularly complex vascular anatomy. If such a

kidney is randomised to EVNP then the local investigator may decide to use CS alone.

Nonetheless, the recipient will be analysed in the EVNP arm of the study in line with the

intention to treat basis. As per protocol analysis will also be performed to assess the effects

of the actual preservation method.

Kidney retrieval

All kidneys will be retrieved by UK national retrieval teams. Following in situ flushing of the

abdominal organs with hyperosmolar citrate solution or University of Wisconsin (UW)

solution, kidneys will be removed and then placed individually in preservation solution and

packed in ice. The perfusion solution used will be recorded.

Ex-vivo normothermic perfusion

The EVNP circuit has been designed using paediatric cardiopulmonary bypass technology

(Medtronic, Watford, UK) and consists of a centrifugal blood pump (Bio-pump 560), a heat

exchanger, a venous reservoir (Medtronic), 1/4 inch PVC tubing and an Affinity membrane

oxygenator (Medtronic). The hardware includes a speed controller, a TX50P flow transducer

and a temperature probe (Cole-Parmer, London, UK). Two infusion pumps are also

incorporated into the system.

Perfusate

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The circuit will be primed with perfusate solution (Ringer’s solution, Baxter Healthcare,

Thetford, Norfolk, UK) and one unit of O Positive or O Negative packed red cells from the

blood bank. Manntiol 10% (Baxter Healthcare), dexamethasone 8 mg (Organon Laboratories,

Cambridge, UK) and heparin (CP Pharmaceuticals, Wrexham, UK) will be added to the

perfusate. Sodium bicarbonate 8.4% (Fresenius Kabi, Cheshire, UK) will be added to

normalize the pH. A nutrient solution (Synthamin 17, Baxter Healthcare) with sodium

bicarbonate 8.4%, insulin (Novo Nordisk, Denmark) and multivitamins (Cernevit, Baxter

Healthcare) will be infused into the circuit at a rate of 20 mL/h. Prostacyclin 0.5 mg (Flolan,

Glaxo-Wellcome, Middlesex, UK) will be infused into the arterial arm of the circuit at a rate

of 5 mL/h and glucose 5% (Baxter Healthcare) at 5 mL/h. Ringer’s solution will be used to

replace urine output mL for ml.

Perfusion Chamber

Kidneys undergoing EVNP will be placed in a custom designed sterile perfusion chamber

and the renal artery and vein will be cannulated and primed with cold 0.9% sodium chloride.

Perfusion Parameters

Kidneys will be perfused at a set mean arterial pressure (75 mmHg). The plasma-free red

cell-based perfusate will be circulated from the venous reservoir through the centrifugal

pump into the membrane oxygenator, where it is oxygenated and also warmed to 35-36◦C. It

will then flow through the arterial limb of the circuit to the renal artery. Venous return from

the renal vein will be fed back into the reservoir.

Renal blood flow (RBF) will be monitored continuously during EVNP. Intra-renal resistance

(IRR) will be calculated (mean arterial pressure/RBF) every 5 min until the end of perfusion.

The total urine output will be recorded. Blood gas analysis will be used to measure the acid

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base balance pre and post EVNP.

Post-perfusion

After EVNP, kidneys will be flushed with approximately 500 mL of cold (4◦C) hyperosmolar

citrate (HOC, Baxter Healthcare, UK) to remove the perfusate and then placed back in ice

until transplanted. Prior to transplantation the arterial Carrel patch may have to be excised

along with a short segment of vein in order to remove the cannula ligature sites.

EVNP Assessment Scoring (Table 1)

An assessment score will be recorded for all kidneys undergoing EVNP but will not be used

to make decisions about the suitability of kidneys for transplantation 13

.

Transplantation

This will be performed using standard techniques. Anaesthesia will be given according to

local protocols. Kidneys will be transplanted into either iliac fossa with anastomosis of the

artery to either the common, external or internal iliac arteries. The vein will be anastomosed

to either the common or the external iliac vein. The ureteric anastomosis will be performed

as an extravesical onlay over a double J stent.

Immunosuppressive therapy

All centres will use similar immunosuppressive protocols as follows: Patients will receive

20mg of basiliximab i.v. pre-transplant and 20mg i.v. on postoperative day 4. Patients will

receive a bolus of methylprednisolone i.v. at induction of anaesthesia using a dosage

according to local practice. The post-transplant oral prednisolone regimen will also be

according to local practice.

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Patients may be treated with either tacrolimus or cyclosporine according to local protocols.

There will be no restriction on the formulation of the prescribed calcineurin inhibitors.

Tacrolimus will be prescribed to achieve target trough levels of 3-12 ng/ml. Cyclosporin will

be prescribed to achieve target trough levels of 100-250 ng/ml. The first dose of calcineurin

inhibitor may be given pre- or post-operatively. All patients will receive mycophenolate as

either mycophenolate mofetil (Cellcept) at a starting dose of at least 1g/day or mycophenolate

sodium (Myfortic) starting at a dose of at least 720mg/day.

Anti-microbial and anti-thrombotic prophylaxis will be given according to local protocols. It

is expected that patients will also receive prophylaxis against Pneumocystis jiroveci

pneumonia, oral candidiasis and cytomegalovirus (Valganciclovir for 100 days in CMV +ve

donor to CMV –ve recipient transplants).

Outcomes

Primary outcome measure

The primary outcome measure is delayed graft function (DGF) defined as the need for

dialysis in the first 7 days post-transplantation 18

.

Secondary outcome measures

The secondary outcome measures include incidences of primary non-function (PNF) defined

as the permanent lack of allograft function from the time of transplantation. This will include

graft losses due to irreversible rejection and vascular thrombosis. The cause of graft loss will

be recorded. The duration of DGF in days. Functional DGF (fDGF) defined as <10% fall in

serum creatinine for 3 consecutive days in the first week post-transplant. Creatinine reduction

ratio day 2 (CRR2 = creatinine day 1 – creatinine day 2/ creatinine day 1) and Creatinine

reduction ratio day 5 (CRR 5 = pre-transplant creatinine - creatinine day 5/ pre-transplant

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creatinine) 19

. Length of hospital stay, rates of biopsy-proven acute rejection rate and

measures of renal function (serum creatinine and eGFR) at 1, 3, 6 and 12 months post-

transplant. Patient survival (time from transplant to death) and allograft survival (time from

transplant to graft loss or return to dialysis) will be recorded. The EVNP score will be

calculated for each kidney undergoing EVNP (Table 1). The predictive value of this

assessment score on graft function and outcome will be evaluated. A clinical decision on the

suitability of the kidney for transplantation will be made using normal criteria prior to

perfusion. However, the EVNP assessment score will be taken into consideration. Arterial

and venous samples will be collected during perfusion and used to measure oxygen

consumption, acid base balance and concentrations of sodium, potassium, glucose, lactate

and calcium. Concentrations of sodium, potassium will also be measured in the urine at the

end of EVNP.

Renal fibrosis

One of the commonest causes for graft failure after transplantation is the development of

chronic allograft nephropathy 20

. The aim of this study is to determine if EVNP can slow the

progression of fibrosis. Biopsies of the kidney will be taken pre-transplant and after 3

months. Biopsies will be fixed in formalin and paraffin embedded cut sections of the graft

with be stained with sirius red (stains for collagen III). The degree of fibrosis will be

quantified using computerised digital image analysis.

Injury markers

Ischaemia reperfusion injury is a leading cause of early graft dysfunction. The aim of this

study is to determine if EVNP can reduce the amount inflammation and injury after

transplantation. Blood and urine samples will be collected pre and post-transplant and used to

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measure inflammation [inflammatory cytokines Interleukin-6 (IL-6), Tumour Necrosis Factor

alpha, (TNF-α), Interleukin- 8 (Il-8)] and kidney injury [neutrophil gelatinase-associated

lipocalin (NGAL), Liver fatty acid binding protein (L-FABP)]. Further biopsies of the kidney

will be taken and snap frozen in liquid nitrogen or stored in RNA later, pre-implantation and

30 minutes post-transplant. These will be used for light microscopy and RNA sequencing to

determine the degree of acute tubular, measure inflammatory cytokines and downstream

signalling molecules such as VEGF and EPO.

Sample storage

Samples will be stored in the clinical and research laboratories within the participating

centres. Samples will be coded and donor identifiable material will only be available to the PI

and the research team at the participating centres. Samples are appropriately labelled in

accordance with the trial procedures to comply with the 1998 Data Protection Act. Biological

samples collected from participants as part of this trial will be transported, stored, accessed

and processed in accordance with national legislation relating to the use and storage of human

tissue for research purposes and such activities shall at least meet the requirements as set out

in the 2004 Human Tissue Act and the 2006 Human Tissue (Scotland) Act.”

On completion of the trial samples will be disposed of in accordance with the Human Tissue

Authority’s Code of Practice.

Statistics

Sample size determination

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The trial size was calculated with respect to the primary end-point, which is delayed graft

function defined as the requirement for dialysis in the first 7 days post-transplantation. Based

on 5 years of data from the three participating centres, the overall rate of DGF in DCD kidney

transplants is 50%. In a pilot series of kidney transplants from extended criteria donors, 18

kidneys undergoing CS followed by 1 hour of EVNP were compared to a historical control

group of 47 ECD transplants after CS alone. The DGF rates were 1/18 (6%) in the EVNP

group compared to 17/47 (36%) in the CS group 14

.

Using a fixed sample size study, with interim analyses after 125 and 250 patients have been

enrolled and reached 365 days post-transplant, a total of 376 patients receiving a DCD kidney

(Maastricht category III & IV controlled donors) will be required to detect a 30% relative

reduction in DGF (from 50 to 35%) with a power of 80% and a statistical significance of α =

0.05. To allow for study withdrawal rate of 6%, a total of 400 patients will be recruited.

Interim Analysis

Two interim analyses will be performed during the study period. The first of these will be

after 125 patients have received a transplant and reached 7 days post-transplant and the

second after 250 patients have been recruited (and have received a transplant and reached 7

days post-transplant).

Analysis population and principles

The population used for efficacy analyses will be an intent to treat population including all

eligible randomised patients. This will be the primary analysis for the trial. Characteristics of

all randomised patients will be tabulated by arm of the trial to describe the cohort.

The primary and secondary outcome will also be analysed per protocol.

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Analysis of primary and secondary outcomes

The analyses will be described in detail in a full Statistical Analysis Plan. This section

summarises the main issues. A full statistical analysis plan will be drawn up prior to the first

interim analysis.

Primary analysis

The number of patients whom experience delayed graft function between the two groups will

be compared using a logistic regression model adjusting for cold ischemic time and donor

age.

Secondary outcomes

Primary non-function: The number of patients experiencing primary non-function in each

arm will be compared using a Fisher’s exact text. The cause of graft loss will be tabulated by

arm. The duration of DGF in days will be summarised using the Kaplan Meier estimate of the

duration of DGF for all those who experienced DGF and compared using a log rank test.

The number of participants whom experience functional DGF: The number of patients in

each arm will be compared using a Fisher’s exact test. The Creatinine reduction ratio day 2

and day 5 will be compared by arm using a two sample t-test. The length of hospital stay

defined from admission to discharge will be estimated using the Kaplan Meier method, with

deaths in hospital censored, and compared between arms using the log-rank test.

Biopsy-proven acute rejection rate; the number of patients in each arm will be compared

using a Fisher’s exact test. Longitudinal changes in serum creatinine and eGFR will be

separately assessed at 1, 3, 6 and 12 months post-transplant and mean values compared using

two-way ANOVA with repeated measures for patients in each arm of the trial. Any

difference between arms in the way serum creatinine and eGFR changes over time will also

be assessed using this model. Patient survival (time from transplant to death) and Allograft

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survival (time from transplant to graft loss or return to dialysis) will be analysed using a

Kaplan-Meier estimate of the probability of an event after 12 months and a log rank test.

Time to graft loss or return to dialysis will be modelled.

Analysis Population and Missing Data

Normally if a patient experiences DGF, they would remain in hospital for a minimum of 7

days. Hence for pragmatic reasons, if a patient is discharged from the hospital prior to 7 days

post-transplant and the patient is known to be alive at 7 days post-transplant, then such

patients will be imputed to have not experienced DGF. Some patients may also withdraw

consent, be withdrawn or die during the conduct of the trial. In either of these cases, it is

impossible to know whether such patients are either less or more likely to experience DGF

had they not experienced early censoring. Sensitivity analyses will be performed to account

for this.

Safety outcomes

Incidences of acute rejection, renal artery or renal vein thrombosis, complications of the renal

transplant biopsy and the number of hospital admission for any recognised complication of

renal transplantation and immunosuppression will be summarised by arm.

The University of Cambridge and Cambridge University Hospital NHS Foundation Trust will

be the sponsor for this study. A Trial Steering Committee will meet 6 monthly to review the

trial, monitor recruitment rates to consider protocol amendments and provide advice. A Trial

Management Group will be responsible for the ethics committee application and the

production of reports and the day to day running of the trial. A data monitoring committee

will consist of three independent members with expertise in renal transplantation, clinical

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trials and statistics. They will meet at least annually to review data, primarily concentrating

on patient safety.

Data handling

A data will be collected prospectively and recorded on the electronic case report forms. The

data will be monitored by the trial manager and audited each month. Each participant will be

allocated a unique study number and will be identifiable by this number throughout the

course of the study. This number will be used on all documentation and during analysis of the

results. Tissue, blood and urine samples will be coded with a unique number. Any data that

is transferred will be carried out under the NHS Code of Practice on Confidentiality.

Ethical Considerations

The study protocol and trial documents including the consent form and participant

information sheet have been approved by the NHS Health Research Authority East of

England, Cambridge Central Research Committee (15/EE/0356). Approval has also been

granted by the NHS Research & Development (R&D) department and will be sought at each

participating centre. Substantial amendments will require ethical review. Amendments will

also need to be reviewed and accepted by the NHS R&D departments before they can be

implemented in practice at sites.

Insurance of negligent or non-negligent harm will be covered under the University's clinical

trial policy.

There are no conflicts of interest for the PIs or members of the study team.

Dissemination

The results of the study will be submitted for peer review for publication in a scientific

journal. The results of the study will also be presented at national and international meetings.

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Acknowledgements

This study was supported by Kidney Research UK, the Cambridge National Institute for

Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and

Transplant Research Unit in Organ Donation and Transplantation at the University of

Cambridge in collaboration with Newcastle University and in partnership with NHS Blood

and Transplant (NHSBT). The views expressed are those of the authors and not necessarily

those of the NHS, the NIHR, the Department of Health or NHSBT.

Contributorship statement

Sarah A Hosgood, co-wrote the trial protocol, Kourosh Saeb-Parsy,

Colin Wilson,

and

Christopher Callaghan reviewed the protocol and aided in the study design. Dave Collett

carried out the statistics and Michael L Nicholson is the principal investigator. He designed

the study and wrote the protocol.

Competing interests

The authors have no competing interests.

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References

1: Summers DM, Watson CJ, Pettigrew GJ, Johnson RJ, Collett D, Neuberger JM,

Bradley JA. Kidney donation after circulatory death (DCD): state of the art. Kidney Int. 2015

Aug;88(2):241-9.

2: Saidi RF, Elias N, Kawai T, et al. Outcome of kidney transplantation using expanded

criteria donors and donation after cardiac death kidneys: Realities and costs. Am J Transplant

2007; 7: 2769–2774.

3: van der Vliet JA, Warle MC, Cheung CL, Teerenstra S, Hoitsma AJ. Influence of

prolonged cold ischemia in renal transplantation. Clin Transplant 2011; 25: E612–E616.

4: Snoeijs MG, Winkens B, Heemskerk MB, et al. Kidney transplantation from donors after

cardiac death: A 25-year experience. Transplantation 2010; 90: 1106–1112.

5: Yarlagadda SG, Coca SG, Formica RN, Jr, Poggio ED, Parikh CR. Association between

delayed graft function and allograft and patient survival: A systematic review and meta-

analysis. Nephrol Dial Transplant 2009; 24: 1039–1047.

6: Rao PS, Ojo A. The alphabet soup of kidney transplantation: SCD, DCD, ECD–

fundamentals for the practicing nephrologist. Clin J Am Soc Nephrol 2009; 4: 1827–1831.

7: Quiroga I, McShane P, Koo DD, et al. Major effects of delayed graft function and cold

ischaemia time on renal allograft survival. Nephrol Dial Transplant 2006; 21: 1689–1696.

8: Dare AJ, Pettigrew GJ, Saeb-Parsy K. Preoperative assessment of the deceased-donor

kidney: from macroscopic appearance to molecular biomarkers. Transplantation 2014 Apr

27;97(8):797-807.

9: Callaghan CJ, Harper SJ, Saeb-Parsy K, Hudson A, Gibbs P, Watson CJ, et al. The discard

of deceased donor kidneys in the UK. Clin Transplant 2014 Mar;28(3):345-353.

10: Nourbakhsh N, Singh P. Role of renal oxygenation and mitochondrial function in the

pathophysiology of acute kidney injury. Nephron Clin Pract. 2014;127(1-4):149-52

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11: Summers DM, Johnson RJ, Allen J, Fuggle SV, Collett D, Watson CJ, Bradley JA.

Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac

death in the UK: a cohort study. Lancet. 2010 Oct16;376(9749):1303-11.

12: Summers DM, Johnson RJ, Hudson A, Collett D, Watson CJ, Bradley JA. Effect of donor

age and cold storage time on outcome in recipients of kidneys donated after circulatory death

in the UK: a cohort study. Lancet. 2013 Mar 2;381(9868):727-34.

13: Hosgood SA, Nicholson ML. First in Man Renal Transplantation after Ex Vivo

Normothermic Perfusion. Transplantation 2011 Aug 11.

14: Nicholson ML, Hosgood SA. Renal transplantation after ex vivo normothermic perfusion:

the first clinical study. Am J Transplant 2013 May;13(5):1246-1252.

15: Hosgood SA, Nicholson ML. The first clinical case of intermediate ex vivo normothermic

perfusion in renal transplantation. Am J Transplant 2014 Jul;14(7):1690-1692.

16: Hosgood SA, Nicholson ML. Ex vivo normothermic perfusion of declined human

kidneys after inadequate in situ perfusion. Am J Transplant 2014 Feb;14(2):490-491.

17: Hosgood SA, Barlow AD, Hunter JP, Nicholson ML. Ex-vivo normothermic perfusion -

an innovative technology for quality assessment of marginal donor kidney transplants. 2015

Br J Surg. 2015 Oct;102 (11):1433-40.

18: Mallon DH, Summers DM, Bradley JA, Pettigrew GJ. Defining delayed graft function

after renal transplantation: simplest is best. Transplantation. 2013 Nov 27;96(10):885-9.

19: Vilar E, Varagunam M, Yaqoob MM, Raftery M, Thuraisingham R. Creatinine reduction

ratio: a useful marker to identify medium and high-risk renal transplants. Transplantation.

2010 Jan 15;89(1):97-103.

20: Boor P, Floege J. Renal allograft fibrosis: biology and therapeutic targets. Am J

Transplant. 2015 Apr;15(4):863-86. doi: 10.1111/ajt.13180. Epub 2015 Feb 17. Review.

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EVNP Score

Macroscopic appearance Points

Excellent perfusion with global and even pink appearance 1 point

Moderate perfusion with some areas of patchy or mottled perfusion 2 points

Poor perfusion with a globally mottled and purple appearance 3 points



Total Urine Output (ml) <43ml/hr 1 point

Total Urine Output (ml) >43ml/hr 0 point

Table 1: Ex-vivo normothermic perfusion (EVNP) score. Scores for macroscopic appearance,

renal blood flow and urine output will be added to yield an overall assessment score ranging

from 1 (the highest quality) to 5 (the lowest quality).

Appendix 1: Patient information sheet

Appendix 2: Patient consent form

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Figure 1

210x297mm (300 x 300 DPI)

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Pre-Transplant Patient Information Sheet You are being invited to take part in a research study. Before you decide, it is important for you to understand why the research is being done and what it will involve. Please take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part. Study Title: Ex-vivo Normothermic Perfusion Trial Summary We would like to assess whether a new technique of kidney preservation can improve early graft function compared to the standard cold storage technique. 1 What is the purpose of the study? When kidneys are removed from an organ donor they are normally stored on ice until they are ready to be transplanted. A kidney can be preserved safely at a low temperature in these conditions. However, there is some degree of deterioration and the longer they are left in this condition the more they deteriorate (rather like food that is kept in the fridge). We have developed a technique that may improve the quality of the kidney. This involves placing the kidney on a machine and passing a warmed, oxygen-rich solution containing red blood cells through it for about one hour. Under these conditions the kidney can start to function again and produce urine. This improves the condition of the kidney and may improve function after transplantation. 2 How is this study designed? This study will assess the technique of warming a kidney and compare it to the standard cold storage technique that is commonly used. Kidneys will be randomly assigned to receive either the warming technique or standard cold storage. 3 Why have I been invited? The kidney you are being offered is a suitable match for you. It is a kidney from a donation after circulatory death donor and meets the criteria for entry into the trial. 4 Do I have to take part? It is completely your choice whether you want to take part. If you decline to be included in the study the kidney will undergo the standard cold storage technique of preservation with no intervention. 5 What will happen to me if I take part? You will be prepared for surgery in the normal way. Standard practice involves keeping the transplant kidney under cold storage in ice until the time of the transplant operation. If you consent to take part in this trial then your kidney will be randomly assigned to either standard practice or to having warm perfusion for one hour immediately before the kidney is transplanted. Should there be any problem with the warm perfusion procedure then the kidney can be quickly removed from the perfusion machine and returned to cold storage in

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ice before transplantation. This failsafe position has not been required so far in our first 40 cases. During the transplant operation we will also take a small tissue biopsy from the kidney 30 minutes after it has been transplanted. Although there is a small risk of causing bleeding from the kidney biopsy site (<5%) your surgeon will be able to repair the bleeding site if this happens. 6 What do I have to do? After your transplant you will receive the normal standard care but will also be asked to provide a few additional blood and urine samples for analysis. Your participation in this study will not affect the way you are followed up after a transplant. The normal follow up involves clinical visits at least twice a week for six weeks and then weekly for a further six weeks. At three months after your transplant we will plan to perform a routine needle biopsy of the kidney to look for scarring. This would help us with our research but it is not compulsory. Needle biopsies have a good safety record but there is a small risk (less than 1%) of significant bleeding. After three months you will be seen either in Cambridge or your local centre. The length between clinical visits will be gradually extended after the first three months. 7 What are the alternatives for treatment? If you decide not to take part in the trial the kidney will not receive any intervention and will be transplanted as normal. 8 What are the possible disadvantages and risks of taking part? There are no potential side effects to you. This technique of perfusion is applied to the kidney only, before it is transplanted. There is a small risk that the kidney might be damaged during the assessment and therefore could not be transplanted. This has not happened in our experience of 40 cases so far but it remains as a potential risk. Although your kidney may be deemed suitable for transplantation it is a kidney from a marginal donor and we know that this increases the rate of delayed graft function. This means that it may take some time for the kidney to start to function fully. There is also a small risk that the kidney will never function. 9 What are the possible benefits of taking part? This trial is being performed because we are uncertain whether or not warm perfusion improves the outcome of kidney transplantation. Our experience so far suggests that using this technique to recondition the kidney can result in better postoperative function. It is also possible however that warm perfusion worsens the outcome of a kidney transplant. 10 What happens when the research study stops? At the end of the research study you will continue to be followed up for your kidney transplant either at Addenbrooke’s Hospital or at your local renal hospital.

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10 What if new information becomes available? If new information becomes available your Transplant Consultant might consider it to be in your best interests to withdraw you from the study. He/she will explain the reasons and arrange for your care to continue. 12 What will happen if I do not want to carry on with the study? You will be given normal care after the kidney transplant. If you withdraw from the study we will ask permission to use the data collected up to your withdrawal. 13 What will happen to the samples I give? All urine, blood and tissue samples requested following renal transplantation, either routinely or because of a clinical need, will be tested or disposed of according to normal hospital policies and procedures. We will keep a small amount of these samples within the Hospital in a secured area for analysis at a later date. Once analysed, these will be disposed of according to normal hospital policy. Tissue samples will also be kept within the hospitals pathology department. 14 What will happen to the results of the research study? The results of the research will be published in specialist journals in order to inform other transplant doctors around the world. You will not be identified in any report or publication. You will be able to get a copy of the results by asking the kidney doctors in the follow up clinic. 15 Will my General Practitioner/Family Doctor (GP) be involved? Participation in this trial will not affect your treatment and follow-up by your GP after discharge from the hospital. 16 Who is organising the research? The research is being organised by doctors at the Cambridge Transplant Unit. The trial is funded by Kidney Research UK and approximately 400 patients will be recruited. 17 Who has reviewed the study? The study has been reviewed by the transplant doctors in Cambridge, Kidney Research UK and the Local Research Ethics Committee. 18 Will my taking part in this study be kept confidential? We will follow ethical and legal best practice and all information about you will be handled confidentially. If you join the study, some parts of your medical records and the data collected for the study will be looked at by authorised persons from the research team. They may also be looked at by representatives of the regulatory authority or by those responsible for research and development audit (for monitoring the quality of the research). All have a duty of confidentiality to you as a research participant and will do their best to meet this duty. Our procedure for handling, processing, storage and destruction of data will match the Data Protection Act 1998. Your name will not be disclosed outside the hospital. The data collected will be stored and retained securely for 10 years and it will also be disposed of

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securely. You have the right to check the accuracy of data held about you and correct any errors. 19 What if there is a problem? Any complaint about the way you have been dealt with during the trial or any possible harm you might suffer will be addressed. If you have any concerns about any aspect of this trial you should speak to your trial doctor who will do their best to answer your questions. In the event that something does go wrong and you are harmed by taking part in the research and this is due to someone’s negligence then you may have grounds for a legal action for compensation against Cambridge University Hospitals NHS Foundation Trust or the University of Cambridge. The normal National Health Service complaints mechanisms will still be available to you (if appropriate). The University has obtained insurance, which provides no-fault compensation i.e. for non-negligent harm, you may be entitled to make a claim for this. Obtaining further information If you have any questions or concerns about any aspect of this study, you should ask to speak to the researchers who will do their best to answer your questions or to Professor Michael Nicholson (01223 339221). Complaints and Independent Advice If you wish to speak to an independent body about any concerns or complaints about any aspect of the way you have been approached or treated during this trial, you can do this through the Addenbrooke’s Kidney Patient’s Association or the Patient Advice and Liaison Service (PALS) at Addenbrooke’s Hospital. The formal NHS complaints procedure is also available to you. Details can be obtained through the hospital. Complaints If you remain unhappy and wish to complain formally, you can do this through the NHS complaints procedure. NHS based research If you are harmed by taking part in this research project, there are no special compensation arrangements. If you are harmed due to someone’s negligence, then you may have grounds for a legal action but you may have to pay for it. Regardless of this, if you wish to complain, or have any concerns about any aspect of the way you have been approached or treated during the course of this study, the normal National Health Service complaints mechanisms will be available to you. Contacts for further information A) General information about research can be found on www.nres.org.uk; www.addenbrookes.nhs.uk; or www.instituteofclinicalresearch.org.uk B) For specific information about this research project, contact Professor Michael Nicholson, 01223 339221.

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C) For advice on whether you should participate in the study, contact either Professor Michael Nicholson on 01223 339221, or one of the other transplant doctors on G5 on 01223 217306. D) For independent advice you can also contact the Patient Advice and Liaison Service (PALS) on 01223 216 756, email [email protected] E) Addenbrooke’s Kidney Patient’s Association email [email protected] Thank you for reading this information sheet and for considering taking part in this study. If you agree to take part you will be given a copy of this information sheet and a signed copy of your consent form to keep.

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Patient consent form v1.1 EVNP DCD Trial 4th Nov 2015 Page 1

Patient Consent Form

Patient Identification Number:

Ex-vivo Normothermic Perfusion Kidney Trial

1. I confirm that I have read and understood the information sheet for the above study. I have

had the opportunity to consider the information, ask questions and have had these answered satisfactorily.

Initial

2. I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my medical care or legal rights being affected.

Initial

3. I understand that relevant sections of my medical notes and data collected during the study,

may be looked at by individuals from the Cambridge University Hospitals NHS Foundation Trust, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my medical records.

Initial

4. I agree for the storage and analysis of my serum, urine and kidney biopsy samples. I understand that these samples may be kept for analysis at a later date.

Initial

5. I agree to take part in the above study. Initial

Name of Participant ………………………………………………………………………………………………. Signature………………………………………………………………… Date……………………………… Name of Person Taking Consent ……………………………………………………………………………… Signature………………………………………………………………… Date……………………………… Name of Principal Investigator: Professor Michael Nicholson (Consultant Transplant Surgeon)

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SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and

related documents*

Section/item ItemNo

Description

Administrative information

Title 1 Descriptive title identifying the study design, population, interventions,

and, if applicable, trial acronym

Trial registration 2a Trial identifier and registry name. If not yet registered, name of

intended registry

2b All items from the World Health Organization Trial Registration Data

Set

Protocol version 3 Date and version identifier

Funding 4 Sources and types of financial, material, and other support

Roles and

responsibilities

5a Names, affiliations, and roles of protocol contributors

5b Name and contact information for the trial sponsor

5c Role of study sponsor and funders, if any, in study design; collection,

management, analysis, and interpretation of data; writing of the report;

and the decision to submit the report for publication, including whether

they will have ultimate authority over any of these activities

5d Composition, roles, and responsibilities of the coordinating centre,

steering committee, endpoint adjudication committee, data

management team, and other individuals or groups overseeing the

trial, if applicable (see Item 21a for data monitoring committee)

Introduction

Background and

rationale

6a Description of research question and justification for undertaking the

trial, including summary of relevant studies (published and

unpublished) examining benefits and harms for each intervention

6b Explanation for choice of comparators

Objectives 7 Specific objectives or hypotheses

Trial design 8 Description of trial design including type of trial (eg, parallel group,

crossover, factorial, single group), allocation ratio, and framework (eg,

superiority, equivalence, noninferiority, exploratory)

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Methods: Participants, interventions, and outcomes

Study setting 9 Description of study settings (eg, community clinic, academic hospital)

and list of countries where data will be collected. Reference to where

list of study sites can be obtained

Eligibility criteria 10 Inclusion and exclusion criteria for participants. If applicable, eligibility

criteria for study centres and individuals who will perform the

interventions (eg, surgeons, psychotherapists)

Interventions 11a Interventions for each group with sufficient detail to allow replication,

including how and when they will be administered

11b Criteria for discontinuing or modifying allocated interventions for a

given trial participant (eg, drug dose change in response to harms,

participant request, or improving/worsening disease)

11c Strategies to improve adherence to intervention protocols, and any

procedures for monitoring adherence (eg, drug tablet return,

laboratory tests)

11d Relevant concomitant care and interventions that are permitted or

prohibited during the trial

Outcomes 12 Primary, secondary, and other outcomes, including the specific

measurement variable (eg, systolic blood pressure), analysis metric

(eg, change from baseline, final value, time to event), method of

aggregation (eg, median, proportion), and time point for each

outcome. Explanation of the clinical relevance of chosen efficacy and

harm outcomes is strongly recommended

Participant

timeline

13 Time schedule of enrolment, interventions (including any run-ins and

washouts), assessments, and visits for participants. A schematic

diagram is highly recommended (see Figure)

Sample size 14 Estimated number of participants needed to achieve study objectives

and how it was determined, including clinical and statistical

assumptions supporting any sample size calculations

Recruitment 15 Strategies for achieving adequate participant enrolment to reach

target sample size

Methods: Assignment of interventions (for controlled trials)

Allocation:

Sequence

generation

16a Method of generating the allocation sequence (eg, computer-

generated random numbers), and list of any factors for stratification.

To reduce predictability of a random sequence, details of any planned

restriction (eg, blocking) should be provided in a separate document

that is unavailable to those who enrol participants or assign

interventions

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Allocation

concealment

mechanism

16b Mechanism of implementing the allocation sequence (eg, central

telephone; sequentially numbered, opaque, sealed envelopes),

describing any steps to conceal the sequence until interventions are

assigned

Implementation 16c Who will generate the allocation sequence, who will enrol participants,

and who will assign participants to interventions

Blinding

(masking)

17a Who will be blinded after assignment to interventions (eg, trial

participants, care providers, outcome assessors, data analysts), and

how

17b If blinded, circumstances under which unblinding is permissible, and

procedure for revealing a participant’s allocated intervention during

the trial

Methods: Data collection, management, and analysis

Data collection

methods

18a Plans for assessment and collection of outcome, baseline, and other

trial data, including any related processes to promote data quality (eg,

duplicate measurements, training of assessors) and a description of

study instruments (eg, questionnaires, laboratory tests) along with

their reliability and validity, if known. Reference to where data

collection forms can be found, if not in the protocol

18b Plans to promote participant retention and complete follow-up,

including list of any outcome data to be collected for participants who

discontinue or deviate from intervention protocols

Data

management

19 Plans for data entry, coding, security, and storage, including any

related processes to promote data quality (eg, double data entry;

range checks for data values). Reference to where details of data

management procedures can be found, if not in the protocol

Statistical

methods

20a Statistical methods for analysing primary and secondary outcomes.

Reference to where other details of the statistical analysis plan can be

found, if not in the protocol

20b Methods for any additional analyses (eg, subgroup and adjusted

analyses)

20c Definition of analysis population relating to protocol non-adherence

(eg, as randomised analysis), and any statistical methods to handle

missing data (eg, multiple imputation)

Methods: Monitoring

Data monitoring 21a Composition of data monitoring committee (DMC); summary of its role

and reporting structure; statement of whether it is independent from

the sponsor and competing interests; and reference to where further

details about its charter can be found, if not in the protocol.

Alternatively, an explanation of why a DMC is not needed

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21b Description of any interim analyses and stopping guidelines, including

who will have access to these interim results and make the final

decision to terminate the trial

Harms 22 Plans for collecting, assessing, reporting, and managing solicited and

spontaneously reported adverse events and other unintended effects

of trial interventions or trial conduct

Auditing 23 Frequency and procedures for auditing trial conduct, if any, and

whether the process will be independent from investigators and the

sponsor


Research ethics

approval

24 Plans for seeking research ethics committee/institutional review board

(REC/IRB) approval

Protocol

amendments

25 Plans for communicating important protocol modifications (eg,

changes to eligibility criteria, outcomes, analyses) to relevant parties

(eg, investigators, REC/IRBs, trial participants, trial registries, journals,

regulators)

Consent or assent 26a Who will obtain informed consent or assent from potential trial

participants or authorised surrogates, and how (see Item 32)

26b Additional consent provisions for collection and use of participant data

and biological specimens in ancillary studies, if applicable

Confidentiality 27 How personal information about potential and enrolled participants will

be collected, shared, and maintained in order to protect confidentiality

before, during, and after the trial

Declaration of

interests

28 Financial and other competing interests for principal investigators for

the overall trial and each study site

Access to data 29 Statement of who will have access to the final trial dataset, and

disclosure of contractual agreements that limit such access for

investigators

Ancillary and

post-trial care

30 Provisions, if any, for ancillary and post-trial care, and for

compensation to those who suffer harm from trial participation

Dissemination

policy

31a Plans for investigators and sponsor to communicate trial results to

participants, healthcare professionals, the public, and other relevant

groups (eg, via publication, reporting in results databases, or other

data sharing arrangements), including any publication restrictions

31b Authorship eligibility guidelines and any intended use of professional

writers

31c Plans, if any, for granting public access to the full protocol, participant-

level dataset, and statistical code

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5

Appendices

Informed consent

materials

32 Model consent form and other related documentation given to

participants and authorised surrogates

Biological

specimens

33 Plans for collection, laboratory evaluation, and storage of biological

specimens for genetic or molecular analysis in the current trial and for

future use in ancillary studies, if applicable

*It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013

Explanation & Elaboration for important clarification on the items. Amendments to the

protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT

Group under the Creative Commons “Attribution-NonCommercial-NoDerivs 3.0 Unported”

license.

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Appendix 1 and 2


bmj open · for peer review only protocol for a randomised controlled, open label trial of ex-vivo...

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