Prospective randomized study of the tolerability and efficacy of combination therapy for hypertensive chronic kidney disease: results of the PROTECT-CKD study

Association of Intensive Blood Pressure Control and Kidney Disease Progression in Nondiabetic Patients With Chronic Kidney Disease: A Systematic Review and Meta-analysis

Importance

The optimal blood pressure (BP) target remains debated in nondiabetic patients with chronic kidney disease (CKD).

Objective

To compare intensive BP control (<130/80 mm Hg) with standard BP control (<140/90 mm Hg) on major renal outcomes in patients with CKD without diabetes.

Data Sources

Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications up to March 24, 2016.

Study Selection

Randomized clinical trials that compared an intensive vs a standard BP target in nondiabetic adults with CKD, reporting changes in glomerular filtration rate (GFR), doubling of serum creatinine level, 50% reduction in GFR, end-stage renal disease (ESRD), or all-cause mortality.

Data Extraction and Synthesis

Random-effects meta-analyses for pooling effect measures. Meta-regression and subgroup analyses for exploring heterogeneity.

Main Outcomes and Measures

Differences in annual rate of change in GFR were expressed as mean differences with 95% CIs. Differences in doubling of serum creatinine or 50% reduction in GFR, ESRD, composite renal outcome, and all-cause mortality were expressed as risk ratios (RRs) with 95% CIs.

Results

We identified 9 trials with 8127 patients and a median follow-up of 3.3 years. Compared with standard BP control, intensive BP control did not show a significant difference on the annual rate of change in GFR (mean difference, 0.07; 95% CI, -0.16 to 0.29 mL/min/1.73 m2/y), doubling of serum creatinine level or 50% reduction in GFR (RR, 0.99; 95% CI, 0.76-1.29), ESRD (RR, 0.96; 95% CI, 0.78-1.18), composite renal outcome (RR, 0.99; 95% CI, 0.81-1.21), or all-cause mortality (RR, 0.95; 95% CI, 0.66-1.37). Nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP control.

Conclusions and Relevance

Targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment during a follow-up of 3.3 years in patients with CKD without diabetes. However, nonblack patients or those with higher levels of proteinuria might benefit from the intensive BP-lowering treatments.

Comparative effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers for major renal outcomes in patients with diabetes: A 15-year cohort study

BACKGROUND

Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are considered to have similar renoprotective effects; so far there has been no consensus about their priorities. This study aimed to compare ACEIs and ARBs for major renal outcomes and survival in a 15-year cohort of adults with diabetes.

METHODS

This study utilized Taiwan's medical and pharmacy claims data in the Longitudinal Cohort of Diabetes Patients. The primary outcome was long-term dialysis, and secondary outcomes were hospitalization for acute kidney injury, hospitalization for hyperkalemia, all-cause death, cardiovascular death, and non-cardiovascular death. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes comparing ACEIs with ARBs. We conducted subgroup analyses and interaction tests among patients with different age and comorbid diseases.

RESULTS

A total of 34,043 patients received ACEIs and 23,772 patients received ARBs. No differences were found for primary or secondary outcomes in the main analyses. ACEIs showed significantly lower hazard than ARBs for long-term dialysis among patients with cardiovascular disease (HR 0.80, 95% CI 0.66-0.97, interaction P = 0.003) or chronic kidney disease (0.81, 0.71-0.93, interaction P = 0.001).

CONCLUSIONS

Our analyses show similar effects of ACEIs and ARBs in patients with diabetes. However, ACEIs might provide additional renoprotective effects among patients who have cardiovascular disease or chronic kidney disease.

Outcomes of diuretic use in pre-dialysis CKD patients with moderate renal deterioration attending tertiary care referral center

INTRODUCTION

Diuretic therapy has been the mainstay of treatment in chronic kidney disease (CKD) patients, primarily for hypertension and fluid overload. Apart from their beneficial effects, diuretic use is associated with adverse renal outcomes. The current study is aimed to determine the outcomes of diuretic therapy.

METHODOLOGY

A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by Bioimpedance analysis (BIA).

RESULTS

A total 312 patients (mean age 64.5 ± 6.43) were enrolled. Among 144 (46.1%) diuretic users, furosemide and hydrochlorothiazide (HCTZ) were prescribed in 69 (48%) and 39 (27%) patients, respectively, while 36 (25%) were prescribed with combination therapy (furosemide plus HCTZ). Changes in BP, fluid compartments, eGFR decline and progression to RRT were assessed over a follow-up period of 1 year. Maximum BP control was observed with combination therapy (-19.3 mmHg, p < 0.001) followed by furosemide [-10.6 mmHg with 80 mg thrice daily (p < 0.001)], -9.3 mmHg with 40-60 mg (p < 0.001) and -5.9 mmHg with 20-40 mg (p = 0.02) while HCTZ offered minimal SBP control [-3.7 mmHg with 12.5-25 mg (p = 0.04)]. Decline in extracellular water (ECW) ranged from -1.5 L(p = 0.01) with thiazide diuretics to -3.8 L(p < 0.001) with combination diuretics. Decline in eGFR was maximum (-3.4 ml/min/1.73 m², p = 0.01) with combination diuretics and least with thiazide diuretics (-1.6 ml/min/1.73 m², p = 0.04). Progression to RRT was observed in 36 patients.

CONCLUSION

It is cautiously suggested to discourage the use of diuretic combination therapy and high doses of single diuretic therapy. Prescribing of diuretics should be done by keeping in view benefit versus harm for each patient.

Comparison of efficacy and safety between benidipine and hydrochlorothiazide in fosinopril-treated hypertensive patients with chronic kidney disease: protocol for a randomised controlled trial

INTRODUCTION

Co-administration of a diuretic or calcium channel blocker with an ACE inhibitor are both preferred combinations in patients with hypertensive chronic kidney disease (CKD). According to the available evidence, it is still unknown which combination plays a more active role in renal protection. We hypothesised that a combination of fosinopril and benidipine may delay the progression of CKD more effectively than a combination of fosinopril and hydrochlorothiazide (HCTZ).

METHODS AND ANALYSIS

This study will be a multicentred, prospective, double-blind, randomised parallel controlled trial for hypertensive CKD patients in China. Patients will be randomised to one of two treatment groups: a combination of benidipine 4-8 mg/day and fosinopril 20 mg/day; or a combination of HCTZ 12.5-25 mg/day and fosinopril 20 mg/day. Patients will be followed up for 24 months after a month's fosinopril run-in. There will be dose-titration after 1 and 2 months. The primary endpoint is changes in estimated glomerular filtration rate (eGFR) from baseline to month 24. Secondary endpoints include changes in home blood pressure (BP), ambulatory BP, proteinuria, urinary albumin/creatinine ratio, and composite renal events in 24 months. Inclusion criteria are: age 18-80 years, non-dialysis CKD patients with eGFR >30 mL/min/1.73 m², home BP >130 mm Hg systolic or BP >80 mm Hg diastolic at the screening and randomisation, and 24 hour proteinuria <3.5 g. Principal exclusions are hypertensive crisis, transplantation, cancer, severe diabetes complications, hyperkalaemia and severe allergy. The required sample size was 511 patients for detecting a difference in the change of eGFR (one sided α=0.025, power 1-β=0.90).

ETHICS AND DISSEMINATION

BEAHIT (Benidipine and Hydrochlorothiazide in Fosinopril Treated Chronic Kidney Disease Patients with Hypertension) was approved by Changzheng Hospital Ethics Committee (CZ-20160504-16). The outcomes will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02646397.

Antihypertensive and metabolic effects of hydrochlorothiazide versus amlodipine when added to losartan in patients with type 2 diabetes

We performed a prospective, randomized, multicenter, parallel-group, per-protocol study to compare the effects of hydrochlorothiazide (HCTZ) and amlodipine as add-on to losartan treatment in hypertensive type 2 diabetic patients. A total of 49 Japanese type 2 diabetic patients with inadequate control of blood pressure while receiving losartan 50 mg were randomly allocated to receive a fixed-dose single-pill combination of HCTZ 12.5 mg plus losartan (N = 26) or a free combination of amlodipine 5 mg plus losartan (N = 23). During 8 weeks of follow-up, changes in blood pressure and laboratory data including HbA1c, uric acid, and potassium were compared between the groups using analysis of covariance. Systolic and diastolic blood pressure decreased in both groups, the reductions of which were greater in the amlodipine group. However, the least square mean (95 % CI) differences between groups were not statistically significant [2.3 (-6.8 to 11.4) mmHg, p = 0.618 and 2.7 (-2.4-7.9) mmHg, p = 0.293, respectively]. HbA1c increased in patients receiving HCTZ but not in the amlodipine group. Uric acid also increased in patients receiving HCTZ but decreased in patients receiving amlodipine, yielding a significant between-group difference of 1.0 (0.5-1.5) mg/dl (p < 0.001). No intra- or intergroup change was observed in serum potassium levels. This pilot study suggests that HCTZ and amlodipine result in nonsignificant effects on systolic and diastolic blood pressure reduction when administrated as add-on therapy to losartan in hypertensive patients with type 2 diabetes; however, addition of HCTZ may be associated with less favorable effects on metabolic profiles than amlodipine.