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Ruggenenti P, Podestà MA, Trillini M, Perna A, Peracchi T, Rubis N, Villa D, Martinetti D, Cortinovis M, Ondei P, Condemi CG, Guastoni CM, Meterangelis A, Granata A, Mambelli E, Pasquali S, Genovesi S, Pieruzzi F, Bertoli SV, Del Rosso G, Garozzo M, Rigotti A, Pozzi C, David S, Daidone G, Mingardi G, Mosconi G, Galfré A, Romei Longhena G, Pacitti A, Pani A, Hidalgo Godoy J, Anders HJ, Remuzzi G. Ramipril and Cardiovascular Outcomes in Patients on Maintenance Hemodialysis: The ARCADIA Multicenter Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:575-587. [PMID: 33782036 PMCID: PMC8092055 DOI: 10.2215/cjn.12940820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 02/15/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Renin-angiotensin system (RAS) inhibitors reduce cardiovascular morbidity and mortality in patients with CKD. We evaluated the cardioprotective effects of the angiotensin-converting enzyme inhibitor ramipril in patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this phase 3, prospective, randomized, open-label, blinded end point, parallel, multicenter trial, we recruited patients on maintenance hemodialysis with hypertension and/or left ventricular hypertrophy from 28 Italian centers. Between July 2009 and February 2014, 140 participants were randomized to ramipril (1.25-10 mg/d) and 129 participants were allocated to non-RAS inhibition therapy, both titrated up to the maximally tolerated dose to achieve predefined target BP values. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the single components of the primary end point, new-onset or recurrence of atrial fibrillation, hospitalizations for symptomatic fluid overload, thrombosis or stenosis of the arteriovenous fistula, and changes in cardiac mass index. All outcomes were evaluated up to 42 months after randomization. RESULTS At comparable BP control, 23 participants on ramipril (16%) and 24 on non-RAS inhibitor therapy (19%) reached the primary composite end point (hazard ratio, 0.93; 95% confidence interval, 0.52 to 1.64; P=0.80). Ramipril reduced cardiac mass index at 1 year of follow-up (between-group difference in change from baseline: -16.3 g/m2; 95% confidence interval, -29.4 to -3.1), but did not significantly affect the other secondary outcomes. Hypotensive episodes were more frequent in participants allocated to ramipril than controls (41% versus 12%). Twenty participants on ramipril and nine controls developed cancer, including six gastrointestinal malignancies on ramipril (four were fatal), compared with none in controls. CONCLUSIONS Ramipril did not reduce the risk of major cardiovascular events in patients on maintenance hemodialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ARCADIA, NCT00985322 and European Union Drug Regulating Authorities Clinical Trials Database number 2008-003529-17.
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Affiliation(s)
- Piero Ruggenenti
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy,Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Manuel Alfredo Podestà
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy,Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Matias Trillini
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Tobia Peracchi
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Nadia Rubis
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Villa
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Martinetti
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Patrizia Ondei
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Carmela Giuseppina Condemi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Maria Guastoni
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Ospedali di Legnano e Magenta, Milano, Italy
| | - Agnese Meterangelis
- Unit of Nephrology and Dialysis, Policlinico San Pietro, Ponte San Pietro, Bergamo, Italy
| | - Antonio Granata
- Unit of Nephrology and Dialysis, Azienda Ospedaliera per l'Emergenza “Cannizzaro,” Catania, Italy
| | - Emanuele Mambelli
- Unit of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Sonia Pasquali
- Unit of Nephrology and Dialysis, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Simonetta Genovesi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Monza, Ospedale San Gerardo, Monza, Italy,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Federico Pieruzzi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Monza, Ospedale San Gerardo, Monza, Italy,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Silvio Volmer Bertoli
- Unit of Nephrology and Dialysis, Istituto di Ricovero e Cura a Carattere Scientifico MultiMedica, Sesto San Giovanni, Milano, Italy
| | - Goffredo Del Rosso
- Unit of Nephrology and Dialysis, Ospedale Giuseppe Mazzini, Teramo, Italy
| | - Maurizio Garozzo
- Unit of Nephrology and Dialysis, Presidio Ospedaliero S. Marta e S. Venera, Acireale, Catania, Italy
| | - Angelo Rigotti
- Unit of Nephrology and Dialysis, Ospedale Infermi, Rimini, Italy
| | - Claudio Pozzi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Nord Milano-Ospedale Bassini, Cinisello Balsamo, Milano, Italy
| | - Salvatore David
- Department of Nephrology and Dialysis, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giuseppe Daidone
- Unit of Nephrology and Dialysis, Ospedale Umberto I, Siracusa, Italy
| | - Giulio Mingardi
- Unit of Nephrology and Dialysis, Humanitas Gavazzeni, Bergamo, Italy
| | - Giovanni Mosconi
- Unit of Nephrology and Dialysis, Ospedale “Morgagni-Pierantoni,” Forlì, Italy
| | - Andrea Galfré
- Unit of Nephrology and Dialysis, Azienda Sanitaria Locale 8, Cagliari, Italy
| | - Giorgio Romei Longhena
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Rhodense-Ospedale Garbagnate Milanese, Milano, Italy
| | - Alfonso Pacitti
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | - Antonello Pani
- Unit of Nephrology and Dialysis, Department of Reproduction, Genitourinary and Kidney Disease and Kidney Transplantation, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Jorge Hidalgo Godoy
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy,Institute of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital, Ludwig Maximilians Universität Munich, Munich, Germany
| | - Giuseppe Remuzzi
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Bellinghieri G, Condemi CG, Saitta S, Trifirò G, Gangemi S, Savica V, Buemi M, Santoro D. Erythropoiesis-stimulating agents: dose and mortality risk. J Ren Nutr 2014; 25:164-8. [PMID: 25529282 DOI: 10.1053/j.jrn.2014.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/29/2014] [Indexed: 12/26/2022] Open
Abstract
Hypo-responsiveness to erythropoiesis-stimulating agents (ESAs) has been associated with increased mortality in end-stage renal disease patients. It is not clear if this effect is related to the elevated ESAs dosage for targeting hemoglobin levels or underlying morbid conditions that lead to ESA resistance. We retrospectively evaluated from 2008 to death or December 2011, 28 consecutive incident hemodialysis patients. We identified 2 cohort of patients based on their mean annual ESAs dosage. The correlation between data was evaluated with the Spearman's rho test. Kaplan-Meier curves were generated to assess survival in subjects with high and low ESAs mean dose. Median ESAs dosage, used as a cutoff point between patients at high and low ESAs dose, was at 11.000 IU/week for epoetin alfa and beta, 55 mcg/week for darbopoietin, and 220 mcg/month for cera. Mean hemoglobin (Hb) level was 10.58 ± 0.13 g/dL. Of 28 patients, during follow-up, 6 (21,4%) died of all causes. High-dose ESA therapy was associated with increased all-cause mortality (P = .047). Moreover, there was a negative correlation between ESAs dose and Hb levels (rho = -0.825; P < .001). Higher ESAs dose for the treatment of anemia in incident hemodialysis patients was associated with higher mortality risk. ESAs and Hb serum levels were inversely correlated with mortality. Together, these findings suggest that ESAs dosage and Hb level may play a role through an independent manner or an interactive effect that adversely affects mortality.
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Affiliation(s)
- Guido Bellinghieri
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Carmela Giuseppina Condemi
- Department of Clinical and Experimental Medicine, University of Messina, Italy; Unit of Nephrology and Dialysis, San Giovanni XXII Hospital, Bergamo, Italy
| | - Salvatore Saitta
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Gianluca Trifirò
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Vincenzo Savica
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Italy.
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