Angiotensin blockade in late autosomal dominant polycystic kidney disease

Vicente E. Torres, Kaleab Z. Abebe, Arlene B. Chapman, Robert W. Schrier, William E. Braun, Theodore I. Steinman, Franz T. Winklhofer, Godela Brosnahan, Peter G. Czarnecki, Marie C. Hogan, Dana C. Miskulin, Frederic F. Rahbari-Oskoui, Jared J. Grantham, Peter C. Harris, Michael F. Flessner, Charity G. Moore, Ronald D. Perrone

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142 Scopus citations

Abstract

BACKGROUND Hypertension develops early in patients with autosomal dominant polycystic kidney disease (ADPKD) and is associated with disease progression. The renin-angiotensin- aldosterone system (RAAS) is implicated in the pathogenesis of hypertension in patients with ADPKD. Dual blockade of the RAAS may circumvent compensatory mechanisms that limit the efficacy of monotherapy with an angiotensin-converting- enzyme (ACE) inhibitor or angiotensin II-receptor blocker (ARB).

METHODS In this double-blind, placebo-controlled trial, we randomly assigned 486 patients, 18 to 64 years of age, with ADPKD (estimated glomerular filtration rate [GFR], 25 to 60 ml per minute per 1.73 m2 of body-surface area) to receive an ACE inhibitor (lisinopril) and placebo or lisinopril and an ARB (telmisartan), with the doses adjusted to achieve a blood pressure of 110/70 to 130/80 mm Hg. The composite primary outcome was the time to death, end-stage renal disease, or a 50% reduction from the baseline estimated GFR. Secondary outcomes included the rates of change in urinary aldosterone and albumin excretion, frequency of hospitalizations for any cause and for cardiovascular causes, incidence of pain, frequency of ADPKD-related symptoms, quality of life, and adverse study-medication effects. Patients were followed for 5 to 8 years.

RESULTS There was no significant difference between the study groups in the incidence of the composite primary outcome (hazard ratio with lisinopril-telmisartan, 1.08; 95% confidence interval, 0.82 to 1.42). The two treatments controlled blood pressure and lowered urinary aldosterone excretion similarly. The rates of decline in the estimated GFR, urinary albumin excretion, and other secondary outcomes and adverse events, including hyperkalemia and acute kidney injury, were also similar in the two groups.

CONCLUSIONS Monotherapy with an ACE inhibitor was associated with blood-pressure control in most patients with ADPKD and stage 3 chronic kidney disease. The addition of an ARB did not alter the decline in the estimated GFR.

Original languageEnglish (US)
Pages (from-to)2267-2276
Number of pages10
JournalNew England Journal of Medicine
Volume371
Issue number24
DOIs
StatePublished - Dec 11 2014

ASJC Scopus subject areas

  • Medicine(all)

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    Torres, V. E., Abebe, K. Z., Chapman, A. B., Schrier, R. W., Braun, W. E., Steinman, T. I., Winklhofer, F. T., Brosnahan, G., Czarnecki, P. G., Hogan, M. C., Miskulin, D. C., Rahbari-Oskoui, F. F., Grantham, J. J., Harris, P. C., Flessner, M. F., Moore, C. G., & Perrone, R. D. (2014). Angiotensin blockade in late autosomal dominant polycystic kidney disease. New England Journal of Medicine, 371(24), 2267-2276. https://doi.org/10.1056/NEJMoa1402686