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Randomized Controlled Trial
. 2008 Apr 28;168(8):832-9.
doi: 10.1001/archinte.168.8.832.

Long-term effects of renin-angiotensin system-blocking therapy and a low blood pressure goal on progression of hypertensive chronic kidney disease in African Americans

Lawrence J Appel  1 , Jackson T Wright Jr, Tom Greene, John W Kusek, Julia B Lewis, Xuelei Wang, Michael S Lipkowitz, Keith C Norris, George L Bakris, Mahboob Rahman, Gabriel Contreras, Stephen G Rostand, Joel D Kopple, Francis B Gabbai, Gerald I Schulman, Jennifer J Gassman, Jeanne Charleston, Lawrence Y Agodoa; African American Study of Kidney Disease and Hypertension Collaborative Research Group
Collaborators, Affiliations
Randomized Controlled Trial

Long-term effects of renin-angiotensin system-blocking therapy and a low blood pressure goal on progression of hypertensive chronic kidney disease in African Americans

Lawrence J Appel et al. Arch Intern Med. .

Abstract

Background: Antihypertensive drugs that block the renin-angiotensin system (angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers) are recommended for patients with chronic kidney disease (CKD). A low blood pressure (BP) goal (BP, <130/80 mm Hg) is also recommended. The objective of this study was to determine the long-term effects of currently recommended BP therapy in 1094 African Americans with hypertensive CKD.

Methods: Multicenter cohort study following a randomized trial. Participants were 1094 African Americans with hypertensive renal disease (glomerular filtration rate, 20-65 mL/min/1.73 m2). Following a 3x2-factorial trial (1995-2001) that tested 3 drugs used as initial antihypertensive therapy (ACEIs, calcium channel blockers, and beta-blockers) and 2 levels of BP control (usual and low), we conducted a cohort study (2002-2007) in which participants were treated with ACEIs to a BP lower than 130/80 mm Hg. The outcome measures were a composite of doubling of the serum creatinine level, end-stage renal disease, or death.

Results: During each year of the cohort study, the annual use of an ACEI or an angiotensin receptor blocker ranged from 83.7% to 89.0% (vs 38.5% to 49.8% during the trial). The mean BP in the cohort study was 133/78 mm Hg (vs 136/82 mm Hg in the trial). Overall, 567 participants experienced the primary outcome; the 10-year cumulative incidence rate was 53.9%. Of 576 participants with at least 7 years of follow-up, 33.5% experienced a slow decline in kidney function (mean annual decline in the estimated glomerular filtration rate, <1 mL/min/1.73 m2).

Conclusion: Despite the benefits of renin-angiotensin system-blocking therapy on CKD progression, most African Americans with hypertensive CKD who are treated with currently recommended BP therapy continue to progress during the long term.

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Figures

Figure 1
Figure 1
Participant flow in the trial phase and the cohort study of the African American Study of Kidney Disease and Hypertension. ESRD indicates end-stage renal disease. *Doubling of the creatinine level from trial baseline was the first event. †Those individuals who experienced a doubling of their serum creatinine level in the trial phase were enrolled in the cohort study. However, for the present study they did not contribute follow-up time in the cohort study because the event occurred in the trial phase.
Figure 2
Figure 2
Cumulative incidence of renal outcome (doubling of the serum creatinine level from trial baseline or end-stage renal disease [ESRD]), death, and a renal outcome or death.
Figure 3
Figure 3
Cumulative incidence of composite outcome (doubling of the serum creatinine level from trial baseline, end-stage renal disease, or death) separately for those assigned to a low blood pressure (BP) goal and angiotensin-converting enzyme inhibitor (ACEI) therapy during the trial phase and the cohort study and for those assigned to the usual BP goal and non-ACEI therapies (β-blockers or calcium channel blockers) during the trial phase. All participants had at least 3 years of follow-up in the trial phase. The period between 3 and 6.5 years is a mixed period and corresponds to the trial phase for early enrollees and to the cohort study for late enrollees. The last 3.5 years (6.5–10 years) include cohort data only.
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References

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