Title: RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 3 GROUPS BY BASELINE GLOMERULAR FILT
1RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS
STRATIFIED INTO 3 GROUPS BY BASELINE GLOMERULAR
FILTRATION RATE (GFR)
2Introduction
- Hypertension is the second most common cause of
end-stage renal disease (ESRD) in the US - Hypertension is a key factor contributing to
progression of chronic kidney disease - Successful treatment of hypertension is important
in slowing down progression of renal disease
3Background
- In diabetic (DM) and nondiabetic (NDM)
hypertensive patients with established chronic
renal insufficiency and proteinuria, inhibition
of the renin angiotensin axis is suggested to be
superior to conventional therapy in slowing
decline in renal function - Few studies directly compared effects of
different classes of antihypertensive drug
therapy on decline in renal function in
hypertensive patients with mild reduction in
glomerular filtration rate (GFR).
4Overall Results Renal Outcomes
- In the ALLHAT study population as a whole, no
difference was noted in the risk of ESRD with
chlorthalidone compared to amlodipine and
lisinopril - Estimated GFR was higher at the end of the study
in patients randomized to amlodipine compared to
chlorthalidone.
5Objective
Post-hoc analysis of the ALLHAT study to
determine whether treatment with a calcium
channel blocker or an ACE inhibitor, each versus
a diuretic, lowers incidence of renal outcomes in
high risk hypertensive patients stratified by
baseline GFR.
6Baseline Characteristics Stratified By Estimated
GFR
Estimated (eGFR) (ml/min/1.73 m2) calculated by
simplified MDRD equation (Levey et al., J Am Soc
Nephrol 11, A 0828. 2000.) plt.05 compared with
normal GFR NOTE Within each GFR stratum, there
was no significant difference in these
characteristics between patients assigned to
amlodipine or lisinopril compared with patients
assigned to chlorthalidone.
7eGFR During the Course of the Study (Baseline
eGFR 90)
plt0.05 vs. Chlorthalidone Estimated GFR (eGFR)
calculated from the simplified MDRD equation
8eGFR During the Course of the Study (Baseline
eGFR 60-89)
plt0.05 vs. Chlorthalidone Estimated GFR (eGFR)
calculated from the simplified MDRD equation
9eGFR During the Course of the Study (Baseline
eGFR lt60)
plt0.05 vs. Chlorthalidone Estimated GFR (eGFR)
calculated from the simplified MDRD equation
10Evaluating Treatment Effects by Subgroup
Interaction Use subgroup estimates of treatment
effects No interaction Use estimate of
treatment effect in total population
11(No Transcript)
12(No Transcript)
13(No Transcript)
14(No Transcript)
15(No Transcript)
16(No Transcript)
17End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline Diabetes Treatment
Amlodipine vs Chlorthalidone
18End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline GFR Treatment Amlodipine
vs Chlorthalidone
19End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline GFR Treatment Diabetic
Participants Amlodipine vs Chlorthalidone
20End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline Diabetes Treatment
Lisinopril vs Chlorthalidone
21End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline GFR Treatment Lisinopril
vs Chlorthalidone
22End Stage Renal Disease or 50 or Greater Decline
in GFR by Baseline GFR Treatment Diabetic
Participants Lisinopril vs Chlorthalidone
23Summary
- The overall study results of no difference in
ESRD and the composite (ESRD/50 decline in GFR)
for the lisinopril vs. chlorthalidone and
amlodipine vs. chlorthalidone comparisons was
consistent across diabetes, GFR, and diabetes-GFR
subgroups.
24Discussion
- High risk hypertensive patients are at higher
risk for CVD than ESRD - Risk of ESRD is higher in diabetic participants,
and those with reduced GFR at baseline - Since risk of CVD is much higher than risk for
ESRD in CKD patients, choices of therapy need to
be guided by effects on CVD outcomes
25Strengths Limitations
- Strength -
- The number of patients with moderate reduction in
GFR, and the number of patients developing ESRD
are higher in ALLHAT compared to any other renal
study, including AASK, RENAAL and IDNT - Limitation
- Proteinuria is an independent predictor of
decline in renal function. Information about
proteinuria was not available in ALLHAT
participants.
26Conclusion
- In high risk hypertensive patients with reduced
GFR, amlodipine and lisinopril are not superior
to chlorthalidone in reducing the rate of
development of ESRD and significant decrements in
GFR