AASK about Hypertension- JOURNAL CLUB
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Transcript of AASK about Hypertension- JOURNAL CLUB
Journal Club
7-October-2010
NSLIJHS/Hofstra University
NKF: K/DOQI Hypertension is both a and a
of CKD: more than 50% to 75% of patients with CKD have blood
pressure >140/90 mm Hg but…
cause complication
NKF: K/DOQI Goals of Antihypertensive Therapy:
1. Lower Blood Pressure to:1. Reduce the Risk for CVD
2. Slow Progression of CKD
BUT, How do we KNOW what the target is???
Current Guidelines JNC 7 (2003)
Where did “130/80” Come From?
130/80
History of Blood Pressure Reverend Stephen Hales
1711: First History of Blood Pressure Measurement
Inserted a glass tube into the artery of a horse and watched as the column of blood fluctuated
The Horse Died Everytime, as the artery used was the carotid artery
History of Blood Pressure 1847-1856: First measurement in human
Faivre, measured during a limb amputation (i.e., still not exactly clinically feasible for
screening…) 1855: First Human Non-invasive
measurement Karl Vierordt used an inflatable cuff with enough
pressure to obliterate the arterial pulse Tall, bulky machine…
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1543468/pdf/procrsmed00089-0065.pdf
History of Blood Pressure 1882: Robert Ellis Dudgeon
Simplified the sphygmograph Became standard from the US Navy
1896: Riva-Rocci Developed the standard mercury
sphygmomanometer 1901: Harvey Cushing
Brought it to the US 1905: Nikoli Korotkoff
Identified diastolic blood pressure by ausculatation
(previously done only by palpation, hence the Korotkoff sounds)
BP Guidelines From 1905 to Mid-Twentieth Century…
SBP
Diastolic Blood Pressure became the “fad”…until JNC 7 came along
Current Guidelines The Urban Legend…
Is often told that “140/90” was chosen by insurance companies who noticed that people with BP lower than this lived longer than others…
JNC offers more sound clinical evidence…
JNC-7 Guidelines
Age-specific relevance of usual pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
The Lancet 360:9349, Dec 14, 2002; Pages 1903-1913
Is THE citation for JNC-7 “Blood Pressure and Cardiovascular Risk”
Age-specific relevance…
One million adults 61 prospective observational studies
During 12·7 million person-years at risk 56 000 vascular deaths
12 000 stroke 34000 IHD 10000 “other” vascular
66 000 other deaths at ages 40–89 years Meta-analyses:
Age-Specific Risk… Major Limitation?
Epidemiologic Observation Lack of Therapeutic Intervention
Early Studies Evaluating Hypertension treatment excluded patients with CKD
ACCORD:Action to Control Cardiovascular Risk in Diabetes blood pressure
4377 Patients DM 2 +
CVD, or 2 additional CV risk factors
Assigned to either: Intensive BP control Conventional BP control
ACCORD:Action to Control Cardiovascular Risk in Diabetes blood pressure
Intensive BP Control Standard BP Control
SBP < 120 mmHg SBP < 140 mmHgAchieved: 119 mmHg 133 mmHg
Follow Up: No Difference: All Cause Mortality
4.7 years No Difference: Annual Rate of Nonfatal MI, stroke or death from CVD
Decreased risk of total and non-fatal stroke
Increased risk anti-hypertensive adverse effects
ACCORD:Action to Control Cardiovascular Risk in Diabetes blood pressure
Intensive Control: Rx Side Effects: 3.3 vs.
1.3% Hypotension Syncope Bradycardia Arrhythmia Hyperkalemia Angioedema Renal Failure
The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of
Chronic Renal Disease
Saulo Klahr, Andrew S. Levey, Gerald J. Beck, Arlene W. Caggiula, Lawrence Hunsicker, John W. Kusek, and Gary Striker for the Modification of Diet in Renal Disease Study
GroupN Engl J Med 1994; 330:877-884
MDRD Trial
MDRD Study Hypothesis: “Lower” BP will decrease the
decline in GFR Randomized Trial
840 Patients with CKD GFR 25-55 cc/min (Study A) GFR 13-24 cc/min (Study B)
Treatment Goal: MAP < 92 mmHg (125/75) or MAP < 107 mmHg (140/90)
MDRD Design:
Comparison of 2 Groups:
“Usual” BP ControlTarget MAP <107 mmHg
Low BP ControlTarget MAP <92 mmHg
Achieved MAP 96mmHg Achieved MAP 91mmHg
130/80 125/75
Copyright ©2010 American Society of Nephrology
GFR 25-55 cc/min (Study A) GFR 13-24 cc/min (Study B)
Results of MDRD
MDRD: Long Term Follow Up
10 years later… 32% reduction in end-stage renal-disease
(ESRD) risk for patients randomized to the low BP arm
Limitations: Lack of blood-pressure measurements for the final
seven years Higher rate of usage of ACE-I in low BP arm
REIN-2 StudyRenoprotection In Patients with Nondiabetic Chronic Renal Disease
Renoprotective Evaluated effect of BP control in nondiabetic
CKD Aim: assess the effect of “intense” versus
conventional blood-pressure control on progression to end-stage renal disease
REIN-2 Randomized Trial
338 patients receiving ramipril (2.5-5mg/day)
Primary Endpoint Time to ESRD over 36 months of follow up
Conventional GroupGoal: DBP<90 mmHg
Achieved: 134/82
Intensive GroupGoal: <130/80
Achieved: 130/80Add-On Therapy:
Felodipine 5-10mg/day
REIN-2 Reported no decrease in ESRD events
Concluded: No additional benefit from further blood-pressure reduction by felodipine added to therapy with ACE-I
Terminated at 19months for “futility”
AASK:African-American Study of Kidney Disease and Hypertension
Hypothesis: Intensive Blood Pressure Control may retard the
progression of Chronic Kidney Disease
AASK:African-American Study of Kidney Disease and Hypertension
Objective: To compare the effects of 2 levels of BP control
and 3 antihypertensive drug classes of GFR decline in hypertension
AASK: Study Design Patient Population:
Ages 18-70 years Black Hypertensive Kidney Disease
DBP >95 mmHg GFR 20-65 mL/min by labeled iothalamate
clearance
Exclusion Criteria Diabetes
Fasting glucose >140 mg/dL Random Glucose >200 mg/dL Drug therapy for diabetes
Urinary Tp:Cr > 2.5 Malignant Hypertension
Defined by each center “Serious Systemic Disease” Heart Failure Specific Indication for, or contraindication to a study drug
Outcomes Primary: Progression of CKD
Doubling of sCr Diagnosis of ESRD
Initiation of RRT Transplant
Death
Study Design:Two Phases
Initial Trial Phase 1995-1998 3 x 2 Design
Cohort Phase April 2002 Included Surviving
patients without ESRD All Switched to Ramipril Conventional Control
140/90 until 130/80 in 2004
AASK:African-American Study of Kidney Disease and Hypertension
Effect of Blood Pressure Lowering and Antihypertensive Drug Class on Progression
of Hypertensive Kidney Disease Results From the AASK Trial
Jackson T. Wright, Jr, MD, PhD; George Bakris, MD; Tom Greene, PhD; Larry Y. Agodoa, MD; Lawrence J. Appel, MD, MPH; Jeanne Charleston, RN; DeAnna
Cheek, MD; Janice G. Douglas-Baltimore, MD; Jennifer Gassman, PhD; Richard Glassock, MD; Lee Hebert, MD; Kenneth Jamerson, MD; Julia Lewis, MD; Robert A. Phillips, MD, PhD; Robert D. Toto, MD; John P. Middleton, MD; Stephen G. Rostand, MD; for the African American Study of Kidney Disease and Hypertension Study
Group
JAMA. 2002;288:2421-2431.
Copyright restrictions may apply.
Wright, J. T. et al. JAMA 2002;288:2421-2431.
Participant Recruitment and Follow-up Flow Diagram
2:2:1 Ratio used for CCB
Initial PhaseFeb 1995 – Sept 1998
N = 1094
Intensive Group
MAP: 92 mmHg
Standard Control Group
MAP: 102 - 107 mmHg
Ramipril
AmlodipineMetoprolol
Ramipril
Metoprolol Amlodipine
Furosemide
Doxazosin
Clonidine
Hydralazine
Minoxidil
AASK:African-American Study of Kidney Disease and Hypertension
Measurements Blood Pressure
3 Consecutive seated BP measurements Mean of second two BP recorded
GFR estimation I125 iothalamate
Twice at baseline Once at 3, 6, and Q6 months thereafter
Proteinuria Urinary Tp:Cr Q6months
AASK:African-American Study of Kidney Disease and Hypertension
Outcome: Slope of decline of GFR
Secondary Composite Outcome: Reduction in GFR by 50% Proteinuria ESRD Death
AASK:African-American Study of Kidney Disease and Hypertension
Interruptions: September 2000:
Termination of Amlodipine arm of trial Data censored after 3 years
Copyright restrictions may apply.
Wright, J. T. et al. JAMA 2002;288:2421-2431.
Mean Change in Glomerular Filtration Rate by Randomized Group
Copyright restrictions may apply.
Wright, J. T. et al. JAMA 2002;288:2421-2431.
Mean Change in Glomerular Filtration Rate by Randomized Group for Proteinuria Subgroups
Copyright restrictions may apply.
Wright, J. T. et al. JAMA 2002;288:2421-2431.
Percentage Changes in Proteinuria by Randomized Group
Trial Phase
AASK:African-American Study of Kidney Disease and Hypertension
Cohort Phase Published NEJM 2010 Follow up of Trial Phase Followed patients from
Transition Phase Cohort Phase
Cohort Phase Initiated April 2002
Patients who had not progressed to ESRD invited to participate
All Patients received Ramipril Common target BP:
<140/90 from 2002-2004 <130/80 from 2004 to completion
Cohort Phase Outcomes
Progression of CKD Doubling of creatinine ESRD Death
Monitoring sCr measured Q6months
Conclusions of AASK:Trial Phase In the comparison of target BP:
MAP of 102-107 versus <92 mmHg:
In the comparison of class of antihypertensive:
NO Difference in rate of decline of GFR
ACE-I may be more effective than B-blockers in slowing GFR decline
However… Average rate of decline of GFR in both BP
treatment groups was 2mL/min/year
Similar to previous trial of Hypertensive CKD
Cohort Phase Conclusions: After follow up of 8.8-12.2 years:
“Intensive” BP control had no effect on CKD progression
There MAY be differential effects on patients with more severe proteinuria
Other Endpoints… ???Effect in patients with significant
proteinuria
Final Thought… Lower BP goals may be protective in
patients with significant proteinuria
Lower BP targets did not increase adverse effects such as ischemic heart disease or ischemic stroke.