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Chronic Kidney Disease (CKD) Clinical Trials: A Critical Appraisal

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Informing Clinical Practice in Nephrology

Abstract

For the last three decades, and since the publication of the “Hyperperfusion–Hyperfiltration” hypothesis by Brenner and his colleagues in Boston, USA [1], considerable research has focused on the understanding of the pathophysiology of chronic kidney disease (CKD). Numerous additional hypotheses and theories have been published, focusing on the key role of renal as well as extrarenal cells in the pathogenesis of progressive renal scarring and fibrosis and the consequent decline in kidney function witnessed in CKD. These have been followed by a slow transition from the preclinical world of laboratory investigations to the bedside with a number of key clinical trials.

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References

  1. Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med. 1982;307(11):652–9.

    Article  CAS  PubMed  Google Scholar 

  2. Khwaja A, El Kossi M, Floege J, El Nahas M. The management of CKD: a look into the future. Kidney Int. 2007;72:1316–23.

    Article  CAS  PubMed  Google Scholar 

  3. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO_BP_GL.pdf.

  4. Paul A, James MD, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–20. doi:10.1001/jama.2013.284427.

    Article  Google Scholar 

  5. Kusek JW, Coyne T, de Velasco A, Drabik MJ, Finlay RA, Gassman JJ, Kiefer S, Powers SN, Steinman TI. Recruitment experience in the full-scale phase of the Modification of Diet in Renal Disease Study. Control Clin Trials. 1993;14(6):538–57.

    Article  CAS  PubMed  Google Scholar 

  6. El Nahas AM, Coles GA. Dietary treatment of chronic renal failure: ten unanswered questions. Lancet. 1986;1(8481):597–600.

    Article  PubMed  Google Scholar 

  7. Locatelli F, Alberti D, Graziani G, Buccianti G, Redaelli B, Giangrande A. Prospective, randomised, multicentre trial of effect of protein restriction on progression of chronic renal insufficiency. Northern Italian Cooperative Study Group. Lancet. 1991;1(337):1299–304.

    Article  Google Scholar 

  8. Kaysen GA, Odabaei G. Dietary protein restriction and preservation of kidney function in chronic kidney disease. Blood Purif. 2013;35(1–3):22–5.

    Article  CAS  PubMed  Google Scholar 

  9. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  10. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329(20):1456–62.

    Article  CAS  PubMed  Google Scholar 

  11. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  12. Thomas MC, Tikellis C, Burns WC, Thallas V, Forbes JM, Cao Z, Osicka TM, Russo LM, Jerums G, Ghabrial H, Cooper ME, Kantharidis P. Reduced tubular cation transport in diabetes: prevented by ACE inhibition. Kidney Int. 2003;63(6):2152–61.

    Article  CAS  PubMed  Google Scholar 

  13. Thomas MC, Jerums G, Tsalamandris C, Macisaac R, Panagiotopoulos S, Cooper ME, MDNSG Study Group. Increased tubular organic ion clearance following chronic ACE inhibition in patients with type 1 diabetes. Kidney Int. 2005;67(6):2494–9.

    Article  PubMed  Google Scholar 

  14. Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia). Lancet. 1997;349(9069):1857–63.

    Google Scholar 

  15. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO_BP_GL.pdf.

  16. Paul A, James MD, et al. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–20. doi:10.1001/jama.2013.284427.

    Article  Google Scholar 

  17. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  18. Svensson P, de Faire U, Sleight P, Yusuf S, Ostergren J. Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy. Hypertension. 2001;38(6):E28–32.

    Article  CAS  PubMed  Google Scholar 

  19. http://www.bmj.com/content/334/7597/786.

  20. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  21. Zhang GH, Hou FF, Zhang X, Liu QF. Can angiotensin-converting enzyme inhibitor be used in chronic kidney disease patients with serum creatinine level greater than 266 micromol/L? Zhonghua Nei Ke Za Zhi. 2005;44(8):592–6.

    PubMed  Google Scholar 

  22. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  23. Wright Jr JT, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, Cheek D, Douglas-Baltimore JG, Gassman J, Glassock R, Hebert L, Jamerson K, Lewis J, Phillips RA, Toto RD, Middleton JP, Rostand SG, African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288(19):2421–31.

    Article  CAS  PubMed  Google Scholar 

  24. Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, Striker G. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330(13):877–84.

    Article  CAS  PubMed  Google Scholar 

  25. Appel LJ, Wright Jr JT, Greene T, Agodoa LY, Astor BC, Bakris GL, Cleveland WH, Charleston J, Contreras G, Faulkner ML, Gabbai FB, Gassman JJ, Hebert LA, Jamerson KA, Kopple JD, Kusek JW, Lash JP, Lea JP, Lewis JB, Lipkowitz MS, Massry SG, Miller ER, Norris K, Phillips RA, Pogue VA, Randall OS, Rostand SG, Smogorzewski MJ, Toto RD, Wang X, AASK Collaborative Research Group. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363(10):918–29.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  26. Praga M. Therapeutic measures in proteinuric nephropathy. Kidney Int Suppl. 2005;99:S137–41.

    Article  CAS  PubMed  Google Scholar 

  27. Agarwal R. Home and ambulatory blood pressure monitoring in chronic kidney disease. Curr Opin Nephrol Hypertens. 2009;18(6):507–12.

    Article  PubMed  Google Scholar 

  28. Angeli F, Reboldi G, Poltronieri C, Bartolini C, D’Ambrosio C, de Filippo V, Verdecchia P. Clinical utility of ambulatory blood pressure monitoring in the management of hypertension. Expert Rev Cardiovasc Ther. 2014;12:623–34.

    Article  CAS  PubMed  Google Scholar 

  29. Jamerson KA, Bakris GL, Weber MA. 24-hour ambulatory blood pressure in the ACCOMPLISH trial. N Engl J Med. 2010;363(1):98.

    Article  CAS  PubMed  Google Scholar 

  30. Clark EC, Nath KA, Hostetter MK, Hostetter TH. Role of ammonia in tubulointerstitial injury. Miner Electrolyte Metab. 1990;16(5):315–21.

    CAS  PubMed  Google Scholar 

  31. Łoniewski I, Wesson DE. Bicarbonate therapy for prevention of chronic kidney disease progression. Kidney Int. 2014;85(3):529–35.

    Article  PubMed  Google Scholar 

  32. Chen W, Abramowitz MK. Treatment of metabolic acidosis in patients with CKD. Am J Kidney Dis. 2014;63(2):311–7.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. http://www.bmj.com/content/334/7597/786.

  34. Krum H, Schlaich M, Whitbourn R, Sobotka PA, Sadowski J, Bartus K, Kapelak B, Walton A, Sievert H, Thambar S, Abraham WT, Esler M. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373(9671):1275–81.

    Article  PubMed  Google Scholar 

  35. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Böhm M, Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376(9756):1903–9.

    Article  PubMed  Google Scholar 

  36. Parati G, Ochoa JE, Bilo G. Renal sympathetic denervation and daily life blood pressure in resistant hypertension: simplicity or complexity? Circulation. 2013;128(4):315–7.

    Article  PubMed  Google Scholar 

  37. Pedrini MT, Levey AS, Lau J, Chalmers TC, Wang PH. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med. 1996;124(7):627–32.

    Article  CAS  PubMed  Google Scholar 

  38. Fouque D, Laville M. Low protein diets for chronic kidney disease in non diabetic adults. Cochrane Database Syst Rev. 2009;(3):CD001892.

    Google Scholar 

  39. Kaysen GA, Odabaei G. Dietary protein restriction and preservation of kidney function in chronic kidney disease. Blood Purif. 2013;35(1–3):22–5.

    Article  CAS  PubMed  Google Scholar 

  40. Piccoli GB, Ferraresi M, Deagostini MC, Vigotti FN, Consiglio V, Scognamiglio S, Moro I, Clari R, Fassio F, Biolcati M, Porpiglia F. Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Nephrol Dial Transplant. 2013;28(9):2295–305.

    Article  CAS  PubMed  Google Scholar 

  41. el Nahas AM, Coles GA. Dietary treatment of chronic renal failure: ten unanswered questions. Lancet. 1986;1(8481):597–600.

    Article  PubMed  Google Scholar 

  42. Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet. 1998;352(9136):1252–6.

    Article  CAS  PubMed  Google Scholar 

  43. Kent DM, Jafar TH, Hayward RA, Tighiouart H, Landa M, de Jong P, de Zeeuw D, Remuzzi G, Kamper AL, Levey AS. Progression risk, urinary protein excretion, and treatment effects of angiotensin-converting enzyme inhibitors in nondiabetic kidney disease. J Am Soc Nephrol. 2007;18(6):1959–65.

    Article  CAS  PubMed  Google Scholar 

  44. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO_BP_GL.pdf.

  45. Sharma P, Blackburn RC, Parke CL, McCullough K, Marks A, Black C. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease. Cochrane Database Syst Rev. 2011;(10):CD007751.

    Google Scholar 

  46. Blood Pressure Lowering Treatment Trialists’ Collaboration, Ninomiya T, Perkovic V, Turnbull F, Neal B, Barzi F, Cass A, Baigent C, Chalmers J, Li N, Woodward M, MacMahon S. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials. BMJ. 2013;347:f5680.

    Article  PubMed Central  Google Scholar 

  47. Bakris GL, Williams M, Dworkin L, Elliott WJ, Epstein M, Toto R, Tuttle K, Douglas J, Hsueh W, Sowers J. Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000;36(3):646–61.

    Article  CAS  PubMed  Google Scholar 

  48. Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, Striker G. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330(13):877–84.

    Article  CAS  PubMed  Google Scholar 

  49. Ruggenenti P, Perna A, Loriga G, Ganeva M, Ene-Iordache B, Turturro M, Lesti M, Perticucci E, Chakarski IN, Leonardis D, Garini G, Sessa A, Basile C, Alpa M, Scanziani R, Sorba G, Zoccali C, Remuzzi G, REIN-2 Study Group. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365(9463):939–46.

    Article  PubMed  Google Scholar 

  50. Wright Jr JT, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, Cheek D, Douglas-Baltimore JG, Gassman J, Glassock R, Hebert L, Jamerson K, Lewis J, Phillips RA, Toto RD, Middleton JP, Rostand SG, African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288(19):2421–31.

    Article  CAS  PubMed  Google Scholar 

  51. Khwaja A, El Kossi M, Floege J, El Nahas M. The management of CKD: a look into the future. Kidney Int. 2007;72(11):1316–23.

    Article  CAS  PubMed  Google Scholar 

  52. Tayek JA, Kalantar-Zadeh K. The extinguished BEACON of bardoxolone: not a Monday morning quarterback story. Am J Nephrol. 2013;37(3):208–11.

    Article  PubMed Central  PubMed  Google Scholar 

  53. Ruggenenti P, Gaspari F, Cannata A, Carrara F, Cella C, Ferrari S, Stucchi N, Prandini S, Ene-Iordache B, Diadei O, Perico N, Ondei P, Pisani A, Buongiorno E, Messa P, Dugo M, Remuzzi G, GFR-ADPKD Study Group. Measuring and estimating GFR and treatment effect in ADPKD patients: results and implications of a longitudinal cohort study. PLoS One. 2012;7(2):e32533.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  54. http://www.bmj.com/content/334/7597/786.

  55. Rosansky SJ, Glassock RJ. Is a decline in estimated GFR an appropriate surrogate end point for renoprotection drug trials? Kidney Int. 2014;85(4):723–7.

    Article  PubMed  Google Scholar 

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Acknowledgments

The author acknowledges the contribution made by Swami VJ, Okel J, and Bello AM to an initial version of this chapter.

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Correspondence to Meguid El Nahas MD, PhD, FRCP .

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El Nahas, M. (2015). Chronic Kidney Disease (CKD) Clinical Trials: A Critical Appraisal. In: El Kossi, M., Khwaja, A., El Nahas, M. (eds) Informing Clinical Practice in Nephrology. Springer, Cham. https://doi.org/10.1007/978-3-319-10292-4_5

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  • DOI: https://doi.org/10.1007/978-3-319-10292-4_5

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