Current Hypertension Reports

, Volume 7, Issue 6, pp 474–483 | Cite as

Does ALLHAT change the management of hypertension in chronic kidney disease?

  • Martin MacKinnon
  • Frans H. H. Leenen
  • Marcel Ruzicka


ALLHAT was designed to test the hypothesis that “newer” antihypertensive agents are superior to a thiazide diuretic for cardiovascular outcomes. Pre-specified secondary outcomes included the development of endstage renal disease (ESRD) (dialysis, renal transplantation, or death from renal cause) and estimated glomerular filtration rate (GFR). ALLHAT showed no differences in the overall rates of ESRD between those randomized to chlorthalidone, amlodipine, or lisinopril. It showed a slower rate of decline of GFR among those randomized to amlodipine in both diabetics and nondiabetics, and in the composite end point (ESRD or ≥ 50% decline in GFR) in nondiabetics. The results of ALLHAT are consistent with other studies that, for the patient population studied (presumably largely nonalbuminuric patients with and without diabetes), at systolic BP < 130 mm Hg, there is no difference for renal outcomes between a thiazide diuretic, dihydropyridine calcium channel blocker, and ACEI-initiated treatment for 5 to 6 years of follow-up. These results suggest that BP control per se remains the most important objective for this patient population.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Levey AS, Coresh J, Balk E, et al.: National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003, 139:137–147.PubMedGoogle Scholar
  2. 2.
    Buckalew VM Jr, Berg RL, Wang SR, et al.: Prevalence of hypertension in 1795 subjects with chronic renal disease: the modification of diet in renal disease study baseline cohort. Modification of Diet in Renal Disease Study Group. Am J Kidney Dis 1996, 28:811–821.PubMedGoogle Scholar
  3. 3.
    Griffin KA, Abu-Amarah I, Picken M, Bidani AK: Renoprotection by ACE inhibition or aldosterone blockade is blood pressuredependent. Hypertension 2003, 41:201–206.PubMedCrossRefGoogle Scholar
  4. 4.
    Bidani AK, Griffin KA, Bakris G, Picken MM: Lack of evidence of blood pressure-independent protection by renin-angiotensin system blockade after renal ablation. Kidney Int 2000, 57:1651–1661.PubMedCrossRefGoogle Scholar
  5. 5.
    Bidani AK, Griffin KA, Picken M, Lansky DM: Continuous telemetric blood pressure monitoring and glomerular injury in the rat remnant kidney model. Am J Physiol 1993, 265:F391-F398.PubMedGoogle Scholar
  6. 6.
    Hsu C, McCulloch CE, Darbinian J, et al.: Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Arch Intern Med 2005, 165:923–928. This study provides the best observational evidence for hypertensioncaused renal disease.PubMedCrossRefGoogle Scholar
  7. 7.
    Sarnak MJ, Greene T, Wang X, et al.: The effect of a lower target blood pressure on the progression of kidney disease: longterm follow-up of the Modification of Diet in Renal Disease Study. Ann Intern Med 2005, 142:342–351. This study shows the importance of long-term follow-up for renal outcomes.PubMedGoogle Scholar
  8. 8.
    Lurbe E, Redon J, Kesani A, et al.: Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002, 347:797–805.PubMedCrossRefGoogle Scholar
  9. 9.
    Jafar TH, Schmid CH, Landa M, et al.: Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. The AIRPD Study Group. Ann Intern Med 2001, 135:73–78.PubMedGoogle Scholar
  10. 10.
    Bakris GL, Williams M, Dworkin L, et al.: Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis 2000, 36:646–661.PubMedGoogle Scholar
  11. 11.
    The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group: Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. JAMA 2002, 288:2981–2997.CrossRefGoogle Scholar
  12. 12.
    Wright JT Jr, Bakris G, Greene T, et al.: 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, 288:2421–2431. The randomized clinical trial testing hypothesis of “the lower the BP, the better" as well as "superiority” of blockers of the renin angiotensin system for renal outcomes in patients with hypertension-caused chronic kidney disease.PubMedCrossRefGoogle Scholar
  13. 13.
    Lewis EJ, Hunsicker LG, Clarke WR, et al.: Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001, 345:851–860.PubMedCrossRefGoogle Scholar
  14. 14.
    Brenner BM, Cooper ME, de Zeeuw D, et al.: Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001, 345:861–869.PubMedCrossRefGoogle Scholar
  15. 15.
    Asselbergs FW, Diercks GFH, Hillege HL, et al.: Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria. Circulation 2004, 110:2809–2816.PubMedCrossRefGoogle Scholar
  16. 16.
    Crook ED, Thallapureddy A, Migdal S, et al.: Lipid abnormalities and renal disease: Is dyslipidemia a predictor of progression of renal disease? Am J Med Sci 2003, 325:340–348.PubMedCrossRefGoogle Scholar
  17. 17.
    Wanner C, Quaschning T: Dyslipidemia and renal disease: pathogenesis and clinical consequences. Cur Opinion Nephrol Hypertens 2001, 10:195–201.CrossRefGoogle Scholar
  18. 18.
    Manttari M, Tiula E, Alikoski T, Manninen V: Effects of hypertension and dyslipidemia on the decline in renal function. Hypertension 1995, 26:670–675.PubMedGoogle Scholar
  19. 19.
    Klahr S, Levey AS, Beck GJ, et al.: 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, 330:877–884.PubMedCrossRefGoogle Scholar
  20. 20.
    Khan NA, McAlister FA, Lewanczuk RZ, et al.: The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II—Therapy. The Canadian Hypertension Education Program. Can J Cardiol 2005, 21:657–672.PubMedGoogle Scholar
  21. 21.
    Chobanian AV, Bakris GL, Black HR, et al.: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003, 289:2560–2572.PubMedCrossRefGoogle Scholar
  22. 22.
    Rahman M, Pressel MS, Davis BR, et al.: Renal outcomes in high-risk hypertensive patients treated with an angiotensinconverting enzyme inhibitor or a calcium channel blocker vs diuretic. The ALLHAT Collaborative Research Group. Arch Intern Med 2005, 165:1–10. Renal outcomes from ALLHAT based on diabetic status and GFR at baseline.CrossRefGoogle Scholar
  23. 23.
    USRDS: 2004 annual data report. Am J Kidney Dis 2005, 45:8–280.Google Scholar
  24. 24.
    Heptinstall RH: Essential hypertension. In Pathology of the Kidney, edn 4. Edited by Heptinstall RH. Boston: Little Brown; 1992:951–1028.Google Scholar
  25. 25.
    Baldwin DS, Neugarten J: Blood pressure control and progression of renal insufficiency. Contemp Issues Nephrol 1986, 14:81–110.Google Scholar
  26. 26.
    Neaton JD, Wentworth D: Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med 1992, 152:56–64.PubMedCrossRefGoogle Scholar
  27. 27.
    Brazy PC, Stead WW, Fitzwilliam JF: Progression of renal insufficiency: role of blood pressure. Kidney Int 1989, 35:670–674.PubMedGoogle Scholar
  28. 28.
    Hansson L, Zanchetti A, Carruthers SG, et al.: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) Randomised Trial. HOT Study Group. Lancet 1998, 351:1755–1762.PubMedCrossRefGoogle Scholar
  29. 29.
    Adler AI, Stratton IM, Neil HAW, et al.: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. UK Prospective Diabetes Study Group. BMJ 2000, 321:412–419.PubMedCrossRefGoogle Scholar
  30. 30.
    UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998, 317:703–713.Google Scholar
  31. 31.
    Schrier RW, Estacio RO, Esler A, Mehler P: Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002, 61:1086–1097.PubMedCrossRefGoogle Scholar
  32. 32.
    Estacio RO, Jeffers BW, Gifford N, Schrier RW: Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000, 23(Suppl 2):B54-B64.PubMedGoogle Scholar
  33. 33.
    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, 329:1456–1462.PubMedCrossRefGoogle Scholar
  34. 34.
    Parving HH, Lehnert H, Brochner-Mortensen J, et al.: The effect of irebesartan on development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001, 345:870–878.PubMedCrossRefGoogle Scholar
  35. 35.
    Ruggenenti P, Fassi A, Ilieva AP, et al.: Preventing microalbuminuria in type 2 diabetes. For the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators. N Engl J Med 2004, 351:1941–1951.PubMedCrossRefGoogle Scholar
  36. 36.
    Svensson P, de Faire U, Sleight P, et al.: Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy. Hypertension 2001, 38:E28-E32.PubMedGoogle Scholar
  37. 37.
    UK Prospective Diabetes Study Group: Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998, 317:713–720.Google Scholar
  38. 38.
    Poulsen PL, Hansen KW, Mogensen CE: Ambulatory blood pressure in transition from normo- to microalbuminuria: a longitudinal study in IDDM patients. Diabetes 1994, 43:1248–1253.PubMedCrossRefGoogle Scholar
  39. 39.
    Hansen HP, Rossing P, Tarnow L, et al.: Circadian rhythm of arterial blood pressure and albuminuria in diabetic nephropathy. Kidney Int 1996, 50:579–585.PubMedCrossRefGoogle Scholar
  40. 40.
    Pecis M, Azevedo MJ, Moraes RS, et al.: Autonomic dysfunction and urinary albumin excretion rate are associated with an abnormal blood pressure pattern in normotensive normoalbuminuric type 1 diabetic patients. Diabetes Care 2000, 23:989–993.PubMedCrossRefGoogle Scholar
  41. 41.
    Verdecchia P, Schillaci G, Gatteschi C, et al.: Blunted nocturnal fall in blood pressure in hypertensive women with future cardiovascular morbid events. Circulation 1993, 88:986–992.PubMedGoogle Scholar
  42. 42.
    Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The Sixth Report of the JNC on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997, 157:2413–2446.CrossRefGoogle Scholar
  43. 43.
    Whelton PK, Barzilay J, Cushman WC, et al.: For the ALLHAT Collaborative Research Group. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2005, 165:1–9.CrossRefGoogle Scholar
  44. 44.
    Opie LH: ACE inhibitors: specific agents. Pharmacokinetics. In Angiotensin-Converting Enzyme Inhibitors. Edited by Opie LH. New York: Wiley-Liss, Authors’ Publishing House; 1999:184–206.Google Scholar

Copyright information

© Current Science Inc 2005

Authors and Affiliations

  • Martin MacKinnon
    • 1
  • Frans H. H. Leenen
    • 1
  • Marcel Ruzicka
    • 1
  1. 1.Division of Nephrology and Kidney Research CentreThe Ottawa Hospital-Riverside CampusOttawaCanada

Personalised recommendations