Telmisartan Versus Losartan in Kidney Transplantation (COSTANT)

This study has been completed.
Sponsor:
Information provided by (Responsible Party):
Mario Negri Institute for Pharmacological Research
ClinicalTrials.gov Identifier:
NCT01224860
First received: October 19, 2010
Last updated: February 24, 2014
Last verified: February 2014
  Purpose

In renal transplant recipients, residual renal insufficiency combined to the effects of immunosuppressive therapy with steroids or calcineurin inhibitors may reduce insulin activity and may contribute to several of the abnormalities associated with the metabolic syndrome, such as hypertension, glucose intolerance and hyperlipidemia. In turn, insulin resistance, hypertension, hyperglycemia and dyslipidemia may importantly contribute to the excess cardiovascular risk of renal transplant patients (an excess comparable to that of diabetes subjects with over diabetic nephropathy)and may also accelerate progressive renal function deterioration and promote graft loss. Thus, amelioration of the insulin activity and of the related metabolic syndrome is a key component of treatments aimed to improve patient and graft survival in renal transplant recipients. Recently, drugs such as peroxisome proliferators-activated receptor-gamma activators, that ameliorate insulin sensitivity and metabolic syndrome, have become available.These agents, however, can provoke fluid retention, weight gain, edema and, in some cases, heart failure.

Recent studies showed that telmisartan, an angiotensin II type 1 receptor antagonist, in addition to block the angiotensin II type 1 - a key surface receptor involved in the regulation of blood pressure - may also activate peroxisome proliferators-activated receptor-gamma activators, thus improving some of the features of the metabolic syndrome. Thus telmisartan may substantially reduce the overall cardiovascular and renal risk of renal transplant recipients by ameliorating some of the modifiable components of the metabolic syndrome. On the other hand, telmisartan is devoid of the adverse effects of peroxisome proliferators-activated receptor-gamma activators such as fluid retention, and has therefore a remarkably better risk/benefit profile. Thus, whether telmisartan in addition to the beneficial effects of a reference angiotensin II type 1 receptor antagonist (such as losartan) may offer adjunctive advantages related to improved insulin sensitivity in renal transplant patients on chronic therapy with steroids and/or calcineurin inhibitors, is worth investigating.


Condition Intervention Phase
Renal Transplant
Drug: Telmisartan
Drug: Losartan
Phase 2

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Crossover Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: A Prospective, Randomized, Open Label Blinded End Point (Probe), Crossover Study to Compare the Effects of Telmisartan and Losartan on Metabolic Profile of Renal Transplant Patients

Resource links provided by NLM:


Further study details as provided by Mario Negri Institute for Pharmacological Research:

Primary Outcome Measures:
  • Insulin sensitivity. [ Time Frame: At baseline and then every four months. ] [ Designated as safety issue: No ]
    Glucose disposal rate as assessed by an euglycemic hyperinsulinemic clamp.

  • Insulin sensitivity. [ Time Frame: At 9 month. ] [ Designated as safety issue: No ]
    Glucose disposal rate as assessed by an euglycemic hyperinsulinemic clamp.


Secondary Outcome Measures:
  • Systemic variables. [ Time Frame: At baseline and then every four months. ] [ Designated as safety issue: No ]
    Sitting systolic/diastolic blood pressure, 24-h blood pressure profile.

  • Systemic variables. [ Time Frame: At 9 month. ] [ Designated as safety issue: No ]
    Sitting systolic/diastolic blood pressure, 24-h blood pressure profile.

  • Metabolic variables. [ Time Frame: At baseline and then every four months. ] [ Designated as safety issue: No ]
    Morning fasting blood glucose, Glucose tolerance test, Glicated hemoglobin, Morning fasting insulin, HOMA index, Lipid profile (total cholesterol, triglycerides, HDL, LDL, apolipoprotein A, B.

  • Metabolic variables. [ Time Frame: At 9 month. ] [ Designated as safety issue: No ]
    Morning fasting blood glucose, Glucose tolerance test, Glicated hemoglobin, Morning fasting insulin, HOMA index, Lipid profile (total cholesterol, triglycerides, HDL, LDL, apolipoprotein A, B.

  • Renal variables. [ Time Frame: At baseline and then every four months. ] [ Designated as safety issue: No ]
    UAE (as assessed by nephelometry in three consecutive overnight urine collections), GFR/RPF (as assessed by Iohexol and PAH plasma clearance, respectively), Albumin fractional clearance.

  • Renal variables. [ Time Frame: At 9 month. ] [ Designated as safety issue: No ]
    UAE (as assessed by nephelometry in three consecutive overnight urine collections), GFR/RPF (as assessed by Iohexol and PAH plasma clearance, respectively), Albumin fractional clearance.


Enrollment: 20
Study Start Date: January 2009
Study Completion Date: January 2014
Primary Completion Date: June 2013 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Telmisartan Drug: Telmisartan
One week 40 mg daily, followed by fifteen weeks treatment period with 80 mg daily.
Experimental: Losartan Drug: Losartan
One week 50 mg daily, followed by fifteen weeks treatment period with 100 mg daily.

Detailed Description:

BACKGROUND In renal transplant recipients, residual renal insufficiency combined to the effects of immunosuppressive therapy with steroids or calcineurin inhibitors may reduce insulin activity and may contribute to several of the abnormalities associated with the metabolic syndrome, such as hypertension, glucose intolerance and hyperlipidemia. In turn, insulin resistance, hypertension, hyperglycemia and dyslipidemia may importantly contribute to the excess cardiovascular risk of renal transplant patients (an excess comparable to that of diabetes subjects with over diabetic nephropathy)and may also accelerate progressive renal function deterioration and promote graft loss. Thus, amelioration of the insulin activity and of the related metabolic syndrome is a key component of treatments aimed to improve patient and graft survival in renal transplant recipients. Recently, drugs such as peroxisome proliferators-activated receptor-gamma activators, that ameliorate insulin sensitivity and metabolic syndrome, have become available. These agents, however, can provoke fluid retention, weight gain, edema and, in some cases, heart failure. Thus, the risk/benefit profile of peroxisome proliferators-activated receptor-gamma activators is still uncertain, in particular in renal transplant patients where the risks of therapy may overwhelm the potential benefits.

Recent studies showed that telmisartan, an angiotensin II type 1 receptor antagonist, in addition to block the angiotensin II type 1 - a key surface receptor involved in the regulation of blood pressure - may also activate PPAR-gamma, thus improving some of the features of the metabolic syndrome, such as hyperglycemia and dyslipidemia in people with hypertension and/or diabetes. Thus, in addition to control high blood pressure and to limit some of the adverse effects of angiotensin II, including target organ damage, graft fibrosis and cyclosporine (CsA) nephrotoxicity, telmisartan may also substantially reduce the overall cardiovascular and renal risk of renal transplant recipients by ameliorating some of the modifiable components of the metabolic syndrome, such as hypertension, glucose intolerance and hyperlipidemia. On the other hand, telmisartan is devoid of the adverse effects of peroxisome proliferators-activated receptor-gamma activators such as fluid retention, and has therefore a remarkably better risk/benefit profile. Thus, whether telmisartan in addition to the beneficial effects of a reference AII receptor antagonist (such as losartan) may offer adjunctive advantages related to improved insulin sensitivity in renal transplant patients on chronic therapy with steroids and/or calcineurin inhibitors, is worth investigating.

AIMS The primary aim is to compare the short-term effects of telmisartan and losartan on insulin sensitivity in kidney transplant recipients with stable renal function and concomitant treatment with steroids and/or calcineurin inhibitors.

DESIGN This will be a pilot, explorative study. On the basis of previous experimental evidence, a crossover study on 20 patients should have the power to detect a statistically significant difference in the effect on insulin activity between each treatment period as compared to baseline.

Patients will be randomised on a 1:1 basis to the sequence Telmisartan-Losartan or to sequence losartan-telmisartan.

  Eligibility

Ages Eligible for Study:   18 Years to 80 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Informed consent;
  • Age > 18 years;
  • Single renal transplant or dual marginal > 6 months duration;
  • Blood pressure >130/85 mmHg or need for anti-hypertensive therapy;
  • Stable renal function (changes in serum creatinine < 30%) and no acute rejection episodes in the last six months;
  • Stable (for at least six months) dual or triple immunosuppressive therapy including corticosteroids or calcineurin inhibitors;
  • Legal capacity.

Exclusion Criteria:

  • Vascular disease of the kidney;
  • Heart failure: NYHA classification class III-IV on ACE or AII inhibitor therapy;
  • Cerebral haemorrhage, stroke or TIA within three months prior to study enrolment;
  • Myocardial infarction within three months prior to study enrolment;
  • Unstable angina pectoris;
  • Severe hepatic disease;
  • Pregnancy or women of child-bearing potential without following a scientifically accepted form of contraception;
  • Overt diabetes or concomitant treatment with oral antidiabetic agents and/or insulin;
  • Specific clinical indication (other than arterial hypertension) to be treated with ACE inhibitors or AII receptor antagonists;
  • Specific contraindications or history of hypersensitivity to the study drugs, glitazones, ACE inhibitors or AII receptor antagonists;
  • Participation to other clinical trials over the last three months;
  • Legal incapacity;
  • Previous diagnosis of: intellectual disability/mental retardation, dementia, schizophrenia.
  Contacts and Locations
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Please refer to this study by its ClinicalTrials.gov identifier: NCT01224860

Locations
Italy
Mario negri Institute - Clinical Research Center for Rare Diseases
Ranica, Bergamo, Italy, 24020
Sponsors and Collaborators
Mario Negri Institute for Pharmacological Research
  More Information

No publications provided

Responsible Party: Mario Negri Institute for Pharmacological Research
ClinicalTrials.gov Identifier: NCT01224860     History of Changes
Other Study ID Numbers: COSTANT, 2008-000822-38
Study First Received: October 19, 2010
Last Updated: February 24, 2014
Health Authority: Italy: Ministry of Health

Keywords provided by Mario Negri Institute for Pharmacological Research:
Telmisartan
Losartan
Renal transplant

Additional relevant MeSH terms:
Losartan
Telmisartan
Anti-Arrhythmia Agents
Cardiovascular Agents
Therapeutic Uses
Pharmacologic Actions
Antihypertensive Agents
Angiotensin II Type 1 Receptor Blockers
Angiotensin Receptor Antagonists
Molecular Mechanisms of Pharmacological Action

ClinicalTrials.gov processed this record on August 19, 2014