Aldosterone Breakthrough During Diovan, Tekturna, and Combination Therapy in Patients With Proteinuric Kidney Disease - Full Text View

Purpose

Primary Hypothesis: Aldosterone breakthrough will occur at a far lower frequency during renin inhibition (0-10% over 9 months), alone or in combination with an ARB, compared to conventional ARB therapy (35-45% over 9 months). The investigators hypothesize that aldosterone breakthrough occurs due to accumulation of active precursor substances, most notably angiotensin II, produced in response to conventional RAAS blockade with ACEinhibitors and ARBs. The investigators believe that direct renin inhibition (DRI) should minimize this accumulation and therefore significantly lower or possibly eliminate the breakthrough effect.

Interruption of the renin-angiotensin-aldosterone system (RAAS) with angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs), alone and in combination, has become a leading therapy to slow the progression of chronic heart and kidney disease. Both types of drugs inhibit the formation of aldosterone, a hormone, which has been shown to have harmful effects on patients with chronic heart and kidney disorders. This treatment is effective but not perfect since, even after an initial improvement, many patients become worse over the long term. This may be due to an unexpected increase in aldosterone, a phenomenon called "aldosterone breakthrough."

The purpose of this study is to find out whether the use of a direct renin inhibitor (DRI) alone, or in combination with an angiotensin receptor blocker (ARB), will lessen the occurrence of aldosterone breakthrough since direct renin inhibitors inhibit the formation of aldosterone at a very early step. This study will compare the effectiveness of adding Diovan (valsartan) or Tekturna (aliskiren) or a combination of Diovan and Tekturna to the usual antihypertensive treatment. The investigators will follow blood pressure, aldosterone levels, and urinary protein levels over 9 months to evaluate which of these therapies is most effective for treating hypertension in patients with proteinuric kidney disease.

Condition	Intervention	Phase
Proteinuric Kidney Disease Diabetic Nephropathy Hypertensive Nephrosclerosis IgA Nephropathy Focal Segmental Glomerulosclerosis Glomerulopathy (Obesity-associated) Glomerulonephritis, Membranous	Drug: Aliskiren Drug: Valsartan	Phase 4


Study Type:	Interventional
Study Design:	Allocation: Randomized Intervention Model: Parallel Assignment Masking: Open Label Primary Purpose: Treatment
Official Title:	Aldosterone Breakthrough During Diovan (Valsartan), Tekturna (Aliskiren), and Combination (Valsartan+Aliskiren) Anti-hypertensive Therapy in Patients With Proteinuric Kidney Disease

Resource links provided by NLM:

MedlinePlus related topics: Kidney Diseases

Drug Information available for: Aldosterone Valsartan Aliskiren

Genetic and Rare Diseases Information Center resources: IgA Nephropathy Glomerulonephritis Membranous Nephropathy Focal Segmental Glomerulosclerosis Nephrosclerosis

U.S. FDA Resources

Further study details as provided by Pietro Canetta, MD, Columbia University:

Primary Outcome Measures:

Cumulative Incidence of Aldosterone Breakthrough in Subjects Who Completed the 9-month Study Protocol. [ Time Frame: 9 months ]
The primary outcome of this study is the 9-month cumulative incidence of aldosterone breakthrough, defined as a sustained increase in 24-hour urine aldosterone above baseline, in each treatment arm.

Secondary Outcome Measures:

Serum Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline, 3-, 6-, and 9-months ]
Mean serum aldosterone at baseline, 3-, 6-, and 9-months.
Urine Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline, 3-, 6-, and 9-months ]
Mean urine aldosterone at baseline, 3-, 6-, and 9-months.
Serum Potassium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline, 3-, 6-, and 9-months ]
Mean serum potassium at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Mean 24-hour Urine Sodium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline, 3-, 6-, and 9-months ]
Mean 24-hour urine sodium (mmol/day) at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Pre- and Post-treatment Blood Pressure in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) blood pressure for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Creatinine in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) serum creatinine for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Potassium in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) serum potassium for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-hour Urine Protein in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) 24-hour urine protein for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-hour Urine Sodium in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) 24-hour urine sodium for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-urine Aldosterone in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) 24-hour urine aldosterone for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Aldosterone in Subjects With and Without Aldosterone Breakthrough. [ Time Frame: Baseline and Final (9 month) ]
Compares baseline and final (9 month) serum aldosterone for subjects with and without aldosterone breakthrough


Enrollment:	46
Study Start Date:	September 2009
Study Completion Date:	December 2012
Primary Completion Date:	January 2012 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Active Comparator: Tekturna Tekturna (Aliskiren), a direct renin inhibitor (DRI) 300 mg by mouth once daily for 9 months	Drug: Aliskiren Other Name: Tekturna
Active Comparator: Diovan Diovan (Valsartan), an angiotensin receptor blocker (ARB) 320 mg by mouth once daily for 9 months	Drug: Valsartan Other Name: Diovan
Active Comparator: Tekturna & Diovan Tekturna (Aliskiren), a direct renin inhibitor (DRI) 150 mg by mouth once daily & Diovan (Valsartan), an angiotensin receptor (ARB) 160 mg by mouth once daily for 9 months	Drug: Aliskiren Other Name: Tekturna Drug: Valsartan Other Name: Diovan

Detailed Description:

This is a randomized, open-label, three-arm study comparing Diovan (valsartan, an ARB), Tekturna (aliskiren, a DRI), and the combination of valsartan + aliskiren (i.e. ARB + DRI). One hundred twenty subjects (40 per arm) will be treated with Tekturna, Diovan, or a combination of both drugs for 9 months on top of their usual antihypertensive treatment. Changes in urinary aldosterone excretion will be monitored during therapy to measure the incidence of aldosterone breakthrough, defined as any sustained positive change from baseline urinary aldosterone excretion by the completion of the 9-month study period. This frequency measure will be compared during ARB, DRI, and ARB + DRI therapy. Changes in urinary protein excretion will also be monitored alongside the urinary aldosterone levels to determine whether aldosterone breakthrough is associated with refractory proteinuria. This is an innovative study that will be the first to (1) examine aldosterone breakthrough during DRI therapy, and (2) explore whether addition of a DRI to an ARB protects against aldosterone breakthrough. In addition, this will be the first study to examine whether DRI therapy (alone or in combination with ARB) is effective therapy for hypertension in patients with non-diabetic proteinuric kidney disease.

Eligibility


Ages Eligible for Study:	18 Years and older (Adult, Senior)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

Proteinuria > 300 mg/day
Normal to mildly reduced kidney function (eGFR > 45 ml/min/1.73m2)
Systolic blood pressure >130 mm Hg
Diastolic blood pressure >70 mm Hg
Diagnoses of diabetic nephropathy, hypertensive nephrosclerosis, IgA nephropathy, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, membranous nephropathy, fibrillary glomerulonephritis, or obesity-associated glomerulopathy

Exclusion Criteria:

Concomitant use of cyclosporine (which can interact with aliskiren)
Inability to undergo 6 week washout period if already on RAAS-blocking drug(s) (includes renin inhibitor, ACE-inhibitor, ARB, and mineralocorticoid receptor blocker)
eGFR < 45 ml/min/1.73m2
Urine protein excretion < 300 mg/day
Serum K > 5.0 mEq/l
Systolic blood pressure > 170 mm Hg or < 130 mm Hg after washout period
Diastolic blood pressure > 110 mm Hg or < 70 mm Hg after washout period
Congestive heart failure NYHA class III and IV
History of any cardiovascular events (stroke, TIA, MI, unstable angina, CABG, PCI, CHF hospitalization) in 3 months prior to study visit 1
2nd or 3rd degree heart block without a pacemaker or other uncontrolled arrhythmia
Clinically significant valvular disease
Known renal artery stenosis
Any surgical or medical condition that might significantly alter the pharmacokinetics of the study drugs (n.b. bariatric surgery > 6 months prior to visit 1 is not an exclusion)
History or evidence of drug or alcohol abuse within the last 12 months
Any concurrent life threatening condition with a life expectancy less than 2 years
Pregnant or nursing (lactating) women
Women of child-bearing potential unless postmenopausal for at least 1 year, surgically sterile, or using effective methods of contraception as defined by local health authorities

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01129557

Locations


United States, New York
Columbia University Medical Center
New York, New York, United States, 10032

Sponsors and Collaborators

Columbia University

Novartis Pharmaceuticals

Investigators


Principal Investigator:	Pietro Canetta, MD	Columbia University

More Information

Publications:

Bomback AS, Rekhtman Y, Klemmer PJ, Canetta PA, Radhakrishnan J, Appel GB. Aldosterone breakthrough during aliskiren, valsartan, and combination (aliskiren + valsartan) therapy. J Am Soc Hypertens. 2012 Sep-Oct;6(5):338-45. doi: 10.1016/j.jash.2012.07.003.


Responsible Party:	Pietro Canetta, MD, Instructor in Clinical Medicine, Nephrology, Columbia University
ClinicalTrials.gov Identifier:	NCT01129557 History of Changes
Other Study ID Numbers:	AAAE0863 #IIRP-906 ( Other Identifier: Novartis )
Study First Received:	May 21, 2010
Results First Received:	February 10, 2014
Last Updated:	April 16, 2014

Additional relevant MeSH terms:


Kidney Diseases Diabetic Nephropathies Glomerulonephritis, IGA Glomerulonephritis Glomerulosclerosis, Focal Segmental Glomerulonephritis, Membranous Nephrosclerosis Urologic Diseases Diabetes Complications Diabetes Mellitus	Endocrine System Diseases Nephritis Autoimmune Diseases Immune System Diseases Valsartan Antihypertensive Agents Angiotensin II Type 1 Receptor Blockers Angiotensin Receptor Antagonists Molecular Mechanisms of Pharmacological Action

ClinicalTrials.gov processed this record on July 28, 2017