Angiotensin-converting-enzyme (ACE) Inhibitors in Hemodialysis (ARCADIA)
|First Received Date ICMJE||September 25, 2009|
|Last Updated Date||May 30, 2016|
|Start Date ICMJE||May 2009|
|Primary Completion Date||April 2016 (final data collection date for primary outcome measure)|
|Current Primary Outcome Measures ICMJE
||The main outcome variable will be a combined end-point of cardiovascular death (including sudden death and cardiac arrest resuscitation) and myocardial infarction or non-fatal stroke. [ Time Frame: Baseline, 1st and 2nd year ] [ Designated as safety issue: Yes ]|
|Original Primary Outcome Measures ICMJE||Same as current|
|Change History||Complete list of historical versions of study NCT00985322 on ClinicalTrials.gov Archive Site|
|Current Secondary Outcome Measures ICMJE
||Single components of combined endpoint,myocardial or peripheral revascularizations,new onset paroxysmal,persistent or permanent or recurrence of atrial fibrillation,hospitalizations for chronic heart failure,and thrombosis of artero-venous fistula [ Time Frame: Baseline, 1st and 2nd year ] [ Designated as safety issue: Yes ]|
|Original Secondary Outcome Measures ICMJE||Same as current|
|Current Other Outcome Measures ICMJE||Not Provided|
|Original Other Outcome Measures ICMJE||Not Provided|
|Brief Title ICMJE||Angiotensin-converting-enzyme (ACE) Inhibitors in Hemodialysis|
|Official Title ICMJE||A Prospective, Randomized, Open Label, Blinded End-point (Probe) Trial to Evaluate Whether, at Comparable Blood Pressure Control, ACE Inhibitor Therapy More Effectively Than Non RAS Inhibitor Therapy Reduces CArdiovascular Morbidity and Mortality in Chronic DIAlysis Patients With Left Ventricular Hypertrophy and/or Arterial Hypertension (ARCADIA Study)|
Background: Angiotensin-converting-enzyme (ACE) inhibitors have a specific cardioprotective effect and, compared to treatment not directly interfering with the renin-angiotensin-system (RAS), significantly reduce cardiovascular (CV) mortality and morbidity in subjects with normal renal function.
Despite CV events are the leading cause of death in these patients, no adequately powered trial so far evaluated the specific cardioprotective effect of ACE inhibitors in this population.
Objectives: This prospective, randomized, open label, blinded end point (PROBE) trial is primarily aimed at evaluating whether, at comparable blood pressure (BP) control, ACE inhibitor as compared to non-RAS inhibitor therapy significantly reduces the incidence of a composite end point of CV death (including sudden death) and non-fatal myocardial infarction or stroke in 624 patients with arterial hypertension (pre-dialysis systolic/diastolic BP >140/90 mmHg or post-dialysis systolic/diastolic BP >130/80 mmHg or antihypertensive therapy) and/or echocardiography evidence of LVH (cardiac mass index >130 g/m2 for men and 100 g/m2 for women) who are on dialysis therapy since at least six months. Secondarily, the study will compare the incidence of single components of the primary outcome, new onset paroxysmal or persistent atrial fibrillation, thrombosis of the artero-venous fistula, new onset, progression or regression of LVH, changes in components of the metabolic syndrome, the safety profile of the two treatment regimens and their cost/effectiveness.
Methods: After 1 month wash-out period from previous RAS inhibitor therapy and a baseline evaluation of main clinical and laboratory parameters, patients will be randomized on a 1:1 basis to 2-year treatment with an ACE inhibitor or a BP lowering regiment not including RAS inhibitors. A balanced distribution according to centre, number of dialysis sessions per week (2 or 3), presence of diabetes (YES/NO), arterial hypertension (YES/NO), LVH (YES/NO) will be achieved by the minimization method. Treatment will be adjusted to achieve and maintain a target BP <140/90 mmHg (pre-dialysis) and a target BP <130/80 mmHg (post-dialysis) in both groups.
Expected results: ACE inhibitor compared to non-RAS inhibitor therapy is expected to reduce more effectively fatal and non-fatal CV events, prevent or limit progression or induce regression of LVH, improve some components of the metabolic syndrome, and reduce treatment costs for cardiovascular complications. These findings might help achieving more effective cardioprotection in people on chronic dialysis at lower costs.
Angiotensin converting enzyme (ACE) inhibitors have the broader effect of any drug in cardiovascular medicine, reducing the risk of death, myocardial infarction, stroke, diabetes, and renal impairment.A recent meta-analysis of 33,500 patients included in six randomized clinical trials and a pooled analysis of the Heart Outcomes Prevention Evaluation (HOPE), the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA, and the Prevention of Events with Angiotensin-Converting-Enzyme Inhibition (PEACE) trials showed that ACE inhibitors reduce mortality and cardiovascular events also in subjects with coronary artery disease but preserved left ventricular function. However, all the above studies excluded patients with advanced renal insufficiency or end stage renal disease (ESRD). Thus, whether ACE inhibitors may have a specific cardioprotective effect also in this typology of patients is still matter of investigation. This is an issue of major clinical relevance since CV disease is the primary cause of morbidity and mortality in the ESRD population and affects as many as 50-60% of ESRD patients.The burden of CV disease in this population is predicted to dramatically increase over the next few years because of the rapidly increasing number of patients requiring renal replacement therapy and the increasing prevalence of ESRD patients at increased cardiovascular risk because of older age, diabetes and hypertension.
Despite the excess CV risk, a consistent proportion of ESRD patients are not given ACE inhibitor therapy because of concern of hyperkalemia. Others, on the contrary, are treated on the basis of results of available trials. However, whether data in subjects without renal insufficiency can be generalized also to those with ESRD is unknown. This is an itchy point since dialysis patients might respond differently to therapies of proven benefits in non-ESRD patients. For instance, data from the German Diabetes and Dialysis study showed that, unlike in the general population, HmGCoA inhibitor therapy failed to decrease CV mortality in a hemodialysis population. Thus, ad hoc studies in the ESRD population are urgently needed. A recent trial, the Fosinopril in Dialysis (FOSIDIAL) study, tried to address this issue, but was clearly underpowered and results were inconclusive. However, evidence of a non significant trend to less cardiovascular events in the ACE inhibitor arm, suggests that ACE inhibitors might have a specific cardioprotective effect also in this population.
Thus, whether ACE inhibitor therapy more effectively than non-RAS inhibitor therapy reduces CV morbidity in high risk patients on chronic dialysis therapy is worth investigating in an adequately powered trial.
The broad aim of the study is to evaluate whether ACE inhibitor therapy reduces CV mortality and morbidity in high-risk ESRD patients with arterial hypertension and/or LVH who are on chronic hemodialysis therapy since >6 months.
This prospective, randomized, open label, blinded end point (PROBE) trial will include 624 hypertensive ESRD patients with echocardiography evidence of LVH who are on chronic hemodialysis since >6 months. After 1 month wash-out period from previous RAS inhibitor therapy and stratification for diabetes YES/NO, they will have a baseline evaluation of main clinical and laboratory parameters and will be randomized to 2-year treatment with an ACE inhibitor or a BP lowering regimen not including RAS inhibitors. Treatment will be adjusted to achieve and maintain a target BP <140/90 mmHg (pre-dialysis) and a target BP <130/80 mmHg (post-dialysis) in both groups.
|Study Type ICMJE||Interventional|
|Study Phase||Phase 3|
|Study Design ICMJE||Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Study Arm (s)||
|Publications *||Not Provided|
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Status ICMJE||Completed|
|Completion Date||April 2016|
|Primary Completion Date||April 2016 (final data collection date for primary outcome measure)|
|Eligibility Criteria ICMJE||
|Ages||18 Years to 80 Years (Adult, Senior)|
|Accepts Healthy Volunteers||No|
|Contacts ICMJE||Contact information is only displayed when the study is recruiting subjects|
|Listed Location Countries ICMJE||Italy|
|Removed Location Countries|
|NCT Number ICMJE||NCT00985322|
|Other Study ID Numbers ICMJE||ARCADIA, 2008-003529-17|
|Has Data Monitoring Committee||No|
|Plan to Share Data||Not Provided|
|IPD Description||Not Provided|
|Responsible Party||Mario Negri Institute for Pharmacological Research|
|Study Sponsor ICMJE||Mario Negri Institute for Pharmacological Research|
|Collaborators ICMJE||Agenzia Italiana del Farmaco|
|Information Provided By||Mario Negri Institute for Pharmacological Research|
|Verification Date||May 2016|
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP