Effect of Blood Pressure Lowering and Antihypertensive Drug Class on Progression of Hypertensive Kidney DiseaseResults From the AASK Trial
Top Cited Papers
- 20 November 2002
- journal article
- clinical trial
- Published by American Medical Association (AMA) in JAMA
- Vol. 288 (19), 2421-2431
- https://doi.org/10.1001/jama.288.19.2421
Abstract
Context Hypertension is a leading cause of end-stage renal disease (ESRD) in the United States, with no known treatment to prevent progressive declines leading to ESRD. Objective To compare the effects of 2 levels of blood pressure (BP) control and 3 antihypertensive drug classes on glomerular filtration rate (GFR) decline in hypertension. Design Randomized 3 × 2 factorial trial with enrollment from February 1995 to September 1998. Setting and Participants A total of 1094 African Americans aged 18 to 70 years with hypertensive renal disease (GFR, 20-65 mL/min per 1.73 m2) were recruited from 21 clinical centers throughout the United States and followed up for 3 to 6.4 years. Interventions Participants were randomly assigned to 1 of 2 mean arterial pressure goals, 102 to 107 mm Hg (usual; n = 554) or 92 mm Hg or less (lower; n = 540), and to initial treatment with either a β-blocker (metoprolol 50-200 mg/d; n = 441), an angiotensin-converting enzyme inhibitor (ramipril 2.5-10 mg/d; n = 436) or a dihydropyridine calcium channel blocker, (amlodipine 5-10 mg/d; n = 217). Open-label agents were added to achieve the assigned BP goals. Main Outcome Measures Rate of change in GFR (GFR slope); clinical composite outcome of reduction in GFR by 50% or more (or ≥25 mL/min per 1.73 m2) from baseline, ESRD, or death. Three primary treatment comparisons were specified: lower vs usual BP goal; ramipril vs metoprolol; and amlodipine vs metoprolol. Results Achieved BP averaged (SD) 128/78 (12/8) mm Hg in the lower BP group and 141/85 (12/7) mm Hg in the usual BP group. The mean (SE) GFR slope from baseline through 4 years did not differ significantly between the lower BP group (−2.21 [0.17] mL/min per 1.73 m2 per year) and the usual BP group (−1.95 [0.17] mL/min per 1.73 m2 per year; P = .24), and the lower BP goal did not significantly reduce the rate of the clinical composite outcome (risk reduction for lower BP group = 2%; 95% confidence interval [CI], −22% to 21%; P = .85). None of the drug group comparisons showed consistent significant differences in the GFR slope. However, compared with the metoprolol and amlodipine groups, the ramipril group manifested risk reductions in the clinical composite outcome of 22% (95% CI, 1%-38%; P = .04) and 38% (95% CI, 14%-56%; P = .004), respectively. There was no significant difference in the clinical composite outcome between the amlodipine and metoprolol groups. Conclusions No additional benefit of slowing progression of hypertensive nephrosclerosis was observed with the lower BP goal. Angiotensin-converting enzyme inhibitors appear to be more effective than β-blockers or dihydropyridine calcium channel blockers in slowing GFR decline.Keywords
This publication has 25 references indexed in Scilit:
- Racial differences in response to therapy for heart failure: Analysis of the vasodilator-heart failure trialsJournal of Cardiac Failure, 1999
- Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuriaThe Lancet, 1999
- Effects of Blood Pressure Control on Progressive Renal Disease in Blacks and WhitesHypertension, 1997
- Short-term effects of blood pressure control and antihypertensive drug regimen on glomerular filtration rate: The African-American study of kidney disease and hypertension pilot study1American Journal of Kidney Diseases, 1997
- Accuracy of the diagnosis of hypertensive nephrosclerosis in African Americans: A report from the African American Study of Kidney Disease (AASK) TrialKidney International, 1997
- Calcium channel blockers versus other antihypertensive therapies on progression of NIDDM associated nephropathyKidney International, 1996
- Effects of Atenolol and Enalapril on Kidney Function in Hypertensive Diabetic PatientsJournal of Cardiovascular Pharmacology, 1993
- Confounding in epidemiological studies: why "independent" effects may not be all they seem.BMJ, 1992
- Prognostic value of serum creatinine and effect of treatment of hypertension on renal function. Results from the hypertension detection and follow-up program. The Hypertension Detection and Follow-up Program Cooperative Group.Hypertension, 1989
- Renal Insufficiency in Treated Essential HypertensionThe New England Journal of Medicine, 1989