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VA NEPHRON-D: Diabetes iN Nephropathy Study

Information source: Department of Veterans Affairs
ClinicalTrials.gov processed this data on August 23, 2015
Link to the current ClinicalTrials.gov record.

Condition(s) targeted: Kidney Disease; Nephropathy; Type 2 Diabetes

Intervention: losartan (Drug); lisinopril (Drug)

Phase: Phase 3

Status: Terminated

Sponsored by: Department of Veterans Affairs

Official(s) and/or principal investigator(s):
Linda Fried, MD MPH, Study Chair, Affiliation: VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA

Summary

Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States. The overall rate of ESRD secondary to diabetes has risen 68% since 1992. Medications that block the renin angiotensin system have been shown to decrease the progression of diabetic nephropathy. The use of an angiotensin receptor blocker (ARB) has been shown to decrease the risk of progression of kidney disease in two studies of individuals with Type 2 diabetes and proteinuria. Despite the use of an ARB, the incidence of renal failure remained high in the treated group in both studies. The combination of an angiotensin converting enzyme inhibitor (ACEI) and ARB can lead to more complete blockade of the renin angiotensin system. In diabetic kidney disease, combination therapy has been shown to decrease proteinuria in short-term studies. Although there are encouraging results for improvement in proteinuria there are no data on progression of kidney disease for the use of combination of ACEI and ARB therapy in patients with diabetes. In addition, there could be an increased risk of serious hyperkalemia in individuals with diabetes who receive combination ACEI and ARB. The investigators therefore propose a randomized double blind multi-center clinical trial to assess the effect of combination of ACEI and ARB in patients with diabetes and proteinuria on progression of kidney disease.

Clinical Details

Official title: CSP #565 - Combination Angiotensin Receptor Blocker and Angiotensin Converting Enzyme Inhibitor for Treatment of Diabetic Nephropathy (VA NEPHRON-D Study)

Study design: Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver), Primary Purpose: Treatment

Primary outcome: A Composite Endpoint of Reduction in Estimated GFR of 30ml/Min/1.73m*m in Individuals w/a Baseline Estimated GFR >= 60 ml/Min/1.73m*m, Reduction in Estimated GFR >50% in Individuals w/ Baseline Estimated GFR <60ml/Min/1.73m*m; ESRD or Death

Secondary outcome: A Renal Composite Endpoint, Defined as; Reduction in Estimated GFR of >50% (for Individuals With Baseline GFR <60) or Reduction in GFR of >30 (for Individuals With Baseline GFR >= GFR 60) or ESRD.

Detailed description: Primary Hypothesis: To evaluate the combination of an angiotensin converting enzyme inhibitor (ACEI) with an angiotensin receptor blocker (ARB) vs. standard treatment with angiotensin receptor blocker on the progression of kidney disease in individuals with Type 2 diabetes and overt nephropathy. The primary outcome is a composite endpoint of reduction in estimated GFR of 30 ml/min/1. 73m*m in individuals with an estimated baseline GFR greater than or equal to 60 ml/min/1. 73m*m; reduction in estimated GFR of greater than 50% in individuals with an estimated baseline GFR less than 60 mL/min/1. 73m*m; progression to end-stage renal disease (defined as need for dialysis, renal transplant or an eGFR less than 15 ml/min/1. 73m*m) or death. Secondary outcome: a renal composite endpoint, defined as; reduction in estimated GFR of more than 50% (for individuals with a baseline estimated GFR less than 60 ml/min/1. 73m*m); reduction in estimated GFR of more than 30 ml/min/1. 73m*m (for individuals with a baseline estimated GFR greater than or equal to 60 ml/min/1. 73m*m) or progression to end-stage renal disease (defined as need for dialysis, renal transplant or an eGFR of less than 15 ml/min/1. 73m*m). Tertiary outcomes are cardiovascular events (cardiovascular mortality, myocardial infarction, cerebrovascular accident, admission for heart failure), change in albuminuria at 12 months and decline in slope of kidney function. Study Abstract: The study is a multi-center, prospective, randomized, parallel group trial to test the efficacy of the combination of an angiotensin converting enzyme inhibitor (ACEI) with an angiotension receptor blocker (ARB) vs. standard treatment with angiotension receptor blocker on the combined end-point. The primary outcome is a composite endpoint of reduction in estimated GFR of 30 ml/min/1. 73m*m in individuals with an estimated GFR greater than or equal to 60 ml/min/1. 73m*m; reduction in estimated GFR of greater than 50% in individuals with an estimated GFR less than 60 ml/min/1. 73m*m; progression to end-stage renal disease (defined as need for dialysis, renal transplant or en eGFR less than 15 ml/min/1. 73m*m)or death. The study population is individuals with type 2 diabetes and overt nephropathy. Eligible subjects who consent to participate will be randomized into either the combination therapy arm or the mono therapy arm. The randomization will be stratified by site and within sites by baseline albuminuria (< 1 vs. greater than or equal to 1 gram/gram creatinine) and eGFR (< 60 vs. greater than or equal to 60 ml/min/1. 73m*m). All participants will receive open label therapy with losartan, an ARB, as standard of care. Patients not treated with an ACEI or ARB will be initiated on losartan; patients treated with an ACEI or ARB other than losartan (the study ARB) will be converted to losartan (the study ARB) and the dose titrated to 100 mg/day. Individuals who tolerate ARB 100mg/day criteria will be randomized in a 1: 1 ratio to the addition of blinded lisinopril (the study ACEI) or placebo. The medication (lisinopril or placebo) will be titrated from an initial dose of 10 mg/day to a target dose of 40 mg/day. After each adjustment in dose, serum chemistries will be evaluated for kidney function and potassium levels. Subjects will be enrolled over a period of 4. 25 years and the maximum length of follow-up is 6. 25 years. The planned study duration is 6. 25 years with 4. 25 years of accrual and 6. 25 years of follow-up for all enrolled patients. The intervention was stopped on November 7, 2012 for safety concerns after an interim analysis. Patients are still under passively follow-up without intervention.

Eligibility

Minimum age: 18 Years. Maximum age: N/A. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Type 2 diabetes

- Albuminuria >300mg/gram creatinine

- Stage 2 or 3 CKD (eGFR 30 to <90 mg/min/1. 73m*2 )

- Able to give informed consent

- Telephone contact available

Exclusion Criteria:

- History of intolerance to ACEI or ARB

- Serum potassium level >5. 5 meq/L

- Receiving sodium polystyrene sulfonate (Kayexalate)

- Pregnancy, breast feeding, planning to become pregnant or sexually active and not

using birth control

- Renal transplant recipient

- Suspected non-diabetic kidney disease

- Inability to discontinue current use of ACEI/ARB combination

- Current use of Lithium

- Severe (end-stage) comorbid disease

- Prisoner

- Age <18

- Estimated glomerular filtration rate (GFR) <30 or >=90 ml/min/1. 73m*m

- HbA1c >10. 5%

- Patient refusal

- Participation in a concurrent interventional study

- Blood pressure >180/95

- Unwilling to stop any proscribed medications after enrollment

Locations and Contacts

VA Medical Center, San Juan, San Juan 00921, Puerto Rico

Carl T. Hayden VA Medical Center, Phoenix, Arizona 85012, United States

Central Arkansas VHS Eugene J. Towbin Healthcare Ctr, Little Rock, Little Rock, Arkansas 72205-5484, United States

VA Medical Center, Loma Linda, Loma Linda, California 92357, United States

VA Palo Alto Health Care System, Palo Alto, California 94304-1290, United States

VA Connecticut Health Care System (West Haven), West Haven, Connecticut 06516, United States

North Florida/South Georgia Veterans Health System, Gainesville, Florida 32608, United States

VA Medical Center, Miami, Miami, Florida 33125, United States

James A. Haley Veterans Hospital, Tampa, Tampa, Florida 33612, United States

Edward Hines, Jr. VA Hospital, Hines, Illinois 60141-5000, United States

Richard Roudebush VA Medical Center, Indianapolis, Indianapolis, Indiana 46202-2884, United States

VA Medical Center, Iowa City, Iowa City, Iowa 52246-2208, United States

VA Maryland Health Care System, Baltimore, Baltimore, Maryland 21201, United States

VA Medical Center, Minneapolis, Minneapolis, Minnesota 55417, United States

VA Medical Center, Kansas City MO, Kansas City, Missouri 64128, United States

VA Medical Center, St Louis, St Louis, Missouri 63106, United States

VA Medical Center, Omaha, Omaha, Nebraska 68105-1873, United States

VA New Jersey Health Care System, East Orange, East Orange, New Jersey 07018, United States

New Mexico VA Health Care System, Albuquerque, Albuquerque, New Mexico 87108-5153, United States

VA Western New York Healthcare System at Buffalo, Buffalo, New York 14215, United States

VA Medical Center, Durham, Durham, North Carolina 27705, United States

VA Medical Center, Cleveland, Cleveland, Ohio 44106, United States

VA Medical Center, Portland, Portland, Oregon 97201, United States

VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA, Pittsburgh, Pennsylvania 15240, United States

Ralph H Johnson VA Medical Center, Charleston, Charleston, South Carolina 29401-5799, United States

WJB Dorn Veterans Hospital, Columbia, Columbia, South Carolina 29209, United States

VA Medical Center, Memphis, Memphis, Tennessee 38104, United States

VA Medical Center, Nashville, Tennessee 37212-2637, United States

VA North Texas Health Care System, Dallas, Dallas, Texas 75216, United States

Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249, United States

Zablocki VA Medical Center, Milwaukee, Milwaukee, Wisconsin 53295-1000, United States

Additional Information

Related publications:

Fried LF, Duckworth W, Zhang JH, O'Connor T, Brophy M, Emanuele N, Huang GD, McCullough PA, Palevsky PM, Seliger S, Warren SR, Peduzzi P; VA NEPHRON-D Investigators. Design of combination angiotensin receptor blocker and angiotensin-converting enzyme inhibitor for treatment of diabetic nephropathy (VA NEPHRON-D). Clin J Am Soc Nephrol. 2009 Feb;4(2):361-8. doi: 10.2215/CJN.03350708. Epub 2008 Dec 31.

Starting date: July 2008
Last updated: May 8, 2015

Page last updated: August 23, 2015

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