Long-term effects of renin-angiotensin system-blocking therapy and a low blood pressure goal on progression of hypertensive chronic kidney disease in African Americans.
BACKGROUND
Antihypertensive drugs that block the renin-angiotensin system (angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers) are recommended for patients with chronic kidney disease (CKD). A low blood pressure (BP) goal (BP, <130/80 mm Hg) is also recommended. The objective of this study was to determine the long-term effects of currently recommended BP therapy in 1094 African Americans with hypertensive CKD.


METHODS
Multicenter cohort study following a randomized trial. Participants were 1094 African Americans with hypertensive renal disease (glomerular filtration rate, 20-65 mL/min/1.73 m2). Following a 3x2-factorial trial (1995-2001) that tested 3 drugs used as initial antihypertensive therapy (ACEIs, calcium channel blockers, and beta-blockers) and 2 levels of BP control (usual and low), we conducted a cohort study (2002-2007) in which participants were treated with ACEIs to a BP lower than 130/80 mm Hg. The outcome measures were a composite of doubling of the serum creatinine level, end-stage renal disease, or death.


RESULTS
During each year of the cohort study, the annual use of an ACEI or an angiotensin receptor blocker ranged from 83.7% to 89.0% (vs 38.5% to 49.8% during the trial). The mean BP in the cohort study was 133/78 mm Hg (vs 136/82 mm Hg in the trial). Overall, 567 participants experienced the primary outcome; the 10-year cumulative incidence rate was 53.9%. Of 576 participants with at least 7 years of follow-up, 33.5% experienced a slow decline in kidney function (mean annual decline in the estimated glomerular filtration rate, <1 mL/min/1.73 m2).


CONCLUSIONS
Despite the benefits of renin-angiotensin system-blocking therapy on CKD progression, most African Americans with hypertensive CKD who are treated with currently recommended BP therapy continue to progress during the long term.
Appel
Lawrence J
LJ
Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins institutions, Johns Hopkins University, Baltimore, MD 21205-2223, USA. lappel@jhmi.edu
Wright
Jackson T
JT
Greene
Tom
T
Kusek
John W
JW
Lewis
Julia B
JB
Wang
Xuelei
X
Lipkowitz
Michael S
MS
Norris
Keith C
KC
Bakris
George L
GL
Rahman
Mahboob
M
Contreras
Gabriel
G
Rostand
Stephen G
SG
Kopple
Joel D
JD
Gabbai
Francis B
FB
Schulman
Gerald I
GI
Gassman
Jennifer J
JJ
Charleston
Jeanne
J
Agodoa
Lawrence Y
LY
D001741:Black or African American; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D015331:Cohort Studies; D003404:Creatinine / Q000097:blood; D018450:Disease Progression; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000208:ethnology; D017257:Ramipril / Q000627:therapeutic use*
D000806:Angiotensin-Converting Enzyme Inhibitors; D003404:Creatinine; D017257:Ramipril