Late breaking oral abstracts–VA NEPHRON D trial

ACEI and ARB

Combined Angiotensin Inhibition for the Treatment of Diabetic Nephropathy

Combination ACEI/ARB is over and done!

Combination ACEI and ARB: ON TARGET showed a caution for harm.  ALTITUDE which was in DMII and was stopped for futility as well.

Included CKD 2,3 and DMII with albuminuria >300mg/day.  All non diabetic were not included and uncontrolled HTN and DMII.  The primary end points  were eGFR changes and ESRD and death.  Safety outcomes were K, all cause mortality, AKI, and hospitalization.

1648 patients enrolled, 724 were assigned in both groups. Most of the patients were men as it was a VA study. 25% had CAD, 70% were on ACEI at the start, another 16% were on ARB at start and 5% on both at start. Median eGFR was 54 mL/min.

Results: No significant benefit in primary Endpoint of ESRD and eGFR change.  No change in all cause mortality.  No subgroup benefitted in combination therapy (especially 1gm or more albuminuria).  eGFR was slightly lower in combined arm but overall in time, about the same.  Albuminuria is decreased as shown by prior studies.  No benefit in cardiovascular benefits either.

A significant and early difference with hyperkalemia in combined group- and severe as well and peak levels and treatment required. Also significant AKI (serious events requiring being in ER).  In terms of overall safety outcomes, half of them had one serious adverse event.

Combination therapy with an ACEI and ARB was associated with serious adverse events.

Post written by Dr. Kenar Jhaveri, eAJKD Editor.

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