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Effect of Strict Blood Pressure Control and ACE-Inhibition on Progression of Chronic Renal Failure in Pediatric Patients (ESCAPE)

Primary Purpose

Children, Chronic Renal Failure, Hypertension

Status
Completed
Phase
Phase 3
Locations
International
Study Type
Interventional
Intervention
ACE Inhibition
Intensified Blood Pressure Control
Add-on Angiotensin Receptor Blockade
Sponsored by
Heidelberg University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Children focused on measuring Ramipril, Hypertension, Chronic renal failure, Disease progression, Left ventricular hypertrophy, Intima media thickness, Cardiovascular disease, Biomarkers, Gene polymorphisms

Eligibility Criteria

3 Years - 18 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Age 3-18 years Moderate state of renal failure (creatinine clearance 15 - 75 ml / min / 1.73 m²) Mean arterial blood pressure (ABPM) > 50.percentile and/or antihypertensive treatment Written informed consent Exclusion Criteria: Age <3 years or >18 years at start of study Unstable clinical condition (vomiting, anorexia, etc) or superimposed important disease Unilateral or bilateral renal artery stenosis Urological surgery possibly affecting renal function expected during study period Insufficient compliance with prescribed antihypertensive medication during the run-in period Secondary renal diseases such as lupus, amyloidosis and primary hyperoxaluria, and patients treated with immunosuppressive agents (including corticosteroids) Severe primary cardiac disease, hepatic insufficiency and malabsorption syndrome Erythropoietin or growth hormone therapy with a duration of less than 3 months prior to run-in period Pregnancy

Sites / Locations

  • University Hospital Motol, 1st Department of Pediatrics
  • Hopital Necker, Division of Pediatric Nephrology
  • Inserm U574
  • Hopiteaux Universitaires de Strasbourg
  • Humboldt University Berlin, Charité Children's Hospital, Department of Pediatric Nephrology
  • University Hospital Essen, Department of Pediatrics, Pediatric Nephrology Unit
  • University Hospital Hamburg-Eppendorf, University Children's Hospital, Dept. of Pediatric Nephrology
  • Hannover Medical School, Children's Hospital Div. II, Pediatric Nephrology
  • Division of Pediatric Nephrology, Children's Hospital, University of Heidelberg
  • Urban Hospital St. Georg, Department of Pediatrics, Pediatric Nephrology Unit
  • Johannes Gutenberg University Mainz, Department of Pediatrics,
  • Philipps University Marburg, Dept. of Pediatrics
  • University Children's Hospital, Dept. of Nephrology
  • Semmelweis University Budapest, 1st Department of Pediatrics
  • G.Gaslini Institute, Nephrology Unit
  • Azienda Ospedaliera, Istitui Clinici di Perfezionamento, Servizio die Emodialisi Pediatrica
  • Azienda Ospedaliera die Padova. U.O. Nefrologia Dialisi e Trapianto - Dipartimento di Pediatria
  • Ospedale Pediatrico Bambino Gesù, Division of Nephrology and Dialysis
  • Ospedale Infantile Regina Margherita, U.O.A. Nefrologia, Dialisi, Trapianto
  • Vilnius University Children's Hospital, Pediatric Department, Nephrology Unit
  • Jagellonian University Medical College, Department of Pediatric Nephrology
  • Medical University of Gdansk, Pediatric Nephrology Department
  • Clinic of Pediatrics, Pomeranian Academy of Medicine
  • Children's Memorial Health Hospital, Nephrology and Kidney Transplantation Department
  • Hospital S. Joao-Faculade de Medicina do Porto, Dept. of Pediatrics
  • Faculty of Medicine Belgrade, University Children's Hospital, Nephrology Unit
  • Karolinska Institute, Huddinge University Hospital, Dept. of Pediatrics
  • University Children's Hospital, Nephrology Unit
  • Cukurova University School of Medicine, Dept. of Pediatric Nephrology
  • Hacettepe University, Faculty of Medicine, Pediatric Nephrology and Rheumatology
  • Istanbul University, Cerrahpasa Medical Faculty, Dept, of Pediatrics
  • University of Istanbul, Istanbul Medical Faculty, Dept. of Pediatrics
  • Ege University Medical Faculty, Dept. of Pediatric Nephrology

Arms of the Study

Arm 1

Arm 2

Arm Type

Active Comparator

Experimental

Arm Label

Conventional BP Control

Intensified BP Control

Arm Description

Targeted 24-hour mean arterial pressure will be the 50th-95th percentile for age.

Targeted 24-hour mean arterial pressure will be the 5th to 50th percentile for age.

Outcomes

Primary Outcome Measures

Time interval to renal 'loss' as defined by an absolute decrease in creatinine clearance by 50 % or attainment of renal replacement therapy.

Secondary Outcome Measures

Effect of treatment on urinary protein excretion
Effect of treatment on blood pressure
Safety of treatment

Full Information

First Posted
September 15, 2005
Last Updated
January 11, 2010
Sponsor
Heidelberg University
Collaborators
European Commission, Boehringer Ingelheim, Baxter Healthcare Corporation, Aventis Pharmaceuticals
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1. Study Identification

Unique Protocol Identification Number
NCT00221845
Brief Title
Effect of Strict Blood Pressure Control and ACE-Inhibition on Progression of Chronic Renal Failure in Pediatric Patients
Acronym
ESCAPE
Official Title
Molecular Mechanisms of Disease Progression and Renoprotective Pharmacotherapy in Children With Chronic Renal Failure
Study Type
Interventional

2. Study Status

Record Verification Date
January 2010
Overall Recruitment Status
Completed
Study Start Date
January 1998 (undefined)
Primary Completion Date
July 2007 (Actual)
Study Completion Date
January 2010 (Actual)

3. Sponsor/Collaborators

Name of the Sponsor
Heidelberg University
Collaborators
European Commission, Boehringer Ingelheim, Baxter Healthcare Corporation, Aventis Pharmaceuticals

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
In children with chronic kidney disease, progression to end-stage renal failure is associated with high patient morbidity and poor quality of life. In adults, inhibition of the renin angiotensin system (RAS) slows down the rate of renal failure progression. This concept is as yet unproven in children, in whom chronic renal failure (CRF) is more commonly due to hypo/dysplastic malformations than to acquired glomerulopathies as typical for adult chronic kidney disease. The current project aims at assessing the genetic and molecular mechanisms and cardiovascular consequences of progressive CRF and to develop a strategy of pharmacological renoprotection in children.
Detailed Description
Chronic kidney diseases affecting the nephron mass are characterized by a progressive decline of glomerular filtration rate (GFR) occurring irrespectively of the cause of the renal damage once a critical number of nephrons has been lost. Current clinical research efforts focus on preventive strategies to slow down or arrest disease progression. Systemic hypertension and glomerular hyperfiltration with resulting proteinuria and activation of vasoactive, profibrotic and proinflammatory systems have been identified as major causes of further nephron damage. Angiotensin converting enzyme (ACE) inhibitors are not only potent antihypertensive agents but also reduce proteinuria, glomerulosclerosis and tubulointerstitial fibrosis via reduction of the local angiotensin tone in the kidney, and have been demonstrated to slow down renal failure progression in adult patients. Childhood-onset ESRD is a rare but particularly devastating disease with poor life expectancy and quality of life. Chronic renal failure in children is caused by a different spectrum of nephropathies than in adults, with a preponderance of congenital or inherited abnormalities. Since hypertension, proteinuria and tubulointerstitial fibrosis are also common in pediatric chronic renal failure, there is a rationale for pharmacological renoprotection by ACE inhibition in children. The prospective, randomized European clinical trial launched by our consortium will provide the critical mass to assess several aspects of renoprotective therapy in children. Specifically, the trial is designed to address the following scientific objectives: Objective 1 is to evaluate whether ACE inhibition is equally effective in slowing down the progression rate of chronic renal failure in children with different congenital and acquired renal disorders. 400 pediatric patients will be stratified according to their underlying diseases, and the rate of loss in glomerular filtration rate will be assessed from 6 months before to 5 years after start of treatment with the ACE inhibitor ramipril. Objective 2 of the trial is to evaluate whether renal failure progression in patients treated with a fixed dose of ramipril can be further slowed down by additional antihypertensive treatment, achieving a blood pressure below the 50th percentile. To this end, patients will be randomized upon initiation of ramipril to either intensified (aiming below 50th percentile of 24-hour mean arterial pressure) or conventional antihypertensive treatment. Several gene polymorphisms have been described that may affect the rate of renal failure progression and/or the individual susceptibility to ACE inhibition. These polymorphisms include genes encoding for key proteins of the renin-angiotensin system and extracellular matrix turnover. In addition, we will screen for novel polymorphisms in genes determining structural proteins of the glomerular filter, and search for gene mutations causing renal hypo-/dysplasia. Objective 3 is to evaluate whether any of these mutations predict spontaneous disease progression and the therapeutic response to ACE inhibition and intensified blood pressure control. Glomerular endothelin (ET1) synthesis is upregulated in chronic renal failure, and urinary ET1 excretion is correlated with disease progression. ET1 antagonists partially preserve renal function and decrease proteinuria independent of the angiotensin tone. Objective 4 of the trial is to assess ET1 turnover before and after start of ACE inhibition, and to evaluate a possible predictive role of ET1 and/or ET1 degrading peptidase excretion for the persistence of proteinuria and disease progression during ACE inhibition and intensified antihypertensive therapy. Long-term survival of children with chronic renal failure is compromised by precocious atherosclerosis and excessive cardiovascular morbidity. Objective 5 is to assess and correlate prospectively the metabolic causes and morphological consequences of uremic cardiovascular disease in children, and to define their relationship with disease progression during ACE inhibition and intensified blood pressure control. Homocysteine metabolism, apolipoprotein variability, gene polymorphisms putatively involved in atherosclerosis, inflammation states, myocardial function and carotid intima-media thickness will be assessed and compared to a reference group of age-matched healthy children.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Children, Chronic Renal Failure, Hypertension, Acquired Kidney Disease, Congenital Kidney Disease
Keywords
Ramipril, Hypertension, Chronic renal failure, Disease progression, Left ventricular hypertrophy, Intima media thickness, Cardiovascular disease, Biomarkers, Gene polymorphisms

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 3
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
400 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Conventional BP Control
Arm Type
Active Comparator
Arm Description
Targeted 24-hour mean arterial pressure will be the 50th-95th percentile for age.
Arm Title
Intensified BP Control
Arm Type
Experimental
Arm Description
Targeted 24-hour mean arterial pressure will be the 5th to 50th percentile for age.
Intervention Type
Drug
Intervention Name(s)
ACE Inhibition
Other Intervention Name(s)
Delix
Intervention Description
ACE inhibitor ramipril (6 mg/m²/day) will be given to all subjects.
Intervention Type
Drug
Intervention Name(s)
Intensified Blood Pressure Control
Intervention Description
Any antihypertensive drugs except ACE inhibitors and angiotensin receptor blockers will be allowed.
Intervention Type
Drug
Intervention Name(s)
Add-on Angiotensin Receptor Blockade
Other Intervention Name(s)
Micardis
Intervention Description
In patients who show persistent or breakthrough proteinuria at the end of the initial study period, telmisartan (50 mg/m²/day) will be added to the existing medication.
Primary Outcome Measure Information:
Title
Time interval to renal 'loss' as defined by an absolute decrease in creatinine clearance by 50 % or attainment of renal replacement therapy.
Time Frame
two-monthly
Secondary Outcome Measure Information:
Title
Effect of treatment on urinary protein excretion
Time Frame
two-monthly
Title
Effect of treatment on blood pressure
Time Frame
two-monthly
Title
Safety of treatment
Time Frame
initially weekly, than two-monthly

10. Eligibility

Sex
All
Minimum Age & Unit of Time
3 Years
Maximum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Age 3-18 years Moderate state of renal failure (creatinine clearance 15 - 75 ml / min / 1.73 m²) Mean arterial blood pressure (ABPM) > 50.percentile and/or antihypertensive treatment Written informed consent Exclusion Criteria: Age <3 years or >18 years at start of study Unstable clinical condition (vomiting, anorexia, etc) or superimposed important disease Unilateral or bilateral renal artery stenosis Urological surgery possibly affecting renal function expected during study period Insufficient compliance with prescribed antihypertensive medication during the run-in period Secondary renal diseases such as lupus, amyloidosis and primary hyperoxaluria, and patients treated with immunosuppressive agents (including corticosteroids) Severe primary cardiac disease, hepatic insufficiency and malabsorption syndrome Erythropoietin or growth hormone therapy with a duration of less than 3 months prior to run-in period Pregnancy
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Franz Schaefer, MD
Organizational Affiliation
University of Heidelberg, Children's Hospital
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Otto Mehls, MD
Organizational Affiliation
University of Heidelberg, Children's Hospital
Official's Role
Principal Investigator
Facility Information:
Facility Name
University Hospital Motol, 1st Department of Pediatrics
City
Prague
ZIP/Postal Code
150 18
Country
Czech Republic
Facility Name
Hopital Necker, Division of Pediatric Nephrology
City
Paris
ZIP/Postal Code
75015
Country
France
Facility Name
Inserm U574
City
Paris
ZIP/Postal Code
75015
Country
France
Facility Name
Hopiteaux Universitaires de Strasbourg
City
Strasbourg
ZIP/Postal Code
67098
Country
France
Facility Name
Humboldt University Berlin, Charité Children's Hospital, Department of Pediatric Nephrology
City
Berlin
ZIP/Postal Code
13353
Country
Germany
Facility Name
University Hospital Essen, Department of Pediatrics, Pediatric Nephrology Unit
City
Essen
ZIP/Postal Code
45122
Country
Germany
Facility Name
University Hospital Hamburg-Eppendorf, University Children's Hospital, Dept. of Pediatric Nephrology
City
Hamburg
ZIP/Postal Code
20246
Country
Germany
Facility Name
Hannover Medical School, Children's Hospital Div. II, Pediatric Nephrology
City
Hannover
ZIP/Postal Code
30623
Country
Germany
Facility Name
Division of Pediatric Nephrology, Children's Hospital, University of Heidelberg
City
Heidelberg
ZIP/Postal Code
69120
Country
Germany
Facility Name
Urban Hospital St. Georg, Department of Pediatrics, Pediatric Nephrology Unit
City
Leipzig
ZIP/Postal Code
04129
Country
Germany
Facility Name
Johannes Gutenberg University Mainz, Department of Pediatrics,
City
Mainz
ZIP/Postal Code
55131
Country
Germany
Facility Name
Philipps University Marburg, Dept. of Pediatrics
City
Marburg
ZIP/Postal Code
35037
Country
Germany
Facility Name
University Children's Hospital, Dept. of Nephrology
City
Rostock
ZIP/Postal Code
18050
Country
Germany
Facility Name
Semmelweis University Budapest, 1st Department of Pediatrics
City
Budapest
ZIP/Postal Code
1083
Country
Hungary
Facility Name
G.Gaslini Institute, Nephrology Unit
City
Genoa
ZIP/Postal Code
16148
Country
Italy
Facility Name
Azienda Ospedaliera, Istitui Clinici di Perfezionamento, Servizio die Emodialisi Pediatrica
City
Milano
ZIP/Postal Code
20122
Country
Italy
Facility Name
Azienda Ospedaliera die Padova. U.O. Nefrologia Dialisi e Trapianto - Dipartimento di Pediatria
City
Padova
ZIP/Postal Code
35128
Country
Italy
Facility Name
Ospedale Pediatrico Bambino Gesù, Division of Nephrology and Dialysis
City
Rome
ZIP/Postal Code
00165
Country
Italy
Facility Name
Ospedale Infantile Regina Margherita, U.O.A. Nefrologia, Dialisi, Trapianto
City
Torino
ZIP/Postal Code
10126
Country
Italy
Facility Name
Vilnius University Children's Hospital, Pediatric Department, Nephrology Unit
City
Vilnius
ZIP/Postal Code
2600
Country
Lithuania
Facility Name
Jagellonian University Medical College, Department of Pediatric Nephrology
City
Cracow
ZIP/Postal Code
30-663
Country
Poland
Facility Name
Medical University of Gdansk, Pediatric Nephrology Department
City
Gdansk
ZIP/Postal Code
80-211
Country
Poland
Facility Name
Clinic of Pediatrics, Pomeranian Academy of Medicine
City
Szczecin
ZIP/Postal Code
71-344
Country
Poland
Facility Name
Children's Memorial Health Hospital, Nephrology and Kidney Transplantation Department
City
Warsaw
ZIP/Postal Code
04-736
Country
Poland
Facility Name
Hospital S. Joao-Faculade de Medicina do Porto, Dept. of Pediatrics
City
Porto
ZIP/Postal Code
4202 - 451
Country
Portugal
Facility Name
Faculty of Medicine Belgrade, University Children's Hospital, Nephrology Unit
City
Belgrade
ZIP/Postal Code
11000
Country
Serbia
Facility Name
Karolinska Institute, Huddinge University Hospital, Dept. of Pediatrics
City
Stockholm
ZIP/Postal Code
14186
Country
Sweden
Facility Name
University Children's Hospital, Nephrology Unit
City
Zürich
ZIP/Postal Code
8032
Country
Switzerland
Facility Name
Cukurova University School of Medicine, Dept. of Pediatric Nephrology
City
Adana
ZIP/Postal Code
01330
Country
Turkey
Facility Name
Hacettepe University, Faculty of Medicine, Pediatric Nephrology and Rheumatology
City
Ankara
ZIP/Postal Code
06100
Country
Turkey
Facility Name
Istanbul University, Cerrahpasa Medical Faculty, Dept, of Pediatrics
City
Istanbul
ZIP/Postal Code
34303
Country
Turkey
Facility Name
University of Istanbul, Istanbul Medical Faculty, Dept. of Pediatrics
City
Istanbul
ZIP/Postal Code
34390
Country
Turkey
Facility Name
Ege University Medical Faculty, Dept. of Pediatric Nephrology
City
Izmir
ZIP/Postal Code
35100
Country
Turkey

12. IPD Sharing Statement

Citations:
PubMed Identifier
19846849
Citation
ESCAPE Trial Group; Wuhl E, Trivelli A, Picca S, Litwin M, Peco-Antic A, Zurowska A, Testa S, Jankauskiene A, Emre S, Caldas-Afonso A, Anarat A, Niaudet P, Mir S, Bakkaloglu A, Enke B, Montini G, Wingen AM, Sallay P, Jeck N, Berg U, Caliskan S, Wygoda S, Hohbach-Hohenfellner K, Dusek J, Urasinski T, Arbeiter K, Neuhaus T, Gellermann J, Drozdz D, Fischbach M, Moller K, Wigger M, Peruzzi L, Mehls O, Schaefer F. Strict blood-pressure control and progression of renal failure in children. N Engl J Med. 2009 Oct 22;361(17):1639-50. doi: 10.1056/NEJMoa0902066.
Results Reference
background
PubMed Identifier
19685083
Citation
Tabatabaeifar M, Schlingmann KP, Litwin M, Emre S, Bakkaloglu A, Mehls O, Antignac C, Schaefer F, Weber S; ESCAPE Trial Group. Functional analysis of BMP4 mutations identified in pediatric CAKUT patients. Pediatr Nephrol. 2009 Dec;24(12):2361-8. doi: 10.1007/s00467-009-1287-6. Epub 2009 Aug 14.
Results Reference
background
PubMed Identifier
19550356
Citation
Gimpel C, Wuhl E, Arbeiter K, Drozdz D, Trivelli A, Charbit M, Gellermann J, Dusek J, Jankauskiene A, Emre S, Schaefer F; ESCAPE Trial Group. Superior consistency of ambulatory blood pressure monitoring in children: implications for clinical trials. J Hypertens. 2009 Aug;27(8):1568-74. doi: 10.1097/HJH.0b013e32832cb2a8.
Results Reference
background
PubMed Identifier
17901069
Citation
Grenda R, Wuhl E, Litwin M, Janas R, Sladowska J, Arbeiter K, Berg U, Caldas-Afonso A, Fischbach M, Mehls O, Sallay P, Schaefer F; ESCAPE Trial group. Urinary excretion of endothelin-1 (ET-1), transforming growth factor- beta1 (TGF- beta1) and vascular endothelial growth factor (VEGF165) in paediatric chronic kidney diseases: results of the ESCAPE trial. Nephrol Dial Transplant. 2007 Dec;22(12):3487-94. doi: 10.1093/ndt/gfm300. Epub 2007 Sep 26.
Results Reference
background
PubMed Identifier
17215443
Citation
Chinali M, de Simone G, Matteucci MC, Picca S, Mastrostefano A, Anarat A, Caliskan S, Jeck N, Neuhaus TJ, Peco-Antic A, Peruzzi L, Testa S, Mehls O, Wuhl E, Schaefer F; ESCAPE Trial Group. Reduced systolic myocardial function in children with chronic renal insufficiency. J Am Soc Nephrol. 2007 Feb;18(2):593-8. doi: 10.1681/ASN.2006070691. Epub 2007 Jan 10.
Results Reference
background
PubMed Identifier
16731295
Citation
Schonfelder EM, Knuppel T, Tasic V, Miljkovic P, Konrad M, Wuhl E, Antignac C, Bakkaloglu A, Schaefer F, Weber S; ESCAPE Trial Group. Mutations in Uroplakin IIIA are a rare cause of renal hypodysplasia in humans. Am J Kidney Dis. 2006 Jun;47(6):1004-12. doi: 10.1053/j.ajkd.2006.02.177.
Results Reference
background
PubMed Identifier
16280471
Citation
Matteucci MC, Wuhl E, Picca S, Mastrostefano A, Rinelli G, Romano C, Rizzoni G, Mehls O, de Simone G, Schaefer F; ESCAPE Trial Group. Left ventricular geometry in children with mild to moderate chronic renal insufficiency. J Am Soc Nephrol. 2006 Jan;17(1):218-26. doi: 10.1681/ASN.2005030276. Epub 2005 Nov 9.
Results Reference
background
PubMed Identifier
15253732
Citation
Wuhl E, Mehls O, Schaefer F; ESCAPE Trial Group. Antihypertensive and antiproteinuric efficacy of ramipril in children with chronic renal failure. Kidney Int. 2004 Aug;66(2):768-76. doi: 10.1111/j.1523-1755.2004.00802.x.
Results Reference
result
PubMed Identifier
16093916
Citation
Jourdan C, Wuhl E, Litwin M, Fahr K, Trelewicz J, Jobs K, Schenk JP, Grenda R, Mehls O, Troger J, Schaefer F. Normative values for intima-media thickness and distensibility of large arteries in healthy adolescents. J Hypertens. 2005 Sep;23(9):1707-15. doi: 10.1097/01.hjh.0000178834.26353.d5.
Results Reference
result
PubMed Identifier
15772249
Citation
Litwin M, Wuhl E, Jourdan C, Trelewicz J, Niemirska A, Fahr K, Jobs K, Grenda R, Wawer ZT, Rajszys P, Troger J, Mehls O, Schaefer F. Altered morphologic properties of large arteries in children with chronic renal failure and after renal transplantation. J Am Soc Nephrol. 2005 May;16(5):1494-500. doi: 10.1681/ASN.2004110932. Epub 2005 Mar 16.
Results Reference
result
PubMed Identifier
15647341
Citation
Wuhl E, Hadtstein C, Mehls O, Schaefer F; ESCAPE Trial Group. Ultradian but not circadian blood pressure rhythms correlate with renal dysfunction in children with chronic renal failure. J Am Soc Nephrol. 2005 Mar;16(3):746-54. doi: 10.1681/ASN.2004070537. Epub 2005 Jan 12.
Results Reference
result
PubMed Identifier
14744931
Citation
Hadtstein C, Wuhl E, Soergel M, Witte K, Schaefer F; German Study Group for Pediatric Hypertension. Normative values for circadian and ultradian cardiovascular rhythms in childhood. Hypertension. 2004 Mar;43(3):547-54. doi: 10.1161/01.HYP.0000116754.15808.d8. Epub 2004 Jan 26.
Results Reference
result
PubMed Identifier
14630977
Citation
Wuhl E, Hadtstein C, Mehls O, Schaefer F; Escape Trial Group. Home, clinic, and ambulatory blood pressure monitoring in children with chronic renal failure. Pediatr Res. 2004 Mar;55(3):492-7. doi: 10.1203/01.PDR.0000106863.90996.76. Epub 2003 Nov 19.
Results Reference
result

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Effect of Strict Blood Pressure Control and ACE-Inhibition on Progression of Chronic Renal Failure in Pediatric Patients

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