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Aldosterone Breakthrough During Diovan, Tekturna, and Combination Therapy in Patients With Proteinuric Kidney Disease

Primary Purpose

Proteinuric Kidney Disease, Diabetic Nephropathy, Hypertensive Nephrosclerosis

Status
Terminated
Phase
Phase 4
Locations
United States
Study Type
Interventional
Intervention
Aliskiren
Valsartan
Sponsored by
Columbia University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Proteinuric Kidney Disease

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Proteinuria > 300 mg/day
  • Normal to mildly reduced kidney function (eGFR > 45 ml/min/1.73m2)
  • Systolic blood pressure >130 mm Hg
  • Diastolic blood pressure >70 mm Hg
  • Diagnoses of diabetic nephropathy, hypertensive nephrosclerosis, IgA nephropathy, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, membranous nephropathy, fibrillary glomerulonephritis, or obesity-associated glomerulopathy

Exclusion Criteria:

  • Concomitant use of cyclosporine (which can interact with aliskiren)
  • Inability to undergo 6 week washout period if already on RAAS-blocking drug(s) (includes renin inhibitor, ACE-inhibitor, ARB, and mineralocorticoid receptor blocker)
  • eGFR < 45 ml/min/1.73m2
  • Urine protein excretion < 300 mg/day
  • Serum K > 5.0 mEq/l
  • Systolic blood pressure > 170 mm Hg or < 130 mm Hg after washout period
  • Diastolic blood pressure > 110 mm Hg or < 70 mm Hg after washout period
  • Congestive heart failure NYHA class III and IV
  • History of any cardiovascular events (stroke, TIA, MI, unstable angina, CABG, PCI, CHF hospitalization) in 3 months prior to study visit 1
  • 2nd or 3rd degree heart block without a pacemaker or other uncontrolled arrhythmia
  • Clinically significant valvular disease
  • Known renal artery stenosis
  • Any surgical or medical condition that might significantly alter the pharmacokinetics of the study drugs (n.b. bariatric surgery > 6 months prior to visit 1 is not an exclusion)
  • History or evidence of drug or alcohol abuse within the last 12 months
  • Any concurrent life threatening condition with a life expectancy less than 2 years
  • Pregnant or nursing (lactating) women
  • Women of child-bearing potential unless postmenopausal for at least 1 year, surgically sterile, or using effective methods of contraception as defined by local health authorities

Sites / Locations

  • Columbia University Medical Center

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm Type

Active Comparator

Active Comparator

Active Comparator

Arm Label

Tekturna

Diovan

Tekturna & Diovan

Arm Description

Tekturna (Aliskiren), a direct renin inhibitor (DRI) 300 mg by mouth once daily for 9 months

Diovan (Valsartan), an angiotensin receptor blocker (ARB) 320 mg by mouth once daily for 9 months

Tekturna (Aliskiren), a direct renin inhibitor (DRI) 150 mg by mouth once daily & Diovan (Valsartan), an angiotensin receptor (ARB) 160 mg by mouth once daily for 9 months

Outcomes

Primary Outcome Measures

Cumulative Incidence of Aldosterone Breakthrough in Subjects Who Completed the 9-month Study Protocol.
The primary outcome of this study is the 9-month cumulative incidence of aldosterone breakthrough, defined as a sustained increase in 24-hour urine aldosterone above baseline, in each treatment arm.

Secondary Outcome Measures

Serum Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Mean serum aldosterone at baseline, 3-, 6-, and 9-months.
Urine Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Mean urine aldosterone at baseline, 3-, 6-, and 9-months.
Serum Potassium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Mean serum potassium at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Mean 24-hour Urine Sodium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Mean 24-hour urine sodium (mmol/day) at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Pre- and Post-treatment Blood Pressure in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) blood pressure for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Creatinine in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) serum creatinine for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Potassium in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) serum potassium for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-hour Urine Protein in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) 24-hour urine protein for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-hour Urine Sodium in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) 24-hour urine sodium for subjects with and without aldosterone breakthrough
Pre- and Post-treatment 24-urine Aldosterone in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) 24-hour urine aldosterone for subjects with and without aldosterone breakthrough
Pre- and Post-treatment Serum Aldosterone in Subjects With and Without Aldosterone Breakthrough.
Compares baseline and final (9 month) serum aldosterone for subjects with and without aldosterone breakthrough

Full Information

First Posted
May 21, 2010
Last Updated
April 16, 2014
Sponsor
Columbia University
Collaborators
Novartis Pharmaceuticals
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1. Study Identification

Unique Protocol Identification Number
NCT01129557
Brief Title
Aldosterone Breakthrough During Diovan, Tekturna, and Combination Therapy in Patients With Proteinuric Kidney Disease
Official Title
Aldosterone Breakthrough During Diovan (Valsartan), Tekturna (Aliskiren), and Combination (Valsartan+Aliskiren) Anti-hypertensive Therapy in Patients With Proteinuric Kidney Disease
Study Type
Interventional

2. Study Status

Record Verification Date
April 2014
Overall Recruitment Status
Terminated
Study Start Date
September 2009 (undefined)
Primary Completion Date
January 2012 (Actual)
Study Completion Date
December 2012 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Columbia University
Collaborators
Novartis Pharmaceuticals

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Primary Hypothesis: Aldosterone breakthrough will occur at a far lower frequency during renin inhibition (0-10% over 9 months), alone or in combination with an ARB, compared to conventional ARB therapy (35-45% over 9 months). The investigators hypothesize that aldosterone breakthrough occurs due to accumulation of active precursor substances, most notably angiotensin II, produced in response to conventional RAAS blockade with ACEinhibitors and ARBs. The investigators believe that direct renin inhibition (DRI) should minimize this accumulation and therefore significantly lower or possibly eliminate the breakthrough effect. Interruption of the renin-angiotensin-aldosterone system (RAAS) with angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs), alone and in combination, has become a leading therapy to slow the progression of chronic heart and kidney disease. Both types of drugs inhibit the formation of aldosterone, a hormone, which has been shown to have harmful effects on patients with chronic heart and kidney disorders. This treatment is effective but not perfect since, even after an initial improvement, many patients become worse over the long term. This may be due to an unexpected increase in aldosterone, a phenomenon called "aldosterone breakthrough." The purpose of this study is to find out whether the use of a direct renin inhibitor (DRI) alone, or in combination with an angiotensin receptor blocker (ARB), will lessen the occurrence of aldosterone breakthrough since direct renin inhibitors inhibit the formation of aldosterone at a very early step. This study will compare the effectiveness of adding Diovan (valsartan) or Tekturna (aliskiren) or a combination of Diovan and Tekturna to the usual antihypertensive treatment. The investigators will follow blood pressure, aldosterone levels, and urinary protein levels over 9 months to evaluate which of these therapies is most effective for treating hypertension in patients with proteinuric kidney disease.
Detailed Description
This is a randomized, open-label, three-arm study comparing Diovan (valsartan, an ARB), Tekturna (aliskiren, a DRI), and the combination of valsartan + aliskiren (i.e. ARB + DRI). One hundred twenty subjects (40 per arm) will be treated with Tekturna, Diovan, or a combination of both drugs for 9 months on top of their usual antihypertensive treatment. Changes in urinary aldosterone excretion will be monitored during therapy to measure the incidence of aldosterone breakthrough, defined as any sustained positive change from baseline urinary aldosterone excretion by the completion of the 9-month study period. This frequency measure will be compared during ARB, DRI, and ARB + DRI therapy. Changes in urinary protein excretion will also be monitored alongside the urinary aldosterone levels to determine whether aldosterone breakthrough is associated with refractory proteinuria. This is an innovative study that will be the first to (1) examine aldosterone breakthrough during DRI therapy, and (2) explore whether addition of a DRI to an ARB protects against aldosterone breakthrough. In addition, this will be the first study to examine whether DRI therapy (alone or in combination with ARB) is effective therapy for hypertension in patients with non-diabetic proteinuric kidney disease.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Proteinuric Kidney Disease, Diabetic Nephropathy, Hypertensive Nephrosclerosis, IgA Nephropathy, Focal Segmental Glomerulosclerosis, Glomerulopathy (Obesity-associated), Glomerulonephritis, Membranous

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
46 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Tekturna
Arm Type
Active Comparator
Arm Description
Tekturna (Aliskiren), a direct renin inhibitor (DRI) 300 mg by mouth once daily for 9 months
Arm Title
Diovan
Arm Type
Active Comparator
Arm Description
Diovan (Valsartan), an angiotensin receptor blocker (ARB) 320 mg by mouth once daily for 9 months
Arm Title
Tekturna & Diovan
Arm Type
Active Comparator
Arm Description
Tekturna (Aliskiren), a direct renin inhibitor (DRI) 150 mg by mouth once daily & Diovan (Valsartan), an angiotensin receptor (ARB) 160 mg by mouth once daily for 9 months
Intervention Type
Drug
Intervention Name(s)
Aliskiren
Other Intervention Name(s)
Tekturna
Intervention Type
Drug
Intervention Name(s)
Valsartan
Other Intervention Name(s)
Diovan
Primary Outcome Measure Information:
Title
Cumulative Incidence of Aldosterone Breakthrough in Subjects Who Completed the 9-month Study Protocol.
Description
The primary outcome of this study is the 9-month cumulative incidence of aldosterone breakthrough, defined as a sustained increase in 24-hour urine aldosterone above baseline, in each treatment arm.
Time Frame
9 months
Secondary Outcome Measure Information:
Title
Serum Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Description
Mean serum aldosterone at baseline, 3-, 6-, and 9-months.
Time Frame
Baseline, 3-, 6-, and 9-months
Title
Urine Aldosterone Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Description
Mean urine aldosterone at baseline, 3-, 6-, and 9-months.
Time Frame
Baseline, 3-, 6-, and 9-months
Title
Serum Potassium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Description
Mean serum potassium at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Time Frame
Baseline, 3-, 6-, and 9-months
Title
Mean 24-hour Urine Sodium Over Time During 9-month Treatment Course in Subjects With and Without Aldosterone Breakthrough.
Description
Mean 24-hour urine sodium (mmol/day) at baseline, 3-, 6-, and 9-months. (given as reference to interpret contemporaneous plasma & urine aldosterone measurements.)
Time Frame
Baseline, 3-, 6-, and 9-months
Title
Pre- and Post-treatment Blood Pressure in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) blood pressure for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment Serum Creatinine in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) serum creatinine for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment Serum Potassium in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) serum potassium for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment 24-hour Urine Protein in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) 24-hour urine protein for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment 24-hour Urine Sodium in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) 24-hour urine sodium for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment 24-urine Aldosterone in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) 24-hour urine aldosterone for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)
Title
Pre- and Post-treatment Serum Aldosterone in Subjects With and Without Aldosterone Breakthrough.
Description
Compares baseline and final (9 month) serum aldosterone for subjects with and without aldosterone breakthrough
Time Frame
Baseline and Final (9 month)

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Proteinuria > 300 mg/day Normal to mildly reduced kidney function (eGFR > 45 ml/min/1.73m2) Systolic blood pressure >130 mm Hg Diastolic blood pressure >70 mm Hg Diagnoses of diabetic nephropathy, hypertensive nephrosclerosis, IgA nephropathy, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, membranous nephropathy, fibrillary glomerulonephritis, or obesity-associated glomerulopathy Exclusion Criteria: Concomitant use of cyclosporine (which can interact with aliskiren) Inability to undergo 6 week washout period if already on RAAS-blocking drug(s) (includes renin inhibitor, ACE-inhibitor, ARB, and mineralocorticoid receptor blocker) eGFR < 45 ml/min/1.73m2 Urine protein excretion < 300 mg/day Serum K > 5.0 mEq/l Systolic blood pressure > 170 mm Hg or < 130 mm Hg after washout period Diastolic blood pressure > 110 mm Hg or < 70 mm Hg after washout period Congestive heart failure NYHA class III and IV History of any cardiovascular events (stroke, TIA, MI, unstable angina, CABG, PCI, CHF hospitalization) in 3 months prior to study visit 1 2nd or 3rd degree heart block without a pacemaker or other uncontrolled arrhythmia Clinically significant valvular disease Known renal artery stenosis Any surgical or medical condition that might significantly alter the pharmacokinetics of the study drugs (n.b. bariatric surgery > 6 months prior to visit 1 is not an exclusion) History or evidence of drug or alcohol abuse within the last 12 months Any concurrent life threatening condition with a life expectancy less than 2 years Pregnant or nursing (lactating) women Women of child-bearing potential unless postmenopausal for at least 1 year, surgically sterile, or using effective methods of contraception as defined by local health authorities
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Pietro Canetta, MD
Organizational Affiliation
Columbia University
Official's Role
Principal Investigator
Facility Information:
Facility Name
Columbia University Medical Center
City
New York
State/Province
New York
ZIP/Postal Code
10032
Country
United States

12. IPD Sharing Statement

Citations:
PubMed Identifier
22995802
Citation
Bomback AS, Rekhtman Y, Klemmer PJ, Canetta PA, Radhakrishnan J, Appel GB. Aldosterone breakthrough during aliskiren, valsartan, and combination (aliskiren + valsartan) therapy. J Am Soc Hypertens. 2012 Sep-Oct;6(5):338-45. doi: 10.1016/j.jash.2012.07.003.
Results Reference
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Aldosterone Breakthrough During Diovan, Tekturna, and Combination Therapy in Patients With Proteinuric Kidney Disease

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