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

Aldosterone Breakthrough During Diovan (Valsartan), Tekturna (Aliskiren), and Combination (Valsartan+Aliskiren) Anti-hypertensive Therapy in Patients With Proteinuric Kidney Disease

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.

Study Overview

• Status: Terminated
• Conditions: Diabetic Nephropathy; Focal Segmental Glomerulosclerosis; IgA Nephropathy; Glomerulonephritis, Membranous; Hypertensive Nephrosclerosis; Proteinuric Kidney Disease; Glomerulopathy (Obesity-associated)
• Intervention / Treatment: Drug: Valsartan; Drug: Aliskiren

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.

• Study Type: Interventional
• Enrollment (Actual): 46
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10032
      • Columbia University Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Tekturna; Tekturna (Aliskiren), a direct renin inhibitor (DRI) 300 mg by mouth once daily for 9 months	Drug: Aliskiren; Other Names: Tekturna
Active Comparator: Diovan; Diovan (Valsartan), an angiotensin receptor blocker (ARB) 320 mg by mouth once daily for 9 months	Drug: Valsartan; Other Names: Diovan
Active Comparator: Tekturna & Diovan; 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	Drug: Valsartan; Other Names: Diovan; Drug: Aliskiren; Other Names: Tekturna

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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.	9 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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.	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.	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.)	Baseline, 3-, 6-, and 9-months
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.)	Baseline, 3-, 6-, and 9-months
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)
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	Baseline and Final (9 month)

Collaborators and Investigators

• Sponsor: Columbia University
• Collaborators: Novartis Pharmaceuticals
• Investigators: Principal Investigator: Pietro Canetta, MD, Columbia University

Publications and helpful links

General Publications

• 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.

Study record dates

Study Major Dates

• Study Start: September 1, 2009
• Primary Completion (Actual): January 1, 2012
• Study Completion (Actual): December 1, 2012

Study Registration Dates

• First Submitted: May 21, 2010
• First Submitted That Met QC Criteria: May 21, 2010
• First Posted (Estimate): May 24, 2010

Study Record Updates

• Last Update Posted (Estimate): May 15, 2014
• Last Update Submitted That Met QC Criteria: April 16, 2014
• Last Verified: April 1, 2014

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Immune System Diseases; Autoimmune Diseases; Urologic Diseases; Endocrine System Diseases; Diabetes Complications; Diabetes Mellitus; Nephritis; Kidney Diseases; Diabetic Nephropathies; Glomerulonephritis; Glomerulosclerosis, Focal Segmental; Glomerulonephritis, IGA; Nephrosclerosis; Glomerulonephritis, Membranous; Molecular Mechanisms of Pharmacological Action; Antihypertensive Agents; Angiotensin II Type 1 Receptor Blockers; Angiotensin Receptor Antagonists; Valsartan
• Other Study ID Numbers: AAAE0863; #IIRP-906 (Other Identifier: Novartis)