Strict blood-pressure control and progression of renal failure in children.

Full Abstract

BACKGROUND: Although inhibition of the renin-angiotensin system delays the progression of renal failure in adults with chronic kidney disease, the blood-pressure target for optimal renal protection is controversial. We assessed the long-term renoprotective effect of intensified blood-pressure control among children who were receiving a fixed high dose of an angiotensin-converting-enzyme (ACE) inhibitor. METHODS: After a 6-month run-in period, 385 children, 3 to 18 years of age, with chronic kidney disease (glomerular filtration rate of 15 to 80 ml per minute per 1.73 m(2) of body-surface area) received ramipril at a dose of 6 mg per square meter of body-surface area per day. Patients were randomly assigned to intensified blood-pressure control (with a target 24-hour mean arterial pressure below the 50th percentile) or conventional blood-pressure control (mean arterial pressure in the 50th to 95th percentile), achieved by the addition of antihypertensive therapy that does not target the renin-angiotensin system; patients were followed for 5 years. The primary end point was the time to a decline of 50% in the glomerular filtration rate or progression to end-stage renal disease. Secondary end points included changes in blood pressure, glomerular filtration rate, and urinary protein excretion. RESULTS: A total of 29.9% of the patients in the group that received intensified blood-pressure control reached the primary end point, as assessed by means of a Kaplan-Meier analysis, as compared with 41.7% in the group that received conventional blood-pressure control (hazard ratio, 0.65; confidence interval, 0.44 to 0.94; P=0.02). The two groups did not differ significantly with respect to the type or incidence of adverse events or the cumulative rates of withdrawal from the study (28.0% vs. 26.5%). Proteinuria gradually rebounded during ongoing ACE inhibition after an initial 50% decrease, despite persistently good blood-pressure control. Achievement of blood-pressure targets and a decrease in proteinuria were significant independent predictors of delayed progression of renal disease. CONCLUSIONS: Intensified blood-pressure control, with target 24-hour blood-pressure levels in the low range of normal, confers a substantial benefit with respect to renal function among children with chronic kidney disease. Reappearance of proteinuria after initial successful pharmacologic blood-pressure control is common among children who are receiving long-term ACE inhibition. (ClinicalTrials.gov number, NCT00221845.) 2009 Massachusetts Medical Society

Author information

Author/s: ESCAPE Trial Group; Wühl, Elke (E); Trivelli, Antonella (A); Picca, Stefano (S); Litwin, Mieczyslaw (M); Peco-Antic, Amira (A); Zurowska, Aleksandra (A); Testa, Sara (S); Jankauskiene, Augustina (A); Emre, Sevinc (S); Caldas-Afonso, Alberto (A); Anarat, Ali (A); Niaudet, Patrick (P); Mir, Sevgi (S); Bakkaloglu, Aysin (A); Enke, Barbara (B); Montini, Giovanni (G); Wingen, Ann-Margret (AM); Sallay, Peter (P); Jeck, Nikola (N); Berg, Ulla (U); Caliskan, Salim (S); Wygoda, Simone (S); Hohbach-Hohenfellner, Katharina (K); Dusek, Jiri (J); Urasinski, Tomasz (T); Arbeiter, Klaus (K); Neuhaus, Thomas (T); Gellermann, Jutta (J); Drozdz, Dorota (D); Fischbach, Michel (M); Möller, Kristina (K); Wigger, Marianne (M); Peruzzi, Licia (L); Mehls, Otto (O); Schaefer, Franz (F);

Journal and publication information

Publication Type: Journal Article; Randomized Controlled Trial; Research Support, Non-U.S. Gov't

Journal: The New England journal of medicine (N Engl J Med), published in United States. (Language: eng)

Reference: 2009-Oct; vol 361 (issue 17) : pp 1639-50

Dates: Created 2009/10/22; Completed 2009/10/29;

PMID: 19846849, status: MEDLINE (last retrieval date: 10/29/2009, IMS Date: )

Sourced from the National Library of Medicine. Abstract text and other information may be subject to copyright.

Comments and Corrections

CommentIn: N Engl J Med. 2009 Oct 22;361(17):1701-3. (PMID: 19846857)

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