March 23, 2010

Renal outcomes with different fixed-dose combination therapies in patients with hypertension at high risk for cardiovascular events (ACCOMPLISH): a prespecified secondary analysis of a randomised controlled trial

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The ACCOMPLISH trial concluded that initial antihypertensive therapy with benazepril plus amlodipine was superior to benazepril plus hydrochlorothiazide in reducing cardiovascular morbidity and mortality. This pre-specified secondary analysis showed a reduction in progressive chronic kidney disease, defined as a doubling of serum creatinine concentration or development of end-stage renal disease, with an event rate of 2.0% in the benazepril/amlodipinie arm vs 3.7% in the benazepril/hydrochlorothiazide arm.

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Chronic Kidney Disease
  • Rene C Bakker

    Here some critical notes on the conclusions of the investigators who state that the bena/amlo arm does protect kidney function better than the bena/HCT arm.

    I do not come to the same conclusion.

    1. The primary endpoint outcome is biased by the fact that the diuretic arm increases and the amlo arm decreases serum creatinine initially as a result of just giving the drugs. So doubling of creat will be reached much sooner in the HCT group, only a few patients reached CKD stage 5. Thus the endpoint was basically doubling of creat.
    2. In CKD 5 and dialysis was no difference.
    3. The Kaplan-Meier curves seem to keep running parallel after 2 years, see point 1.
    4. Only 81.4% in the CKD patients had normo- or microalbumiuria. Diuretic use can be of more value in case of macroalbuminuria.
    5. Short acting HCT was used instead of chloortalidone, which was so succesfull in the ALLHAT trial.
    6. The trial was funded by Novartis who produces the combi pill bena/amlo.