Individualized prediction of the effect of angiotensin receptor blockade on renal and cardiovascular outcomes in patients with diabetic nephropathy

• Published in: Diabetes, obesity & metabolism obesity & metabolism, 2016-11, Vol.18 (11), p.1120-1127
• Main Authors: van der Sande, N. G. C., Dorresteijn, J. A. N., Visseren, F. L. J., Dwyer, J. P., Blankestijn, P. J., van der Graaf, Y., Heerspink, H. L. J.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Albumin; Angiotensin; Angiotensin II; Angiotensin Receptor Antagonists - pharmacology; Angiotensin Receptor Antagonists - therapeutic use; Antihypertensive Agents - pharmacology; Antihypertensive Agents - therapeutic use; Blood pressure; cardiovascular disease; Cardiovascular diseases; Cardiovascular Diseases - diagnosis; Cardiovascular Diseases - prevention & control; Cardiovascular System - drug effects; Cardiovascular System - physiopathology; Cerebral infarction; Congestive heart failure; Creatinine; Diabetes; Diabetes mellitus; Diabetes Mellitus, Type 2 - complications; Diabetes Mellitus, Type 2 - drug therapy; Diabetes Mellitus, Type 2 - physiopathology; Diabetic Nephropathies - diagnosis; Diabetic Nephropathies - drug therapy; Diabetic Nephropathies - physiopathology; Diabetic nephropathy; end-stage renal disease; Female; Glomerular filtration rate; Health risk assessment; Heart attacks; Humans; Individuality; Kidney - drug effects; Kidney - physiopathology; Kidney Failure, Chronic - diagnosis; Kidney Failure, Chronic - drug therapy; Kidney Failure, Chronic - physiopathology; Male; Middle Aged; Mortality; Multivariate Analysis; Myocardial infarction; Nephropathy; predictors; Prognosis; Renin-Angiotensin System - drug effects; Retrospective Studies; Risk Assessment; Treatment Outcome; type 2 diabetes
• ISSN: 1462-8902; 1463-1326
• DOI: 10.1111/dom.12708

Aims To predict individualized treatment effects of angiotensin receptor blockers (ARBs) on cardiovascular and renal complications in order to help clinicians and patients assess the benefit of treatment (or adherence) and estimate remaining disease risk. Materials and methods In patients with diabetic nephropathy, the 3‐year treatment effect of ARBs was predicted in terms of absolute risk reduction (ARR) for end‐stage renal disease (ESRD) and cardiovascular disease (CVD; i.e. myocardial infarction, stroke, hospitalization for heart failure) and all‐cause mortality. Competing‐risk‐adjusted proportional hazard models were developed based on the Irbesartan Diabetic Nephropathy Trial (IDNT) and externally validated in the Reduction of Endpoints NIDDM with Angiotensin II Antagonist Losartan (RENAAL) trial. Results Predictors included in the model were age, sex, smoking sex, systolic blood pressure, urinary albumin/creatinine ratio, estimated glomerular filtration rate, albumin and phosphorus. The median predicted 3‐year risk without treatment was 6.0% for ESRD and 28.0% for CVD and mortality. The median [interquartile range (IQR)] predicted 3‐year ARR was 1.2 (0.4‐3.1)% for ESRD and 2.2 (1.8‐2.6)% for CVD and mortality, resulting in a combined ARR of 3.4 (2.4‐5.5)%. The remaining disease risk was 4.7 (IQR 1.7‐12.8)% for ESRD and 25.8% (IQR 20.3‐31.9)% for CVD and mortality. Conclusions The combined effects of ARBs on ESRD and CVD and mortality in patients with diabetic nephropathy vary considerably between patients. A substantial proportion of patients remain at high risk for both outcomes despite ARB treatment.