Lowering of blood pressure (BP) in high-risk hypertensive individuals reduces major adverse cardiovascular (CV) and renal events. Diabetic patients with hypertension benefit from BP lowering treatment. The present trial, IPAD-CKD in brief, is a randomized, open-label, parallel-designed, multicenter study involving nearly 5322 patients to be recruited over three years and to be followed up for a median of four years and a half. IPAD-CKD tests the hypothesis that antihypertensive medications in adults with type 2 diabetes, whose seated BP 120-139 mm Hg systolic and below 90 mm Hg diastolic, results in 20% difference in the incidence of major renal events. During follow-up for participants in the intensive group, the sitting systolic pressure should be decreased to below 120 mm Hg, by titration and combination of the double-blind study medications of an angiotensin type-1 receptor blocker Allisartan (240 mg/day), a dihydropyridine calcium-channel blocker (amlodipine 5-10 mg/day), and/or other medications if necessary. For those in the standard group, the sitting systolic pressure should be monitored and controlled below 140 mm Hg.
The IPAD-CKD trial is a randomized, open-label, parallel-designed, multicenter study. 5322 patients will be recruited over three years with a median follow up of 4.5 years. IPAD tests the hypothesis that intensive antihypertensive medical therapy in adult patients with type 2 diabetes, whose seated BP ranges from 120 to 139 mm Hg systolic and \< 90 mm Hg diastolic, results in 20% reduction in the incidence of major renal events (the primary endpoint), a composite of renal failure and proteinuria progression. Secondary endpoints of this study include: renal failure ; proteinuria progression; proteinuria reversion; end stage renal disease; cardiovascular-cause mortality; MI; hospitalization for HF; stroke;hospitalization for unstable angina; all-cause mortality;development of diabetic retinopathy that needs interventional operation; peripheral arterial diseases; new on-set atrial fibrillation or flutter; cancer. Inclusion criteria for the study include T2DM patients aged between 45 and 79 years within the aforementioned BP ranges. For participants in the intensive group, the sitting systolic BP should decrease to \< 120 mm Hg, using titration and combination of study medications consisting of an angiotensin type-1 receptor blocker Allisartan (240 mg/day) and a dihydropyridine calcium-channel blocker (amlodipine 5-10 mg/day), and/or other medications if necessary.For those in the standard group, the sitting systolic pressure should be monitored and controlled below 140 mm Hg. Across the whole study, 310 primary endpoints are expected to occur. Interim analyses will be carried out on an intention-to-treat basis at the accumulation of 107 and 214 primary endpoints respectively. At the completion of the trial, both an intention-to-treat and a per-protocol analysis will be performed.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Allisartan Isoproxil 240mg daily will be used to lower BP to below 120 mm Hg systolic.
Amlodipine 5mg daily will be added to Allisartan Isoproxil and afterwards increased to 10mg daily, if necessary to reach the blood pressure goal (below 120 mm Hg systolic).
Composite of Major Renal Events
The major renal events defined in the study include a composite of renal failure (defined as dialysis, transplantation, or a sustained estimated GFR of \<15 ml per minute per 1.73 m 2), or serum creatinine level \>3.3 mg/dl, or a doubling of the serum creatinine level）and proteinuria progression（defined as:uACR ≥30 mg/gCr if baseline uACR\< 30 mg/gCr; uACR ≥300 mg/gCr if baseline uACR is between 30 to 300 mg/gCr. ）
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
renal failure
dialysis, transplantation, or a sustained estimated GFR of \<15 ml per minute per 1.73 m 2), or serum creatinine level \>3.3 mg/dl, or a doubling of the serum creatinine level
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
proteinuria progression
uACR ≥30 mg/gCr if baseline uACR\< 30 mg/gCr; uACR ≥300 mg/gCr if baseline uACR is between 30 to 300 mg/gCr.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
proteinuria reversion
uACR \<30mg/gCr if baseline uACR is between 30 to 300 mg/gCr.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
cardiovascular-cause mortality
Cardiovascular death include death caused by stroke, MI, HF, sudden death or any other death attributed to cardiovascular diseases. Sudden death (ICD-Code I46.1, R96) encompasses any death of unknown origin occurring instantly or within an estimated 24 hours after the onset of acute symptoms as well as unattended death for which no likely cause can be established by autopsy or recent medical history.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
Acute Myocardial Infarction
Acute myocardial infarction (MI) is defined when any one of the following criteria occurs. (1) Detection of a rise and/or fall of cardiac biomarker values, with at least one value above the 99th percentile upper reference limit and with at least one of the following manifestations: symptoms of ischaemia that should have lasted for at least 30 minutes and should not have been responsive to sublingual administration of nitrates; new or presumed new significant ST-segment-T wave changes or new left bundle branch block (LBBB); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. (2) Identification of an intracoronary thrombus by angiography or autopsy. (3) Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB, but death occurred before cardiac biomarkers were obtained, or before cardiac biomarker values would be increased.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
Hospitalization of Congestive Heart Failure
Congestive heart failure (HF) requires the presence of three conditions, namely symptoms, such as dyspnea, clinical signs, such as ankle edema or crepitations, and the necessity to initiate treatment with open-label diuretics, vasodilators or antihypertensive drugs. HF cases may also be adjudicated as chronic stable HF but this is not considered an outcome of the present study.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
Hospitalization of Unstable Angina
Unstable angina is defined as new onset or worsening angina pectoris requiring hospitalization with angiographically documented coronary atherosclerosis or transient electrocardiographic changes of the ST-segment or T-wave without evidence for myocardial necrosis. This diagnosis excludes patients with angina pectoris admitted to the hospital only for investigation.
Time frame: From date of randomization until the date of first documented incidence of the major renal events prespecified, whichever comes first, assessed up to 60 months
All-cause Mortality
All-cause mortality refers to death from any causes.
Time frame: Time Frame: From date of randomization until the date of death from any causes, assessed up to 60 months.
Diabetic Retinopathy Requiring Interventional Operation or Surgery
Diabetic retinopathy requiring interventional operation or surgery is defined as the confirmed diagnosis of diabetic retinopathy, indicated for interventional operation or surgery, which is documented by ophthalmologists.
Time frame: Time Frame: From date of randomization until the date of death from any causes, assessed up to 60 months.
Peripheral Arterial Diseases Requiring Revascularization
Peripheral arterial diseases requiring revascularization are defined as the confirmed diagnosis of any one of the peripheral arterial diseases indicated for revascularization.
Time frame: Time Frame: From date of randomization until the date of death from any causes, assessed up to 60 months.
New Atrial Fibrillation or Flutter
Atrial fibrillation or flutter is confirmed and documented with electrocardiogram indicating the occurence of atrial fibrillation or flutter. New development of atrial fibrillation or flutter is defined only if a participant at baseline has no history of and his or her electrocardiogram shows no signs of atrial fibrillation or flutter.
Time frame: Time Frame: From date of randomization until the date of death from any causes, assessed up to 60 months.
Cancer
Cancer defined in the present study is recorded only when there is pathologically confirmed evidence.
Time frame: Time Frame: From date of randomization until the date of death from any causes, assessed up to 60 months.
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