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A Randomized Trial of Distal Diuretics versus Dietary Sodium Restriction for Hypertension in Chronic Kidney Disease
Dominique M Bovée1, Wesley J Visser2, Igor Middel3
1Divisions of Nephrology and Transplantation.
Insights
Distal diuretics are as effective as sodium restriction for lowering blood pressure in chronic kidney disease (CKD) patients. This study shows diuretic effectiveness is maintained in CKD, even with reduced kidney function.
Area of Science:
- Nephrology
- Pharmacology
- Hypertension Management
Background:
- Distal diuretics are perceived as less effective than loop diuretics in chronic kidney disease (CKD).
- Limited data exist to substantiate this perception regarding distal diuretic efficacy in CKD patients.
Purpose of the Study:
- To compare the noninferiority of distal diuretics versus dietary sodium restriction in reducing blood pressure (BP).
- To assess effects on kidney function, fluid balance, and diuretic clearance in patients with CKD stages G3-G4 and hypertension.
Main Methods:
- A 6-week, randomized, open-label crossover trial comparing amiloride/hydrochlorothiazide with dietary sodium restriction.
- Patients with CKD (stage G3-G4) and hypertension had antihypertension medication withdrawn prior to randomization.
- Evaluated effects on BP, extracellular water, eGFR, plasma renin, aldosterone, body weight, NT-proBNP, albuminuria, and urinary markers.
Main Results:
- Distal diuretics significantly reduced systolic BP more than sodium restriction.
- Diuretics demonstrated greater effects on extracellular water, eGFR, plasma renin, and aldosterone.
- Diuretic effects on BP and body weight were maintained at lower eGFR, despite reduced diuretic clearance.
Conclusions:
- Distal diuretics are noninferior to dietary sodium restriction for reducing BP and extracellular volume in CKD.
- Diuretic sensitivity is preserved in CKD patients, even with diminished diuretic clearance.
Background:
Distal diuretics are considered less effective than loop diuretics in CKD. However, data to support this perception are limited.
Methods:
To investigate whether distal diuretics are noninferior to dietary sodium restriction in reducing BP in patients with CKD stage G3 or G4 and hypertension, we conducted a 6-week, randomized, open-label crossover trial comparing amiloride/hydrochlorothiazide (5 mg/50 mg daily) with dietary sodium restriction (60 mmol per day). Antihypertension medication was discontinued for a 2-week period before randomization. We analyzed effects on BP, kidney function, and fluid balance and related this to renal clearance of diuretics.
Results:
A total of 26 patients (with a mean eGFR of 39 ml/min per 1.73 m2) completed both treatments. Dietary sodium restriction reduced sodium excretion from 160 to 64 mmol per day. Diuretics produced a greater reduction in 24-hour systolic BP (SBP; from 138 to 124 mm Hg) compared with sodium restriction (from 134 to 129 mm Hg), as well as a significantly greater effect on extracellular water, eGFR, plasma renin, and aldosterone. Both interventions resulted in a similar decrease in body weight and NT-proBNP. Neither approaches decreased albuminuria significantly, whereas diuretics did significantly reduce urinary angiotensinogen and β2-microglobulin excretion. Although lower eGFR and higher plasma indoxyl sulfate correlated with lower diuretic clearance, the diuretic effects on body weight and BP at lower eGFR were maintained. During diuretic treatment, higher PGE2 excretion correlated with lower free water clearance, and four patients developed mild hyponatremia.
Conclusions:
Distal diuretics are noninferior to dietary sodium restriction in reducing BP and extracellular volume in CKD. Diuretic sensitivity in CKD is maintained despite lower diuretic clearance.
Clinical Trial Registry Name And Registration Number:
DD-study: Diet or Diuretics for Salt-sensitivity in Chronic Kidney Disease (DD), NCT02875886.
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