Blog entry by Meguid El Nahas
FROM PROFESSOR GLASSOCK AT ASN 2014:
HALT-PKD- study a showed the a lower BP goal slows rate of increase of total kidney volume (TKV), reduces LVH, reduces albuminuria but has no effect on decline in eGFR (no mGFR reported. Dual ACEi + ARB neither beneficial or harmful. High uncertainty whether the short-term benefits on TKV change and LVH will have a benefit on Survival or ESRD.
Disconnect between BP lower targets and reduction in LVH/albuminuria AND PKD progression in terms of decline of eGFR.
This raises questions regarding the assumption (made for instance in mTOR inhibitors in ADPKD) that a reduction in TKV (Total Kidney Volume) would translate into slowewr ADPKD progression.
Also raises questions regarding the assumption that a reduction in LVH would imrpove CKD survival (by analogy here...a higher hematocrit improves LVH but doesnt survival...).
Clinical trials in Nephrology are a huge challenge:
1. Surrogate markers are unpredictable at best in terms of outcomes.
2. Hard endpoints would take 5-10 years to reach.
UNLESS, BETTER RISK STRATIFICATION OF THOSE INCLUDED IN RCTs. CHOOSING ESTABLISHED AND PREDICTABLE PROGRESSORS (if possible) WHERE A RESPONSE TO AN INTERVENTION WOULD BE MORE LIKELY.