NDT Advance Access originally published online on November 3, 2006
Nephrology Dialysis Transplantation 2007 22(1):281; doi:10.1093/ndt/gfl646
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Candesartan reduces cardiovascular events in patients on chronic haemodialysis
Email: jalmirall{at}cspt.esSir,
We read with great interest the recent report by Takahashi et al. [1] on the beneficial effects of candesartan administered to patients on chronic haemodialysis. The reduction in cardiovascular events and mortality compared with the placebo group was so striking that the core centre recommended termination of the study prematurely.
Cardiovascular events are certainly the major determinants of the prognosis of patients on dialysis, and the renin–angiotensin system plays a crucial role in the pathogenesis of the atherosclerotic lesion. Nevertheless, other variables have been clearly involved in its development and have also been demonstrated to be independent predictors of the prognosis: the state of mineral metabolism (phosphorous in particular) [2], time on dialysis treatment, dialysis doses or residual renal function among others.
None of these characteristics are reported or mentioned in the description of their patients, so it is impossible to analyse the proper balance of the two groups after randomization. Surprisingly, 16% and 33% of patients on dialysis in the control and candesartan groups, respectively, were on diuretic treatment, suggesting that an important number of patients had some residual renal function, and the two groups, at least in this aspect, seem quite different.
The last point we wish to raise is that not only did the candesartan group perform especially well, it also seems that the control group performed especially poorly. As the authors note in their own previous data, the rate of cardiovascular events in patients on chronic maintenance haemodialysis in a stable condition was 26.7 per 100 patients-year. This is not the case with their present results, as can be seen in Figure 3, where 40% of patients drop at 12 months follow-up in the control group.
We think this is a significant study with important consequences in clinical management. We agree with the suggestion that suppressing the renin–angiotensin system can have beneficial effects on these patients, but we need to clarify this points in order to be sure that there is not an overestimation of the benefits.
Conflict of interest statement. None declared.
Nephrology Service
Corporació Parc Taulí
Institut Universitari Parc Taulí
UAB
Barcelona
Spain
References
- Takahashi A, Takase H, Toriyama T, et al. (2006) Candesartan, an angiotensin II type-1 receptor blocker, reduces cardiovascular events in patients on chronic haemodialysis – a randomised study. Nephrol Dial Transplant 21:2507–2512.
[Abstract/Free Full Text] - Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. (2004) Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 15:2208–2218.
[Abstract/Free Full Text]
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