Aldosterone bloCkade for Health Improvement EValuation in End-stage Renal Disease

Globally, over 2 million people receive dialysis for end-stage renal disease (ESRD) and 650,000 new patients start dialysis each year. Furthermore, the number of patients receiving dialysis is increasing as access to dialysis in the developing world improves and the prevalence of diabetes and vascular disease rises. Despite technical advances in dialysis, the outcomes for patients with ESRD are poor. Patients have frequent hospitalizations, poor health related quality of life and strikingly, high mortality rates.

The most common cause of death in patients receiving dialysis is cardiovascular disease, accounting for >40% of all deaths. Observational studies suggest a causal pathway to cardiovascular death that includes progressive ventricular hypertrophy and dilatation as well as accelerated atherosclerosis. These changes result in myocardial ischemia and cardiac fibrosis that, in turn, lead to heart failure, arrhythmias and cardiac arrest. Strongly implicated in this pathophysiology is aldosterone. Mineralocorticoid receptor antagonists (MRAs) in non-ESRD patients, prevent cardiovascular deaths and small randomized controlled trials of MRAs in ESRD suggests they may reduce death and may be safe.

Spironolactone is the most commonly used MRA worldwide. We will conduct a multicentre randomized controlled trial (RCT) to determine if spironolactone reduces cardiac mortality and hospitalizations for heart failure in patients treated with dialysis. This trial is called the Aldosterone bloCkade for Health Improvement EValuation in End-stage renal disease (ACHIEVE).

Inclusion criteria

• Age

• ≥45 years or
• ≥18 with a history of diabetes
• On dialysis ≥ 90 days
• On either

• Hemodialysis prescribed at least 2 treatments per week or
• Peritoneal dialysis prescribed with at least 1 exchange daily
• Provides informed consent

Exclusion criteria

• Hyperkalemia

• Serum potassium >5.8 mmol/L in the 6 weeks prior to enrollment or
• Serum potassium >6.0 mmol/L during active run-in
• Currently taking and unable to withdraw a mineralocorticoid receptor antagonist (i.e. spironolactone or eplerenone).
• Known sensitivity or allergy to spironolactone
• Current or planned pregnancy or breastfeeding
• Scheduled living related donor renal transplant
• Life expectancy < 6 months in the opinion of a treating nephrologist.
• Enrolled in another interventional trial testing a mineralocorticoid receptor antagonist or drug that has a known or likely interaction with spironolactone.
• Treating physician believes either spironolactone is either absolutely indicated or absolutely contra-indicated