Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions

Cardiovascular Diseases Clinical Trial

— CORAL  

Official title:

Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00081731
• Other study ID #: 161
• Secondary ID: U01HL071556
• Status: Completed
• Phase: Phase 3
• First received: April 19, 2004
• Last updated: September 18, 2015
• Start date: April 2004
• Est. completion date: September 2013

Study information

• Verified date: September 2015
• Source: Harvard Clinical Research Institute
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Food and Drug Administration
• Study type: Interventional

Clinical Trial Summary

This study will compare medical therapy plus stenting of hemodynamically significant renal artery stenoses versus medical therapy alone in patients with systolic hypertension and renal artery stenosis.

Description:

BACKGROUND:

Atherosclerotic renal artery stenosis is a common problem for which there is no clear consensus on diagnosis or therapy. There likely exists a progression in which renal ischemia leads to neuroendocrine activation, hypertension, and renal insufficiency resulting in acceleration of atherosclerosis, further renal dysfunction, and development of left ventricular hypertrophy. These events in turn lead to adverse clinical events.

Renal artery stenosis is one of the two major known causes of hypertension and occurs in 1-5% of hypertensive patients. In patients with accelerated hypertension, the prevalence of renal artery stenosis is much higher, ranging from 10-40%. Renal artery stenosis, when occurring bilaterally, or in a solitary kidney, is a significant cause for end-stage renal disease, accounting for several percent of patients with end-stage renal disease. Clinically, atherosclerotic renal artery stenosis is a major problem primarily in older patients, and is often seen in long-standing hypertensives whose blood pressure becomes very difficult to control. Of major significance is the progressive nature of atherosclerotic renal artery stenosis, progressing at the rate of about 10% per year (45-60% progression rate in 4-7 year follow-ups). Over this time period, 10-15% of patients develop total renal artery occlusion. If the renal artery stenosis is greater than 75% when detected, 40% of patients develop total occlusion. Due to the progressive nature of atherosclerotic lesions, the decline in renal function in some individuals, and difficult-to-control hypertension, the medical community has sought to detect those patients in whom intervention would be beneficial. This has been extremely difficult to achieve and tests to date have not been uniformly predictive, including peripheral vein plasma renin activity, renal vein renin activity, captopril-stimulated nuclear medicine renal scans, etc.

Since approximately 50% of patients with unilateral renal artery stenosis of significant degree (definitions vary) benefit from surgical intervention, enthusiasm has continued with the advent of renal artery angioplasty. The entire field is moving very quickly. However, there are neither current data nor prospective studies indicating the benefit of renal artery angioplasty plus stents. Studies over the last decade have shown that balloon angioplasty alone is associated with a high rate of recurrence in patients with atherosclerotic renal artery stenosis. In the present climate, there is great enthusiasm to perform angioplasty plus stent placement in atherosclerotic renal artery stenosis, without supporting data for efficacy compared to medical management alone. Angioplasty and stent placement in the renal arteries had been the domain of interventional radiologists, but recently, interventional cardiologists are also performing these procedures. The questions as to who will benefit from intervention and which intervention to use have not been answered. Renal artery angioplasty and stent placement subjects the patient to procedural risks, as well as increased cost, when compared to aggressive antihypertensive medication and risk factor medication and therapy.

DESIGN NARRATIVE:

This randomized, multicenter clinical trial will contrast the effect of optimal medical therapy alone to stenting with optimal medical therapy, on a composite of cardiovascular and renal endpoints: cardiovascular or renal death, myocardial infarction, hospitalization for congestive heart failure, stroke, doubling of serum creatinine level, and need for renal replacement therapy. These endpoints will be evaluated by a clinical events committee masked to treatment assignment. The secondary endpoints will 1) evaluate the mechanisms linked to clinical events; 2) describe differential effectiveness in critical end-organs; 3) determine the value of stenting from the patient and the health policy perspectives, measured as quality of life and cost-effectiveness; and 4) evaluate for clinically relevant differences in treatment effectiveness within the primary endpoint.

Patients will undergo a baseline evaluation to determine eligibility. Approximately 1,080 patients will be randomized to optimal medical therapy alone or to stenting with optimal medical therapy at an estimated 100 clinical sites. Initially, patients will be followed at 2-week intervals, until blood pressure is at target or up to 2 months. Follow-up visits will be mandated at 2 weeks, every 3 months for the first year and annually thereafter. Coordinator visits will also occur semi-annually.

The CORAL Study Chair is Lance Dworkin, MD, Brown University, Providence, RI. The CORAL Study Co-Chair is William Henrich, MD, University of Texas, San Antonio, TX. The Principal Investigators of the CORAL Clinical Coordinating Center are Christopher Cooper, MD, University of Toledo Health Science Campus, Toledo OH, and Timothy Murphy, MD, Brown University, Providence, RI.

The Principal Investigator of the Angiographic Core Laboratory is Alan Matsumoto, MD, University of Virginia, Charlottesville, VA. The Principal Investigator of the GFR and Biochemistry Core Laboratory is Michael Steffes, MD, University of Minnesota, Minneapolis, MN. The Principal Investigator of the Economics and Quality of Life Core Laboratory is David Cohen, MD, Mid-America Heart Institute, St. Luke's Hospital, Kansas City, MO. The Principal Investigator of the Data Coordinating Center is Donald Cutlip, MD, Beth Israel Deaconess Medical Center, Boston, MA. For additional information about the CORAL trial, please refer to the CORAL website (link given below).

Recruitment information / eligibility

• Status: Completed
• Enrollment: 947
• Est. completion date: September 2013
• Est. primary completion date: September 2013
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years and older

Eligibility

INCLUSION CRITERIA:

1. Either

1. Documented history of hypertension on two or more anti-hypertensive medications OR

2. Renal dysfunction, defined as Stage 3 or greater chronic kidney disease (CKD) based on the new National Kidney Foundation (NKF) classifications (estimated glomerular filtration rate [GFR] less than 60 mL per minute per 1.73 m^2, calculated by the modified Modification of Diet in Renal Disease [MDRD] formula)

2. One or more severe renal artery stenoses by any of the following pathways:

a. Angiographic: greater than or equal to 60% and less than 100% by renal angiogram OR b. Duplex: systolic velocity of greater than 300 cm/sec OR c. Core Lab approved Magnetic Resonance Angiogram (MRA) (refer to the protocol for specific criteria) demonstrating stenosis greater than 80% OR stenosis greater than 70% with spin dephasing on 3D phase contrast MRA OR stenosis greater than 70% and two of the following: i. Ischemic kidney is greater than 1 cm. smaller than contralateral kidney ii. Ischemic kidney enhances less on arterial phase iii. Ischemic kidney has delayed Gd excretion iv. Ischemic kidney hyper-concentrates the urine v. 2-D phase contrast flow waveform shows delayed systolic peak vi. Post-stenotic dilatation d. Clinical index of suspicion combined with a Core Lab approved Computed Tomography Angiography (CTA) demonstrating Stenosis is greater than 80% by visual assessment on high quality CTA Stenosis is greater than 70% on CTA by visual assessment and there are two of the following i. The length of the ischemic kidney is greater than 1 cm. smaller than contralateral kidney ii. Reduced cortical thickness of ischemic kidney iii. Less cortical enhancement of ischemic kidney on arterial phase iv. Post-stenotic dilatation

EXCLUSION CRITERIA:

1. Unable to provide informed consent

2. Unable or willing to comply with study protocol or procedures

3. Must be greater than 18 years of age

4. Fibromuscular dysplasia or other non-atherosclerotic renal artery stenosis known to be present prior to randomization

5. Pregnancy or unknown pregnancy status in female of childbearing potential

6. Participation in any drug or device trial during the study period, unless approved by the Steering Committee

7. Prior enrollment in the CORAL study

8. History of stroke within 6 months, if associated with a residual neurologic deficit*

9. Any major surgery, major trauma, revascularization procedure, unstable angina, or myocardial infarction 30 days prior to study entry*

10. Any planned major surgery or revascularization procedure, outside of the randomly allocated renal stenting indicated by the protocol, after randomization*

11. Hospitalization for heart failure within 30 days*

12. Comorbid condition causing life expectancy of less than or equal to 3 years*

13. Allergic reaction to intravascular contrast, not amenable to pre-treatment

14. Allergy to stainless steel

15. Allergy to all of the following: aspirin, clopidogrel, ticlopidine

16. Known untreated aneurysm of the abdominal aorta greater than 5.0 cm.*

17. Previous kidney transplant

18. a. Stenosis of greater than 50% of a previously treated revascularized renal artery OR b. Treatment of any renal artery stenosis within the past 9 months (roll-in patients can have prior treatment on the contralateral side)

19. Kidney size less than 7 cm. supplied by target vessel

20. Hydronephrosis, nephritis or other known cause of renal insufficiency, not due to large vessel renal artery stenosis

21. Visualized stenosis of only an accessory renal artery supplying greater than 1/2 of the ipsilateral renal parenchyma, without stenosis in a dominant renal artery

22. Local lab serum Cr greater than 4.0 mg/dl on the day of randomization*

23. Presence of a renal artery stenosis not amenable for treatment with a stent, known to be present prior to randomization

1. The index lesion cannot be treated with a single stent (i.e. greater than 18 mm. in length)

2. The placement of a stent will necessitate covering a renal artery branch renal artery with a stent

3. The stenosis is in an artery less than 3.5 mm. in diameter

4. The stenosis involves a segmental renal artery branch

24. Abrupt vessel closure or dissection after diagnostic angiography [NOTE: Patients with abrupt vessel closure or dissection as a result of diagnostic angiography will not be randomized but will undergo stent revascularization, receive optimal medical therapy and will be followed for the full study period] *Roll-in patients do not need to meet these inclusion/exclusion criteria

Study Design

Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Related Conditions & MeSH terms

• Atherosclerosis
• Cardiovascular Diseases
• Hypertension, Renovascular
• Renal Artery Obstruction

Intervention

Drug:
• Atacand/HCT, Caduet
Atacand/HCT and caduet or optimal medical therapy for hypertension

Procedure:
• GENESISTM Embolic Protection Stent and Angioguard Device (Angioplasty plus stenting)
Angioplasty plus stenting of the renal artery GENESISTM Embolic Protection Stent and Angioguard Device

Locations

Country	Name	City	State
United States	University of Toledo	Toledo	Ohio

Sponsors (2)

Lead Sponsor	Collaborator
Harvard Clinical Research Institute	Beth Israel Deaconess Medical Center

Country where clinical trial is conducted

United States, 

References & Publications (3)

Bittl JA. Treatment of atherosclerotic renovascular disease. N Engl J Med. 2014 Jan 2;370(1):78-9. doi: 10.1056/NEJMe1313423. Epub 2013 Nov 18. — View Citation

Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M, Kuntz R, Jamerson K, Reid D, Rosenfield K, Rundback J, D'Agostino R, Henrich W, Dworkin L. Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 2006 Jul;152(1):59-66. — View Citation

Murphy TP, Cooper CJ, Dworkin LD, Henrich WL, Rundback JH, Matsumoto AH, Jamerson KA, D'Agostino RB. The Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study: rationale and methods. J Vasc Interv Radiol. 2005 Oct;16(10):1295-300. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Composite Endpoint: Death From Cardiovascular or Renal Causes, Stroke, Myocardial Infarction, Hospitalization for CHF, Progressive Renal Insufficiency, or Permanent Renal Replacement Therapy	Only the first event per participant is included in the composite	Measured at every 3 months for the first year and annually thereafter	Yes
Primary	Cardiovascular or Renal Death		Measured at every 3 months for the first year and annually thereafter	Yes
Primary	Myocardial Infarction		Measured at every 3 months for the first year and annually thereafter	Yes
Primary	Hospitalization for Congestive Heart Failure		Measured at every 3 months for the first year and annually thereafter	Yes
Primary	Stroke		Measured at every 3 months for the first year and annually thereafter	Yes
Primary	30% Reduction of eGFR From Baseline, Persisting for Greater Than or Equal to 60 Days		Measured at every 3 months for the first year and annually thereafter	Yes
Primary	Need for Renal Replacement Therapy		Measured at every 3 months for the first year and annually thereafter	Yes