Impact of a Treatment With Angiotensin Receptor Blocker on Outcome After Acute Kidney Injury in Patients Discharged From the ICU.

Study Overview
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Brief Summary
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The patients discharged from intensive care units (ICU) have a high incidence of cardiovascular events and mortality rate during the year following ICU discharge. Among patients admitted to the ICU, patients with acute kidney injury (AKI) display high risk of such events. The investigators furthermore demonstrated that AKI could induce remote cardio-vascular injury and fibrosis, which may be involved in the poor prognosis of AKI. Strategies that may prevent the cardiovascular consequences of AKI in most severe patients (i.e. post-AKI ICU survivors) may therefore improve long term outcomes. AKI has been associated with activation of the renin-angiotensin-aldosterone system (RAAS). Activation of the RAAS has been further associated with long-term health consequences especially with cardiovascular damages. Potential protective effects of RAASi following acute injury have been reported in observational studies. With this randomized controlled trial, the investigators aim at investigating the impact of treatment with RAAS inhibitors after AKI on cardiovascular and kidney outcomes.

Detailed Description
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Phase III study Prospective, multicenter, superiority, double-blind, randomized controlled study with two arms (1:1). Inclusion of patients who are discharged alive (or ready to be discharged) from ICU or acute care and developed acute kidney injury during the ICU stay (according to the KDIGO criteria) - and signing of the consent to participate at this research Enrolled patients will be randomly assigned to one of the two study groups once their renal function has stabilized for at least 48 hours and within 30 days from ICU or acute care discharge. Patients randomized will be stratified according to the center and the severity of AKI during ICU stay (KDIGO 1 vs KDIGO 2 or 3) All patients with have a clinical examination and biological visit (i.e. serum creatinine, potassium, and NT-ProBNP) 7(+/-2) days after inclusion, at 2 months, 6 months and at 12 months. Microalbuminuria will be further measure at inclusion and 12 months. In the control and treatment group, treatment will be upgraded to 2 pills (IRBESARTAN 150 mg or Placebo) if Serum creatinine has not risen by more than 30% since previous visit and no hyperkalemia and no hypotension are noticed. Treatment management will be performed by intensivists, nephrologists or cardiologists involved in the protocol. Biological collection A plasma and urine collected as part of the study will be stored in a biological sample collection at inclusion and at the end of the study.

Official Title
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Impact of a Treatment With Angiotensin Receptor Blocker on Outcome After Acute Kidney Injury in Patients Discharged From the ICU START-or-NOT Trial. A Prospective, Randomized, Double Blinded, Multicenter Study

Conditions
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Acute Kidney Injury

Intervention / Treatment
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* Drug: IRBESARTAN, tablet, 150 mg
* Drug: Placebo, tablet, 150 mg


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient between 18 and 75 years old Met criteria for acute kidney injury during the ICU stay (according to the KDIGO criteria) After their renal function has stabilized for at least 48 hours (changes in serum creatinine < 26 micromol/L or < 25%) among patients ready to be discharged from the ICU or within 30 days after ICU discharge.- Signed informed consent Patients affiliated to a Social Security System Women of childbearing potential and men must agree, to use adequate and highly effective contraception, until the end of the research. Exclusion Criteria: Patient treated with ACEi or ARB before ICU admission Patient for whom treatment with ACEi or ARB is strongly recommended according to the international guidelines at discharge (i.e. patients with congestive heart failure and persistent dyspnea with LVEF<40%,, patients with diabetes mellitus and either albuminuria > 300 µg/g creatininuria or hypertension associated with microalbuminuria or hypertension associated with eGFR < 60 ml/min) known before ICU admission. Hyperkalemia>5 mmol/L Systolic blood pressure <100 mmHg Patient with severe renal failure, as defined by estimated glomerular filtration rate creatinine clearance < 15 ml/min/1.73m2), requiring renal replacement therapy at ICU discharge Oral route impossible. Pregnancy Breast feeding Patients chronically treated with Aliskiren Known hypersensitivity to the active substance or to one of its excipients and in particular to lactose Patients with known primary hyperaldosteronism Patients with known severe and symptomatic aortic stenosis, mitral stenosis or obstructive hypertrophic cardiomyopathy. Patients treated with lithium Patient undergoing psychiatric care Inability to consent due to psychiatric disorders defined as psychiatric disorders or patient with a mental state requiring immediate care with either by constant medical surveillance justifying hospitalization, or regular medical follow-up justifying specific treatment Patient deprived of liberty by a judicial or administrative decision Patient to a legal protection measure (guardianship, curatorship and safeguard of justice)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: IRBESARTAN<br>IRBESARTAN will be introduced at 150 mg orally one daily, with a progressive increase to 300 mg a day, at 7 days or 2 months follow-up visit, based on clinical and biological tolerance. Treatment will be continued for 12 months, unless a side effect would occur. | Drug: IRBESARTAN, tablet, 150 mg<br>* IRBESARTAN will be introduced at 150 mg orally one daily, with a progressive increase to 300 mg a day, at 7 days or 2 months follow-up visit.Treatment will be continued for 12 months, unless a side effect would occur.<br>|
| Placebo Comparator: Placebo<br>Placebo will be introduced at 150 mg orally one daily, with a progressive increase to 300 mg a day, at 7 days or 2 months follow-up visit, based on clinical and biological tolerance. Treatment will be continued for 12 months, unless a side effect would occur. | Drug: Placebo, tablet, 150 mg<br>* Placebo will be introduced at 150 mg orally one daily, with a progressive increase to 300 mg a day, at 7 days or 2 months follow-up visit.Treatment will be continued for 12 months, unless a side effect would occur.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to MACE (major adverse cardiovascular events) | cardiovascular events will be defined as: acute heart failure, stroke, acute coronary syndrome | Within the year after randomization | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Occurrence of chronic kidney disease | kidney disease defined as eGFR <60 ml/min/1.73m2 | one year after ICU discharge | 
| Albuminuria>0.3 g/day one year after ICU discharge |  | one year after ICU discharge | 
| Chronic kidney disease staging |  | One year after randomization | 
| Change in Chronic kidney disease staging |  | One year after randomization | 
| New episode of acute kidney injury requiring hospitalization | Acute kidney injury according to the KDIGO criteria | within one year after randomization | 
| Hyperkalemia >6 mmol/L |  | within one year after randomization | 
| Death |  | within one year after randomization | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Angiotensin-Converting-Enzyme Inhibitor, angiotensin-receptor blockers