Clinical trial NCT00081731: Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions
Official title: Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Atherosclerosis
Cardiovascular Diseases
Hypertension, Renovascular
Renal Artery Obstruction
Lead sponsor: Baim Institute for Clinical Research
Sponsor class: OTHER
Collaborators: name: Beth Israel Deaconess Medical Center
First posted: 2004-04-21
Enrollment: 947
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief 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.

Detailed 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).

Eligibility criteria: 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

Primary outcomes:
measure: Composite Endpoint: Death From Cardiovascular or Renal Causes, Stroke, Myocardial Infarction, Hospitalization for CHF, Progressive Renal Insufficiency, or Permanent Renal Replacement Therapy
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: Cardiovascular or Renal Death
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: Myocardial Infarction
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: Hospitalization for Congestive Heart Failure
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: Stroke
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: 30% Reduction of eGFR From Baseline, Persisting for Greater Than or Equal to 60 Days
timeFrame: Measured at every 3 months for the first year and annually thereafter
measure: Need for Renal Replacement Therapy
timeFrame: Measured at every 3 months for the first year and annually thereafter
Secondary outcomes:
Other outcomes:
Locations:
city: Toledo
country: United States
facility: University of Toledo
state: Ohio
Study officials:
affiliation: Mid-America Heart Institute, St. Luke's Hospital, Kansas City, MO
name: David Cohen, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Toledo
name: Christopher J. Cooper, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Beth Israel Deaconess Medcial Center
name: Donald Cutlip, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Virginia School of Medicine
name: Alan Matsumoto, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Minnesota
name: Michael Steffes, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Rhode Island Hospital
name: Timothy P Murphy, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Brigham and Women's Hospital
name: Scott D Solomon, MD
role: STUDY_CHAIR
affiliation: Rhode Island Hospital
name: Lance D Dworkin, MD
role: STUDY_CHAIR
References:
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. doi: 10.1016/j.ahj.2005.09.011.
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. doi: 10.1097/01.RVI.0000176301.69756.28. No abstract available.
citation: 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. No abstract available.
citation: Lerman LO. Cell-based regenerative medicine for renovascular disease. Trends Mol Med. 2021 Sep;27(9):882-894. doi: 10.1016/j.molmed.2021.06.004. Epub 2021 Jun 25.
citation: Chen T, Brewster P, Tuttle KR, Dworkin LD, Henrich W, Greco BA, Steffes M, Tobe S, Jamerson K, Pencina K, Massaro JM, D'Agostino RB Sr, Cutlip DE, Murphy TP, Cooper CJ, Shapiro JI. Prediction of cardiovascular outcomes with machine learning techniques: application to the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) study. Int J Nephrol Renovasc Dis. 2019 Mar 21;12:49-58. doi: 10.2147/IJNRD.S194727. eCollection 2019.
citation: Murphy TP, Cooper CJ, Pencina KM, D'Agostino R, Massaro J, Cutlip DE, Jamerson K, Matsumoto AH, Henrich W, Shapiro JI, Tuttle KR, Cohen DJ, Steffes M, Gao Q, Metzger DC, Abernethy WB, Textor SC, Briguglio J, Hirsch AT, Tobe S, Dworkin LD. Relationship of Albuminuria and Renal Artery Stent Outcomes: Results From the CORAL Randomized Clinical Trial (Cardiovascular Outcomes With Renal Artery Lesions). Hypertension. 2016 Nov;68(5):1145-1152. doi: 10.1161/HYPERTENSIONAHA.116.07744. Epub 2016 Sep 19.
citation: Murphy TP, Cooper CJ, Matsumoto AH, Cutlip DE, Pencina KM, Jamerson K, Tuttle KR, Shapiro JI, D'Agostino R, Massaro J, Henrich W, Dworkin LD. Renal Artery Stent Outcomes: Effect of Baseline Blood Pressure, Stenosis Severity, and Translesion Pressure Gradient. J Am Coll Cardiol. 2015 Dec 8;66(22):2487-94. doi: 10.1016/j.jacc.2015.09.073.
citation: Evans KL, Tuttle KR, Folt DA, Dawson T, Haller ST, Brewster PS, He W, Jamerson K, Dworkin LD, Cutlip DE, Murphy TP, D'Agostino RB Sr, Henrich W, Cooper CJ. Use of renin-angiotensin inhibitors in people with renal artery stenosis. Clin J Am Soc Nephrol. 2014 Jul;9(7):1199-206. doi: 10.2215/CJN.11611113. Epub 2014 Jun 5.
citation: Murphy TP, Cooper CJ, Cutlip DE, Matsumoto A, Jamerson K, Rundback J, Rosenfield KA, Henrich W, Shapiro J, Massaro J, Yen CH, Burtch H, Thum C, Reid D, Dworkin L. Roll-in experience from the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study. J Vasc Interv Radiol. 2014 Apr;25(4):511-20. doi: 10.1016/j.jvir.2013.09.018. Epub 2013 Dec 8.
citation: Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, Cohen DJ, Matsumoto AH, Steffes M, Jaff MR, Prince MR, Lewis EF, Tuttle KR, Shapiro JI, Rundback JH, Massaro JM, D'Agostino RB Sr, Dworkin LD; CORAL Investigators. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014 Jan 2;370(1):13-22. doi: 10.1056/NEJMoa1310753. Epub 2013 Nov 18.