Javier Nieto Iglesias, Luis M. Ruilope Urioste, Soledad García de Vinuesa, Dolores Jarillo Ibáñez, José Mora-Maciá, José C. Rodríguez-Pérez, Ramón Romero, Pedro Aljama, Florencio García-Martín, Alfonso Pérez-García, Raúl Fernández and Jesús Garrido,
on behalf of the PROCOPA Study Group. Spain.
Introduction: Tight blood pressure (BP) control and proteinuria reduction are the main therapeutic objectives in patients with primary renal disease. New Guidelines have established a lower threshold and goal BP in patients with proteinuria. However, a strict BP control could also be accompanied by a greater fall in proteinuria, depending on the type of the therapy chosen.
Objective: To compare the rate of proteinuria decrease when BP is reduced as much as safely possible with different medications (atenolol, verapamil, trandolapril and the combination verapamil plus trandolapril) in patients with primary renal disease. Secondarily, to evaluate renal function and other specific biochemical parameters.
Patients and Methods: After a 4-week run-in placebo period, patients with primary renal disease, proteinuria (1g/day and creatinine clearance >50 ml/min were double-blind, randomised to: atenolol 50 mg/d, verapamil 240 mg/d, trandolapril 2 mg/d or verapamil plus trandolapril 240/2 mg/d. Doses were forcedly doubled in all patients after 4 weeks of treatment. Furosemide was added at week 8 if needed. Patients were followed at 4, 8, 16 and 24 weeks of treatment.
Results: 119 patients comprised the intention-to-treat sample and 101 patients completed the study. A significant BP reduction was obtained in the four treatment groups [SBP/DBP (mmHg): 12.2/9.9 atenolol; 8.2/7.9 verapamil; 12.9/9.3 trandolapril and 13.6/11.3 verapamil plus trandolapril] without differences among them. Despite the good BP response, a significant rate of reduction in proteinuria was only shown in the groups treated with trandolapril alone 40.2% (CI95%: 24.3-56.2%) or associated to verapamil 48% (CI95%: 31.7-64.3%). Only in this latter group, the fall in proteinuria was accompanied by a significant increase in serum albumin (0.25 g/dL, p=0.002) and calcium (0.22 mg/dL, p=0.004).
Conclusions: In patients with primary renal disease and significant proteinuria, an adequate BP control can be achieved provided there is an adequate treatment titration. However, proteinuria fell significantly only in patients receiving the ACE inhibitor, alone or in combination. In patients treated with the trandolapril-verapamil combination, the simultaneous increase in serum albumin and calcium could represent an important additional benefit.