Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions (CORAL)

This study has been completed.
Sponsor:
Information provided by (Responsible Party):
Ingrid Abrahamsen, MS, Harvard University
ClinicalTrials.gov Identifier:
NCT00081731
First received: April 19, 2004
Last updated: December 9, 2013
Last verified: December 2013
  Purpose

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.


Condition Intervention Phase
Atherosclerosis
Cardiovascular Diseases
Hypertension, Renovascular
Renal Artery Obstruction
Drug: Atacand/HCT, Caduet
Procedure: GENESISTM Embolic Protection Stent and Angioguard Device (Angioplasty plus stenting)
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL)

Resource links provided by NLM:


Further study details as provided by Harvard University:

Primary Outcome Measures:
  • Composite Endpoint: Death From Cardiovascular or Renal Causes, Stroke, Myocardial Infarction, Hospitalization for CHF, Progressive Renal Insufficiency, or Permanent Renal Replacement Therapy [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
    Only the first event per participant is included in the composite

  • Cardiovascular or Renal Death [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
  • Myocardial Infarction [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
  • Hospitalization for Congestive Heart Failure [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
  • Stroke [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
  • 30% Reduction of eGFR From Baseline, Persisting for Greater Than or Equal to 60 Days [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]
  • Need for Renal Replacement Therapy [ Time Frame: Measured at every 3 months for the first year and annually thereafter ] [ Designated as safety issue: Yes ]

Enrollment: 947
Study Start Date: April 2004
Study Completion Date: September 2013
Primary Completion Date: September 2013 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Optimal Medical Therapy
Optimal anti-hypertensive therapy
Drug: Atacand/HCT, Caduet
Atacand/HCT and caduet or optimal medical therapy for hypertension
Experimental: Stenting
Stent procedure plus optimal anti-hypertensive therapy
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

  Hide Detailed Description

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

Ages Eligible for Study:   18 Years and older
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
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
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00081731

Locations
United States, Ohio
University of Toledo
Toledo, Ohio, United States, 43614
Sponsors and Collaborators
Harvard University
Investigators
Principal Investigator: David Cohen, MD Mid-America Heart Institute, St. Luke's Hospital, Kansas City, MO
Principal Investigator: Christopher J. Cooper, MD University of Toledo
Principal Investigator: Donald Cutlip, MD Beth Israel Deaconess Medcial Center
Principal Investigator: Alan Matsumoto, MD University of Virginia School of Medicine
Principal Investigator: Michael Steffes, MD University of Minnesota - Clinical and Translational Science Institute
Principal Investigator: Timothy P Murphy, MD Rhode Island Hospital
Study Chair: Scott D Solomon, MD Brigham and Women's Hospital
Study Chair: Lance D Dworkin, MD Rhode Island Hospital
  More Information

Additional Information:
Publications:
Additional publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: Ingrid Abrahamsen, MS, Project Coordinator, Harvard University
ClinicalTrials.gov Identifier: NCT00081731     History of Changes
Other Study ID Numbers: 161, U01 HL71556
Study First Received: April 19, 2004
Results First Received: December 9, 2013
Last Updated: December 9, 2013
Health Authority: United States: Food and Drug Administration

Additional relevant MeSH terms:
Hypertension
Cardiovascular Diseases
Atherosclerosis
Arteriosclerosis
Hypertension, Renovascular
Renal Artery Obstruction
Vascular Diseases
Arterial Occlusive Diseases
Hypertension, Renal
Kidney Diseases
Urologic Diseases

ClinicalTrials.gov processed this record on October 19, 2014