Aldosterone bloCkade for Health Improvement EValuation in End-stage Renal Disease
Aldosterone bloCkade for Health Improvement EValuation in End-stage Renal Disease
Individuals receiving dialysis are at risk of heart failure and heart related death. There is
 an urgent need for treatments that reduce the risk of these problems in patients that require
 dialysis.

 Spironolactone is a pill used to prevent heart failure and related deaths in patients that do
 not require dialysis. It works by blocking a hormone (aldosterone) in your body that causes
 high blood pressure and can damage the heart. Although spironolactone is very effective in
 patients that do not require dialysis, we do not know if spironolactone is effective in
 dialysis patients. Our research will help determine if spironolactone reduces heart failure
 and heart related deaths in dialysis patients.

 The purpose of this study is to determine if spironolactone reduces death or hospitalization
 for heart failure and is well tolerated in patients that require dialysis.
Globally, over 2 million people receive dialysis for end-stage renal disease (ESRD) and
 650,000 new patients start dialysis each year. Furthermore, the number of patients receiving
 dialysis is increasing as access to dialysis in the developing world improves and the
 prevalence of diabetes and vascular disease rises. Despite technical advances in dialysis,
 the outcomes for patients with ESRD are poor. Patients have frequent hospitalizations, poor
 health related quality of life and strikingly, high mortality rates.

 The most common cause of death in patients receiving dialysis is cardiovascular disease,
 accounting for >40% of all deaths. Observational studies suggest a causal pathway to
 cardiovascular death that includes progressive ventricular hypertrophy and dilatation as well
 as accelerated atherosclerosis. These changes result in myocardial ischemia and cardiac
 fibrosis that, in turn, lead to heart failure, arrhythmias and cardiac arrest. Strongly
 implicated in this pathophysiology is aldosterone. Mineralocorticoid receptor antagonists
 (MRAs) in non-ESRD patients, prevent cardiovascular deaths and small randomized controlled
 trials of MRAs in ESRD suggests they may reduce death and may be safe.

 Spironolactone is the most commonly used MRA worldwide. We will conduct a multicentre
 randomized controlled trial (RCT) to determine if spironolactone reduces cardiac mortality
 and hospitalizations for heart failure in patients treated with dialysis. This trial is
 called the Aldosterone bloCkade for Health Improvement EValuation in End-stage renal disease
 (ACHIEVE).
Inclusion Criteria:

 1. Age

 1. ≥45 years or

 2. ≥18 with a history of diabetes

 2. On dialysis ≥ 90 days

 3. On either

 1. Hemodialysis prescribed at least 2 treatments per week or

 2. Peritoneal dialysis prescribed with at least 1 exchange daily

 4. Provides informed consent

 Exclusion Criteria:

 1. Hyperkalemia

 1. Serum potassium >5.8 mmol/L in the 6 weeks prior to enrollment or

 2. Serum potassium >6.0 mmol/L during active run-in

 2. Currently taking and unable to withdraw a mineralocorticoid receptor antagonist (i.e.
 spironolactone or eplerenone).

 3. Known sensitivity or allergy to spironolactone

 4. Current or planned pregnancy or breastfeeding

 5. Scheduled living related donor renal transplant

 6. Life expectancy < 6 months in the opinion of a treating nephrologist.

 7. Enrolled in another interventional trial testing a mineralocorticoid receptor
 antagonist or drug that has a known or likely interaction with spironolactone.

 8. Treating physician believes either spironolactone is either absolutely indicated or
 absolutely contra-indicated